A natural experiment on the impact of fruit supplementation on asthma symptoms in children

A high fruit intake may reduce the risk of asthma. The English National School Fruit Scheme was introduced in the East Midlands region of the UK in June 2003 and in the Eastern region in September 2004. Questionnaires were distributed to children aged 4-6 yrs in schools in May 2003. This was repeated in May 2004 when those in the East Midlands had received free fruit for 1 yr and those in the Eastern region had not. Responses were obtained in 2004 for 4,971 (53%) and 5,770 (54%) children in the intervention and control regions, respectively. Despite an increase in fruit consumption in the intervention compared with the control region between 2003 and 2004, there was no difference between the two regions in the prevalence or severity of asthma symptoms after 1 yr of fruit supplementation (odds ratio for wheeze in the past 12 months in intervention compared with control region 1.00, 95% confidence interval 0.88-1.14). Providing free fruit at school for 1 yr does not have any immediate effect on prevalence or severity of asthma in young children, although these data do not refute the hypothesis that a higher increase in fruit intake improves measures of asthma control.

Risk of new aneurysms after surgery for popliteal artery aneurysm (Br J Surg 2008; 95: 571-575)

The Editors welcome topical correspondence from readers relating to articles published in the Journal. Responses should be sent electronically via the BJS website (www.bjs.co.uk). All letters will be reviewed and, if approved,appear on the website. A selection of these will be edited and published in the Journal. Letters must be no more than 250 words in length.

CT-guided percutaneous transpulmonary adrenal biopsy - a technical note

CT-guided percutaneous adrenal biopsy is commonly performed using a posterior or trans-abdominal approach. However, trans-abdominal access to the gland may not be technically feasible in some patients. In our case, CT-guided transthoracic percutaneous biopsy of the adrenal gland was performed with technical success, identifying the tumour. To the best of our knowledge, there has been no previous case describing this transpulmonary approach in the literature.

Adenovirus and adeno-associated virus-mediated delivery of human myophosphorylase cDNA and LacZ cDNA to muscle in the ovine model of McArdle's disease: expression and re-expression of glycogen phosphorylase

At present there is no satisfactory treatment for McArdle's disease, deficiency of myophosphorylase. Injection of modified adenovirus 5 (AdV5) and adeno-associated virus 2 (AAV2) vectors containing myophosphorylase expression cassettes, into semitendinosus muscle of sheep with McArdle's disease, produced expression of functional myophosphorylase and some re-expression of the non-muscle glycogen phosphorylase isoforms (both liver and brain) in regenerating fibres. Expression of both non-muscle isoforms was also seen after control injections of AdV5LacZ vectors. There was up to an order of magnitude greater expression of phosphorylase after myophosphorylase vector injection than after LacZ controls (62% of sections with over 1000 positive muscle fibres, versus 7%). The results presented here suggest that the use of viral vector-mediated phosphorylase gene transfer may be applicable to the treatment of McArdle's disease and that sustained re-expression of the brain and liver isoforms should also be investigated as a possible treatment.

Current practice, accuracy, effectiveness and cost-effectiveness of the school entry hearing screen

OBJECTIVES

To describe and analyse in detail current practice of school entry hearing screening (SES) in the UK.

DATA SOURCES

Main electronic databases were searched up to May 2005.

REVIEW METHODS

A national postal questionnaire survey was addressed to all leads for SES in the UK, considering current practice in terms of implementation, protocols, target population and performance data. Primary data from cohort studies in one area of London were examined. A systematic review of alternative SES tests, test performance and impact on outcomes was carried out. Finally, a review of published studies on costs, plus economic modelling of current and alternative programmes was prepared.

