Feasibility and ethics of using data from the Scottish newborn blood spot archive for research

Background

Newborn heel prick blood spots are routinely used to screen for inborn errors of metabolism and life-limiting inherited disorders. The potential value of secondary data from newborn blood spot archives merits ethical consideration and assessment of feasibility for public benefit. Early life exposures and behaviours set health trajectories in childhood and later life. The newborn blood spot is potentially well placed to create an unbiased and cost-effective population-level retrospective birth cohort study. Scotland has retained newborn blood spots for all children born since 1965, around 3 million in total. However, a moratorium on research access is currently in place, pending public consultation.

Methods

We conducted a Citizens' Jury as a first step to explore whether research use of newborn blood spots was in the public interest. We also assessed the feasibility and value of extracting research data from dried blood spots for predictive medicine.

Results

Jurors delivered an agreed verdict that conditional research access to the newborn blood spots was in the public interest. The Chief Medical Officer for Scotland authorised restricted lifting of the current research moratorium to allow a feasibility study. Newborn blood spots from consented Generation Scotland volunteers were retrieved and their potential for both epidemiological and biological research demonstrated.

Conclusions

Through the Citizens' Jury, we have begun to identify under what conditions, if any, should researchers in Scotland be granted access to the archive. Through the feasibility study, we have demonstrated the potential value of research access for health data science and predictive medicine.

Research feasibility and ethics in Scottish new-born blood spot archive

ObjectivesThere were two objectives to this study: 1) to gauge public opinion on the use of Guthrie card-derived blood samples for epidemiological and biological research; and 2) to evaluate the feasibility of recovering meaningful molecular data from these samples. ApproachTo address the first objective, a 2-day Citizens’ Jury was conducted in partnership with Ipsos MORI, comprising a diverse adult sample in terms of age, sex, working status and social grade (n=20). Jurors were asked whether research access to Guthrie card blood tests would be in the public interest. To address the second objective, DNA methylation (DNAm) was profiled from samples from 58 Generation Scotland participants, whose Guthrie cards had been stored from birth for between 32 and 38 years. Analyses were performed on Guthrie DNAm samples to determine whether previously-reported associations with perinatal maternal smoking behaviours were detectable. ResultsThe Citizens’ Jury yielded an overall positive response towards data sharing for health research. Concerns were raised about data protection and security, control and oversight, and commercial use. The overall verdict was that access to Guthrie card data would be in the public interest, conditional on the purpose of the research, regulated access procedures, ethical oversight and provision of opportunities for participants to opt out. DNAm detection rates from Guthrie samples were lower than from samples stored in tubes. However, it was possible to confirm linkage to the correct individuals in Generation Scotland using DNAm-derived estimates of genotype and sex. A significant association was observed between a DNAm-based score for smoking and perinatal maternal smoking status derived from the baseline Generation Scotland questionnaire. ConclusionWe showed that: 1) public support exists for using Guthrie samples in research, conditional on certain safeguards; 2) DNAm can be profiled from cards stored for up to 38 years and can predict maternal smoking behaviour. Guthrie cards are a potentially valuable resource for epidemiological studies and predicting health outcomes.

Gender stereotypes in UK children and adolescents: Changing patterns of knowledge and endorsement

Across two studies, we investigated gender stereotype knowledge and endorsement in UK schoolchildren, and their impact on academic subject choice. In Study 1, children aged 9-11 (N = 68) and 13-15 (N = 61) completed a newly developed Gender Attribute scale assessing their knowledge and endorsement of gender stereotypes relating to academic subjects and occupations. Participants demonstrated gender stereotype knowledge and endorsement, although significantly higher knowledge than endorsement scores indicated a level of stereotype rejection. Stereotype knowledge was greater in the older age group, and older girls showed significantly higher levels of stereotype rejection than all other groups. In Study 2, children aged 13-15 (N = 165) completed the Gender Attribute scale and provided information on their school subject choices. Patterns of stereotype knowledge and endorsement followed those of Study 1. Subject choice information showed that boys selected significantly more masculine than feminine subjects, while girls chose a similar proportion of each. Further, boys' level of gender stereotype endorsement predicted their subject choices, while girls' did not. We suggest that in contemporary UK some progress is being made in relation to girls challenging stereotypes that work against them but that more work is needed to encourage boys into female-dominated disciplines.