RESULTS

The survey suggested that SES is used in most of England, Wales and Scotland; just over 10% of respondents have abandoned the screen; others are awaiting national guidance. Coverage of SES is variable, but is often over 90% for children in state schools. Referral rates are variable, with a median of about 8%. The test used for the screen is the pure tone sweep test but with wide variation in implementation, with differing frequencies, pass criteria and retest protocols; written examples of protocols were often poor and ambiguous. There is no national approach to data collection, audit and quality assurance, and there are variable approaches at local level. The screen is performed in less than ideal test conditions and resources are often limited, which has an impact on the quality of the screen. The primary cohort studies show that the prevalence of permanent childhood hearing loss continues to increase through infancy. Of the 3.47 in 1000 children with a permanent hearing loss at school screen age, 1.89 in 1000 required identification after the newborn screen. Newborn hearing screening is likely to reduce significantly the yield of SES for permanent bilateral and unilateral hearing impairments; yield had fallen from about 1.11 in 1000 before newborn screening to about 0.34 in 1000 for cohorts that had had newborn screening, of which only 0.07 in 1000 were unilateral impairments. Just under 20% of permanent moderate or greater bilateral, mild bilateral and unilateral impairments, known to services as 6-year-olds or older, remained to be identified around the time of school entry. No good-quality published comparative trials of alternative screens or tests for SES were identified and studies concerned with the relative accuracy of alternative tests are difficult to compare and often flawed by differing referral criteria and case definitions; with full pure tone audiometry as the reference test, the pure tone sweep test appears to have high sensitivity and high specificity for minimal, mild and greater hearing impairments, better than alternative tests for which evidence was identified. There is insufficient evidence regarding possible harm of the screen. There were no published studies identified that examined the possible effects of SES on longer term outcomes. No good-quality published economic evaluations of SES were identified and a universal SES based on pure tone sweep tests was associated with higher costs and slightly higher quality-adjusted life-years (QALYs) compared with no screen and other screen alternatives; the incremental cost-effectiveness ratio for such a screen is around 2500 pounds per QALY gained; the range of expected costs, QALYs and net benefits was broad, indicating a considerable degree of uncertainty. Targeted screening could be more cost-effective than universal school entry screening; however, the lack of primary data and the wide limits for variables in the modelling mean that any conclusions must be considered indicative and exploratory only. A national screening programme for permanent hearing impairment at school entry meets all but three of the criteria for a screening programme, but at least six criteria are not met for screening for temporary hearing impairment.

CONCLUSIONS

The lack of good-quality evidence in this area remains a serious problem. Services should improve quality and audit screen performance for identification of previously unknown permanent hearing impairment, pending evidence-based policy decisions based on the research recommendations. Further research is needed into a number of important areas including the evaluation of an agreed national protocol for services delivering SES to make future studies and audits of screen performance more directly comparable.

Does participation in a population-based dietary intervention scheme have a lasting impact on fruit intake in young children?

BACKGROUND

The National Schools Fruit Scheme (NSFS) is intended to improve fruit intake in young children by providing free daily fruit at school.

METHODS

We used a parentally completed questionnaire for three consecutive years to study fruit intake in young children before, during and after participation in the NSFS compared with a control region.

RESULTS

In 2003, 2004 and 2005, a total of 224, 220 and 179 schools, respectively, were studied with responses from 5,606, 5,111 and 3,382 children for each survey. Between 2003 and 2004, individual fruit consumption in the intervention region increased by more (from a median of 7.5 to 14.0 pieces/week) than in the control region (from a median of 9.2-11.0 pieces/week), resulting in a difference (P < 0.001) between the two regions in 2004. However, after ceasing to be eligible for the NSFS, fruit intake in children in the intervention region fell to a median of 12 pieces per week, lower than that in the control region (median value of 14 pieces per week, P = 0.02).

CONCLUSIONS

School-based fruit distribution schemes providing free fruit at school appear to be an effective means of increasing dietary fruit intake in young children, including those who live in relatively socio-economically deprived areas. However, this approach does not influence fruit intake after the provision of free fruit ends, so schemes may need to be sustained to provide the maximum benefit to young children.

Briefing: How recent case law affects the conduct of an expert

This article is intended to be a guide for those asked to be expert witnesses in legal proceedings, focusing particularly on the effect of recent case law in this area. It is not a substitute for looking directly at the terms of part 35 of the Civil Procedure Rules and the accompanying practice direction, nor the Protocol for the Instruction of Experts to Give Evidence in Civil Claims prepared by the Civil Justice Council.

Cost-effectiveness of cell salvage and alternative methods of minimising perioperative allogeneic blood transfusion: a systematic review and economic model

OBJECTIVES

To compare patient outcomes, resource use and costs to the NHS and NHS Blood Transfusion Authority (BTA) associated with cell salvage and alternative methods of minimising perioperative allogeneic blood transfusion.

DATA SOURCES

Electronic databases covering the period 1996-2004 for systematic reviews and 1994-2004 for economic evidence.

REVIEW METHODS

Existing systematic reviews were updated with data from selected randomised controlled trials (RCTs) that involved adults scheduled for elective non-urgent surgery. Any resource use or cost data were extracted for potential use in populating an economic model. Relative risks or weighted mean difference of each outcome for each intervention were assessed, taking into account the number of RCTs included in each outcome and intervention and the presence of any heterogeneity. This allowed indirect comparison of the relative effectiveness of each intervention when the intervention is compared with allogeneic blood transfusion. A decision analytic model synthesised clinical and economic data from several sources, to estimate the relative cost-effectiveness of cell salvage for people undergoing elective surgery with moderate to major expected blood loss. The perspective of the NHS and patients and a time horizon of 1 month were used. The economic model was developed from reviews of effectiveness and cost-effectiveness and clinical experts. Secondary analysis explored the robustness of the results to changes in the timing and costs of cell salvage equipment, surgical procedure, use of transfusion protocols and time horizon of analysis.

RESULTS

Overall, 668 studies were identified electronically for the update of the two systematic reviews. This included five RCTs, of which two were cell salvage and three preoperative autologous donation (PAD). Five published systematic reviews were identified for antifibrinolytics, fibrin sealants and restrictive transfusion triggers, PAD plus erythropoietin, erythropoietin alone and acute normovolaemic haemodilution (ANH). Twelve published studies reported full economic evaluations. All but two of the transfusion strategies significantly reduced exposure to allogeneic blood. The relative risk of exposure to allogeneic blood was 0.59 for the pooled trials of cell salvage (95% confidence interval: 0.48 to 0.73). This varied by the type and timing of cell salvage and type of surgical procedure. For cell salvage, the relative risk of allogeneic blood transfusion was higher in cardiac surgery than in orthopaedic surgery. Cell salvage had lower costs and slightly higher quality-adjusted life years compared with all of the alternative transfusion strategies except ANH. The likelihood that cell salvage is cost-effective compared with strategies other than ANH is over 50%. Most of the secondary analyses indicated similar results to the primary analysis. However, the primary and secondary analyses indicated that ANH may be more cost-effective than cell salvage.

CONCLUSIONS

The available evidence indicates that cell salvage may be a cost-effective method to reduce exposure to allogeneic blood transfusion. However, ANH may be more cost-effective than cell salvage. The results of this analysis are subject to the low quality and reliability of the data used and the use of indirect comparisons. This may affect the reliability and robustness of the clinical and economic results. There is a need for further research that includes adequately powered high-quality RCTs to compare directly various blood transfusion strategies. These should include measures of health status, health-related quality of life and patient preferences for alternative transfusion strategies. Observational and tracking studies are needed to estimate reliably the incidence of adverse events and infections transmitted during blood transfusion and to identify the lifetime consequences of the serious hazards of transfusion on mortality, health status and health-related quality of life.

Diversity and sensitivity of epiphytes to oxides of nitrogen in London

This study investigated the distribution and diversity of epiphytes in London in relation to NO(x) using fine-scale atmospheric dispersion modelling. The survey recorded over 3000 epiphytes from 334 trees (Fraxinus excelsior) representing 74 lichen, 14 moss, 7 fungal and 3 algal species. There was a significant inverse relationship between diversity and NO(x). Diversity declined where NO(x) exceeded 70 microg m(-3) and NO2 exceeded 40 microg m(-3), suggesting a phytotoxic effect. However, there was a significant positive relationship between NO(x) and lichen abundance due to the ubiquitous distribution of pollution tolerant species, mainly associated with eutrophication. A scale of lichen sensitivity to NO(x) has been derived.

Randomised controlled trials of conventional antipsychotic versus new atypical drugs, and new atypical drugs versus clozapine, in people with schizophrenia responding poorly to, or intolerant of, current drug treatment

OBJECTIVES

To determine the clinical and cost-effectiveness of different classes of antipsychotic drug treatment in people with schizophrenia responding inadequately to, or having unacceptable side-effects from, their current medication.

DESIGN

Two pragmatic, randomised controlled trials (RCTs) were undertaken. The first RCT (band 1) compared the class of older, inexpensive conventional drugs with the class of new atypical drugs in people with schizophrenic disorders, whose current antipsychotic drug treatment was being changed either because of inadequate clinical response or owing to side-effects. The second RCT (band 2) compared the new (non-clozapine) atypical drugs with clozapine in people whose medication was being changed because of poor clinical response to two or more antipsychotic drugs. Both RCTs were four-centre trials with concealed randomisation and three follow-up assessments over 1 year, blind to treatment.