Involving the Public in Data Linkage Research

Introduction“The Consensus Statement on Public Involvement and Engagement with Data-Intensive Health Research”, recent data breaches, and growing public awareness and controversy associated with secondary use of health data all highlight the need to understand what data sharing the public will support, under what circumstances, for what purposes and with whom. Objectives and ApproachThis symposium explores methods and findings from public engagement at all stages of data linkage research, beginning with short presentations (~6-8 minutes) on recent work: Mhairi Aitken: Consensus Statement - principles and an application using deliberative workshops to explore public expectations of public benefits from data-intensive health research Annette Braunack-Mayer/Felicity Flack: Surveys and citizens’ juries: Sharing government data with private industry Kim McGrail/Mike Burgess: Public deliberations on cross-sector data linkage, and combining public and private sources of data Alison Paprica: Plain language communication informed by Health Data Research Network Canada’s Public Advisory Council. Half the session will be spent interacting with the audience through live polling. The moderator will post a series of poll question such as “What is the most important thing for meaningful public engagement?” to prompt audience thinking on the topic. After the audience responses are revealed, panelists will share their own views about what they think is the best answer, and the main reason(s) behind their choice. The last 10-15 minutes of the session will be reserved for Q&A and dialogue with the audience. ResultsWe anticipate that this approach will surface emerging and tacit knowledge from presenters and the audience, and augment that through generative discussion. Conclusion / ImplicationsSession attendees will leave with a better understanding of the current state of knowledge and ways to talk about that understanding with other researchers, policy makers and the public.

Why the Public Need a Say in How Patient Data are Used for Covid-19 Responses

The global coronavirus pandemic has clearly demonstrated the great urgency to collect and use patient data effectively to understand, track and manage the spread of Covid-19. The value of patient data in this pandemic is undeniable, however considerations around how - and by whom - such data should be collected, accessed and used, and for what purposes, remain to be fully debated and resolved. Who decides, and how such decisions are made remain unclear. We argue that public engagement and deliberation are essential for good governance and are key to establish and maintain a legitimate social licence for data practices around Covid-19.

Public preferences regarding data linkage for research: a discrete choice experiment comparing Scotland and Sweden

BACKGROUND

There are increasing examples of linking data on healthcare resource use and patient outcomes from different sectors of health and social care systems. Linked data are generally anonymised, meaning in most jurisdictions there are no legal restrictions to their use in research conducted by public or private organisations. Secondary use of anonymised linked data is contentious in some jurisdictions but other jurisdictions are known for their use of linked data. The publics' perceptions of the acceptability of using linked data is likely to depend on a number of factors. This study aimed to quantify the preferences of the public to understand the factors that affected views about types of linked data and its use in two jurisdictions.

METHOD

An online discrete choice experiment (DCE) previously conducted in Scotland was adapted and replicated in Sweden. The DCE was designed, comprising five attributes, to elicit the preferences from a representative sample of the public in both jurisdictions. The five attributes (number of levels) were: type of researcher using linked data (four); type of data being linked (four); purpose of the research (three); use of profit from using linked data (four); who oversees the research (four). Each DCE contained 6 choice-sets asking respondents to select their preferred option from two scenarios or state neither were acceptable. Background questions included socio-demographics. DCE data were analysed using conditional and heteroskedastic conditional logit models to create forecasts of acceptability.

RESULTS

The study sample comprised members of the public living in Scotland (n = 1004) and Sweden (n = 974). All five attributes were important in driving respondents' choices. Swedish and Scottish preferences were mostly homogenous with the exception of 'who oversees the research using linked data', which had relatively less impact on the choices observed from Scotland. For a defined 'typical' linked data scenario, the probability (on average) of acceptance was 85.7% in Sweden and 82.4% in Scotland.

CONCLUSION

This study suggests that the public living in Scotland and Sweden are open to using anonymised linked data in certain scenarios for research purposes but some caution is advisable if the anonymised linked data joins health to non-health data.

Improving quality of life in vasculitis patients

Systemic vasculitis are a complex cluster of diseases with high associated morbidity. As disease-related mortality diminishes, the cumulative impact of poor health-related quality of life becomes more pertinent to patients than the initial pathological insult. In this article we explore health-related quality of life in ANCA-associated vasculitis, large-vessel vasculitis and therapeutic strategies that may enhance this critical outcome.