SETTING

Adult mental health settings in England.

PARTICIPANTS

In total, 227 participants aged 18-65 years (40% of the planned sample) were randomised to band 1 and 136 (98% of the planned sample) to band 2.

INTERVENTIONS

Participants were randomised to a class of drug. The managing clinician selected the individual drug within that class, except for the clozapine arm in band 2. The new atypical drugs included risperidone, olanzapine, quetiapine and amisulpride. The conventional drugs included older drugs, including depot preparations. As in routine practice, clinicians and participants were aware of the identity of the prescribed drug, but clinicians were asked to keep their participating patient on the randomised medication for at least the first 12 weeks. If the medication needed to be changed, the clinician was asked to prescribe another drug within the same class, if possible.

MAIN OUTCOME MEASURES

The primary outcome was the Quality of Life Scale (QLS). Secondary clinical outcomes included symptoms [Positive and Negative Syndrome Scale (PANSS)], side-effects and participant satisfaction. Economic outcomes were costs of health and social care and a utility measure.

RESULTS

Recruitment to band 1 was less than anticipated (40%) and diminished over the trial. This appeared largely due to loss of perceived clinical equipoise (clinicians progressively becoming more convinced of the superiority of new atypicals). Good follow-up rates and a higher than expected correlation between QLS score at baseline and at follow-up meant that the sample as recruited had 75% power to detect a difference in QLS score of 5 points between the two treatment arms at 52 weeks. The recruitment to band 2 was approximately as planned. Follow-up assessments were completed at week 52 in 81% of band 1 and 87% of band 2 participants. Band 1 data showed that, on the QLS and symptom measures, those participants in the conventional arm tended towards greater improvements. This suggests that the failure to find the predicted advantage for new atypicals was not due to inadequate recruitment and statistical power in this sample. Participants reported no clear preference for either class of drug. There were no statistically significant differential outcomes for participants entering band 1 for reasons of treatment intolerance to those entering because of broadly defined treatment resistance. Net costs over the year varied widely, with a mean of 18,850 pounds sterling in the conventional drug group and 20,123 pounds sterling in the new atypical group, not a statistically significant difference. Of these costs, 2.1% and 3.8% were due to antipsychotic drug costs in the conventional and atypical group, respectively. There was a trend towards participants in the conventional drug group scoring more highly on the utility measure at 1 year. The results for band 2 showed an advantage for commencing clozapine in quality of life (QLS) at trend level (p = 0.08) and in symptoms (PANSS), which was statistically significant (p = 0.01), at 1 year. Clozapine showed approximately a 5-point advantage on PANSS total score and a trend towards having fewer total extrapyramidal side-effects. Participants reported at 12 weeks that their mental health was significantly better with clozapine than with new atypicals (p < 0.05). Net costs of care varied widely, but were higher than in band 1, with a mean of 33,800 pounds sterling in the clozapine group and 28,400 pounds sterling in the new atypical group. Of these costs, 4.0% and 3.3%, respectively, were due to antipsychotic drug costs. The increased costs in the clozapine group appeared to reflect the licensing requirement for inpatient admission for commencing the drug. There was a trend towards higher mean participant utility scores in the clozapine group.

CONCLUSIONS

For band 1, there is no disadvantage in terms of quality of life and symptoms, or associated costs of care, over 1 year in commencing conventional antipsychotic drugs rather than new atypical drugs. Conventional drugs were associated with non-significantly better outcomes and lower costs. Drug costs represented a small proportion of the overall costs of care (<5%). For band 2, there is a statistically significant advantage in terms of symptoms but not quality of life over 1 year in commencing clozapine rather than new atypical drugs, but with increased associated costs of care. The results suggest that conventional antipsychotic drugs, which are substantially cheaper, still have a place in the treatment of patients unresponsive to, or intolerant of, current medication. Further analyses of this data set are planned and further research is recommended into areas such as current antipsychotic treatment guidance, valid measures of utility in serious mental illness, low-dose 'conventional' treatment in first episode schizophrenia, QLS validity and determinants of QLS score in schizophrenia, and into the possible financial and other mechanisms of rewarding clinician participation in trials.

Effect of primary-care spirometry on the diagnosis and management of COPD

Primary-care spirometry has been promoted as a method of facilitating accurate diagnosis of chronic obstructive pulmonary disease (COPD). The present study examined whether improving rates of diagnosis lead to improvements in pharmacological and nonpharmacological management. From 1999 to 2003, the current authors provided an open-access spirometry and reversibility service to a local primary-care area, to which 1,508 subjects were referred. A total of 797 (53%) had pre-bronchodilator airflow obstruction (AFO). Of the subjects who underwent reversibility testing, 19.3% were no longer obstructed post-bronchodilator. The results and records of a subgroup of 235 subjects with post-bronchodilator AFO were examined. Of the 235 subjects, 130 received a new diagnosis, most commonly COPD. The patients with COPD were significantly undertreated before spirometry and testing led to a significant increase in the use of anticholinergics (37 versus 18%), long-acting beta-agonists (25 versus 8%) and inhaled steroids (71 versus 52%). More than three quarters of smokers received smoking cessation advice but very few were referred for pulmonary rehabilitation. In conclusion, primary-care spirometry not only increases rates of chronic obstructive pulmonary disease diagnosis, but it also leads to improvements in chronic obstructive pulmonary disease treatment. The use of bronchodilator reversibility testing in this setting may be important to avoid misdiagnosis.

Definition of novel GP6 polymorphisms and major difference in haplotype frequencies between populations by a combination of in-depth exon resequencing and genotyping with tag single nucleotide polymorphisms

BACKGROUND

Common genetic variants of cell surface receptors contribute to differences in functional responses and disease susceptibility. We have previously shown that single nucleotide polymorphisms (SNPs) in platelet glycoprotein VI (GP6) determine the extent of response to agonist. In addition, SNPs in the GP6 gene have been proposed as risk factors for coronary artery disease.

METHODS

To completely characterize genetic variation in the GP6 gene we generated a high-resolution SNP map by sequencing the promoter, exons and consensus splice sequences in 94 non-related Caucasoids. In addition, we sequenced DNA encoding the ligand-binding domains of GP6 from non-human primates to determine the level of evolutionary conservation.

RESULTS

Eighteen SNPs were identified, six of which encoded amino acid substitutions in the mature form of the protein. The single non-synonymous SNP identified in the exons encoding the ligand-binding domains, encoding for a 103Leu > Val substitution, resulted in reduced ligand binding. Two common protein isoforms were confirmed in Caucasoid with frequencies of 0.82 and 0.15. Variation at the GP6 locus was characterized further by determining SNP frequency in over 2000 individuals from different ethnic backgrounds.

CONCLUSIONS

The SNPs were polymorphic in all populations studied although significant differences in allele frequencies were observed. Twelve additional GP6 protein isoforms were identified from the genotyping results and, despite extensive variation in GP6, the sequence of the ligand-binding domains is conserved. Sequences from non-human primates confirmed this observation. These data provide valuable information for the optimal selection of genetic variants for use in future association studies.

The British Rheumatoid Outcome Study Group (BROSG) randomised controlled trial to compare the effectiveness and cost-effectiveness of aggressive versus symptomatic therapy in established rheumatoid arthritis

OBJECTIVES

To examine the effectiveness and cost-effectiveness of symptomatic versus aggressive treatment in patients with established, stable rheumatoid arthritis (RA).

DESIGN

A randomised observer-blinded controlled trial and economic evaluation with an initial assessment at randomisation and follow-ups at 12, 24 and 36 months.

SETTING

Five rheumatology centres in England. The 'symptomatic care' patients were managed predominantly in primary care with regular visits by a rheumatology specialist nurse. The 'aggressive care' patients were managed predominantly in the hospital setting.

PARTICIPANTS

Patients with RA for more than 5 years were screened in rheumatology clinics.

INTERVENTIONS

The symptomatic care patients were seen at home every 4 months by a rheumatology specialist nurse and annually by the rheumatologist. The aim of treatment was symptom control. The aggressive care patients were seen at least every 4 months in hospital. Their treatment was altered (following predefined algorithms) with the aim of suppressing both clinical and laboratory evidence of joint inflammation.

MAIN OUTCOME MEASURES

The main outcome measure was the Health Assessment Questionnaire (HAQ). Others included the patient and physician global assessment, pain, tender and swollen joint counts, the erythrocyte sedimentation rate and the OSRA (Overall Status in Rheumatoid Arthritis) score. X-rays of the hands and feet were performed at the beginning and end of the study. The EQ-5D was used in the health economic evaluation. Comprehensive costs were also estimated and were combined with measures of outcome to examine between-group differences.

RESULTS

A total of 466 patients were recruited; 399 patients completed the 3 years of follow-up. There was a significant deterioration in physical function (HAQ) in both arms. There was no significant difference between the groups for any of the clinical outcome measures except the physician global assessment [adjusted mean difference 3.76 (95% CI 0.03 to 7.52)] and the OSRA disease activity component [adjusted mean difference 0.41 (95% CI 0.01 to 0.71)], both in favour of the aggressive arm. During the trial, second-line drug treatment was changed in 77.1% of the aggressive arm and 59.0% of the symptomatic arm. There were instances when the rheumatologist should have changed treatment but did not do so, usually because of mild disease activity. The symptomatic arm was associated with higher costs and higher quality-adjusted life-years (QALYs). There was a net cost of 1517 Pounds Sterling per QALY gained for the symptomatic arm. Overall, the primary economic analysis and sensitivity analyses of the cost and QALY data indicate that symptomatic treatment is likely to be more cost-effective than aggressive treatment in 58-90% of cases.

CONCLUSIONS

This trial showed no benefit of aggressive treatment in patients with stable established RA. However, it was difficult to persuade the rheumatologist and/or the patient to change treatment if the evidence of disease activity was minimal. Patients in the symptomatic arm were able to initiate changes of therapy when their symptoms deteriorated, without frequent hospital assessment. Approximately one-third of current clinic attenders with stable RA could be managed in a shared care setting with annual review by a rheumatologist and regular contact with a rheumatologist nurse. Further research is needed into disease progression and the use of biological agents, minimum disease activity level below which disease progression does not occur, cost-effectiveness through shared care modelling, the development of a robust and fail-safe system of primary-care based disease-modifying anti-rheumatic drug (DMARD) monitoring, and predicting response to DMARDs.

Intravenous aminophylline in patients admitted to hospital with non-acidotic exacerbations of chronic obstructive pulmonary disease: a prospective randomised controlled trial

BACKGROUND

Intravenous aminophylline is commonly used in the treatment of exacerbations of chronic obstructive pulmonary disease (COPD), despite limited evidence for its efficacy and known risks of toxicity. We hypothesised that adding intravenous aminophylline to conventional treatment would not produce clinically important changes in the speed of spirometric or symptomatic recovery or shorten hospital stay in patients with exacerbations of COPD.

METHODS

Eighty patients admitted to hospital with non-acidotic exacerbations of COPD were recruited at admission to a randomised, double blind, placebo controlled study comparing intravenous aminophylline 0.5 mg/kg/hour after an appropriate loading dose with an equivalent volume of 0.9% saline. The primary outcome was the change in post-bronchodilator forced expiratory volume in 1 second (FEV(1)) over the first 5 days of the admission. Secondary end points were changes in self-reported breathlessness, arterial blood gas tensions, forced vital capacity (FVC), and length of hospital stay.

RESULTS

There was no difference in the post-bronchodilator FEV(1) over the first 5 days between the aminophylline and placebo groups. In the aminophylline group, 2 hours of treatment produced a small but significant rise in arterial pH (p = 0.001) and a fall in arterial carbon dioxide tension (p = 0.01) compared with placebo treatment. There were no differences in the severity of breathlessness, post-bronchodilator FVC, or length of hospital stay between the groups. Nausea was a more frequent side effect in the aminophylline group (46% v 22%; p<0.05), but palpitations and headache were noted equally in both groups.

CONCLUSIONS

Although intravenous aminophylline produced small improvements in acid-base balance, these did not influence the subsequent clinical course. No evidence was found for any clinically important additional effect of aminophylline treatment when used with high dose nebulised bronchodilators and oral corticosteroids. Given its known toxicity, we cannot therefore recommend the use of intravenous aminophylline in the treatment of non-acidotic COPD exacerbations.

Secondhand smoke, dietary fruit intake, road traffic exposures, and the prevalence of asthma: a cross-sectional study in young children

The authors have investigated the independent effects of exposure to secondhand smoke, road vehicle traffic, and dietary fruit intake in a cross-sectional study of asthma in young children. They surveyed all children aged 4-6 years in 235 schools in the East Midlands and East of England regions of the United Kingdom in 2003. Data on respiratory symptoms, diagnoses and treatment, smoking in the home, and dietary fruit intake were collected by parental questionnaire. A geographic information system was used to map postcodes and determine the distance of the home from the nearest main road. Responses were obtained from 11,562 children. Wheeze in the past year and physician-diagnosed asthma were reported by 14.1% and 18.2%, respectively. Both of these outcomes were more common in children who lived with a smoker, and the prevalence of asthma increased with the number of smokers in the home. Asthma prevalence was not associated with proximity of the home to a main road or with dietary fruit intake. The authors conclude that, of the potential risk factors considered in this study, preventing secondhand smoke exposure may be the most effective way of preventing asthma.

CRC 'Regional Combinations' project — effects of genetics and growth paths on beef production and meat quality: experimental design, methods and measurements

As a component of the second term of the Cooperative Research Centre (CRC) for Cattle and Beef Quality, a project to further test and validate the effects of varying nutritional growth paths pre-finishing and slaughter on cattle of varying genetic potential for meat yield and eating quality was designed and implemented. This project, ‘Regional Combinations’, was a multi-site experiment, using Bos taurus cattle generated at 4 locations across southern Australia. The design of imposing different growth paths between weaning and finishing on cattle with specific genetic potential is common across sites. Treatment and interaction effects on beef production and meat quality were examined within and across sites. This paper describes the experimental designs, generation of experimental cattle at the various sites and the measurements, collection and storage of the data for multi-site analyses.

Preliminary evidence from Queensland that rural clinical schools have a positive impact on rural intern choices

INTRODUCTION

The unequal and inequitable distribution of the medical workforce between rural and urban parts of Australia has been well documented. Commonwealth and state governments have introduced several significant initiatives in an attempt to address this imbalance, including recruitment of many overseas trained doctors. One longer-term initiative is the funding of university departments of rural health and rural clinical schools in medical schools.

OBJECTIVE

To determine the impact of the rural clinical division of the School of Medicine at the University of Queensland (UQ), Australia, on the intern workforce in central and southern Queensland, Australia.

METHODS

Time series analysis of first preferences for intern allocation among UQ graduates and source of interns (UQ, interstate and overseas) from 2001-2005, and comparison of trends between Rockhampton and Toowoomba (UQ student placements since 2003) with Mackay (no placements).

RESULTS

First preferences for Rockhampton increased from six in 2001 to 10 in 2005, and for Toowoomba from five in 2002 to 12 in 2005, while for Mackay preferences were stable at two. At Rockhampton while two interns came from overseas in 2001 and three were from interstate in 2002, UQ provided all interns in 2004 or 2005. UQ has provided 12/13 interns in 2004 and 13/14 in 2005 for Toowoomba. Mackay continues to source interns from interstate and overseas with UQ providing only 3/5 interns in 2004 and 2005. At Rockhampton, among non-bonded UQ graduates the number of interns choosing to work there increased from zero in 2001 to six in 2005. For Toowoomba, numbers were seven and 10 respectively, while for Mackay it was zero.

CONCLUSIONS

UQ's rural clinical division is having a positive impact on the intern workforce in the regional hospitals most closely allied with it.

The consent process in interventional radiology: the role of specialist nurses

AIMS

To evaluate the impact of patient education by specialist nurses on patients' understanding of interventional procedures, their anxiety levels and satisfaction with the given information.

MATERIALS AND METHODS

Sixty patients attending the radiology department for gastrointestinal interventional procedures were interviewed. Patients were assessed using a combination of categorical and visual analogue scales. Parameters were assessed on admission and after additional information had been given by specialist nurses. After the procedure patients were asked to rate the quality of information given and their overall satisfaction.

RESULTS

Four of the 60 patients were excluded due to a Mini Mental Test score of <7. Only 35 (62.5%) claimed to have been given information by the referring consultant. Fifty-three patients received additional information before formally giving consent, 50 (96.2%) from the specialist nurses. Patient anxiety before and after information did not significantly change (p=0.52) but there was significant improvement in levels of satisfaction (p=0.001) and perceived understanding (p<0.001). Patients rated overall quality of information at an average of 9.2/10 and overall satisfaction was high (median=9.1/10).

CONCLUSION

The use of specialist nurses to educate patients greatly increases patient understanding. The process of informed consent is improved and patient satisfaction is increased.