Multi-axis heterodyne interferometry at MHz frequencies: a short-arm measurement demonstration for LISA with off-the-shelf hardware

We report the design, construction, and operation of a multi-axis heterodyne interferometry (MAHI) system operating at MHz heterodyne frequencies, which provides a testbed for technologies to be used in the Laser Interferometer Space Antenna (LISA) space-based gravitational wave mission. The system was calibrated for measurement of the piston, pitch, and yaw of a three-axis piezo-actuated mirror, giving measured calibration values that closely match those predicted by a simulation based on Gaussian beam tracing. The piston sensitivity of the MAHI system in the LISA band was measured to be below 10  pm Hz^-1/2 for frequencies above 4 mHz and below 1  pm Hz^-1/2 for frequencies above 35 mHz. The sensitivity is limited above 2 Hz by the mechanical vibrations of the apparatus and below 1 mHz by dimensional changes caused by temperature fluctuations. Evidence points towards scattered light as the limiting noise source at intermediate frequencies. The angular sensitivity of the MAHI system was measured to be close to or below 10  nrad Hz^-1/2 for frequencies above 4 mHz and below 1  nrad Hz^-1/2 for frequencies above 100 mHz. Noise budgets for both length and angle were determined, indicating the areas in which improvements must be made in order to reach increased sensitivity. The current operating sensitivity already provides a useful testbed for LISA technologies and a potential blueprint for future ground segment equipment.

Consensus Statement on Public Involvement and Engagement with Data Intensive Health Research

This consensus statement reflects the deliberations of an international group of stakeholders with a range of expertise in public involvement and engagement (PI&E) relating to data-intensive health research. It sets out eight key principles to establish a secure role for PI&E in and with the research community internationally and ensure best practice in its execution. Our aim is to promote culture change and societal benefits through ensuring a socially responsible trajectory for innovations in this field. Our key premise is that the public should not be characterised as a problem to be overcome but a key part of the solution to establish socially beneficial data-intensive health research for all.

Whose Benefit is it Anyway? Public Expectations of Public Benefits from Health Informatics Research

IntroductionPublic benefits serve as a key justification for secondary uses of data in health research. Yet, while it is known that assurances of public benefits are vital for ongoing public support, there is a lack of clarity regarding what constitutes a public benefit. Objectives and ApproachOur research aimed to understand public expectations regarding “public benefits” from health informatics research. In May and June 2017 three full-day deliberative workshops were held with members of the public across Scotland (between 20 and 25 participants per workshop). Participants were selected through quota sampling to represent key demographic characteristics. Workshops were structured around brief introductory presentations, videos in which data scientists presented the ways in which their research was anticipated to lead to public benefits, small group discussions, plenary discussions and activities. ResultsWorkshop participants generally conceptualised “the public” as being “everyone” and had an inclusive view of this often taking an international or global perspective. This led to preferences for research to benefit the widest possible public, however participants also discussed the potential for benefits to be focussed at vulnerable or disadvantaged groups. There were wide-ranging views on what would constitute a “benefit” and participants generally acknowledged the value in keeping this loosely defined. A key theme to emerge was that, while some research might benefit particular individuals or groups more than others, the benefits should be societal benefits. In discussing the various data science projects presented, it was considered important that research had mechanisms in place in order to realise the benefits it was aiming for. Conclusion/ImplicationsPerceived public benefits are crucial for maintaining public support for health informatics research. Our workshops found that there is value in keeping "public benefits" as a broad, loosely defined term. Nevertheless, across each of the workshops the discussions suggested that research should benefit society as widely and fully as possible.

International Consensus Statement on Public Involvement and Engagement with Data-Intensive Health Research

IntroductionData-intensive health research is a fast moving field in which public involvement and engagement (PI\&E) is essential for developing socially acceptable and ethically robust processes and ensuring a social license for research practices. Nevertheless while some consensus is emerging around the importance of PI\&E, commitments and practices are varied. Objectives and ApproachOur objective was to identify a set of principles which would underpin international best practice in data-intensive health research. A one-day consensus workshop was held in Manchester, U.K. in April 2017 and attended by 31 international participants from six countries, with a range of expertise relating to PI&E with data-intensive health research. Participants took part in facilitated discussions to identify key principles and a consensus statement was written to reflect the discussions at the workshop, this developed through iterative drafts on which all workshop participants as well as the four Farr Institute public panels were consulted. ResultsThe consensus statement sets out key principles to establish a secure role for PI&E related to data-intensive health research internationally and to ensure best practice in its execution. While methods used may not vary greatly from PI&E with other types of research, or other policy areas, we have identified a number of particular features of data-intensive health research which make PI&E in this area worthy of special consideration. Often using data from multiple sources without explicit consent, PI&E in data-intensive health research is particularly important for raising awareness, for giving people a voice and for enabling people to participate in processes of research and governance. The consensus statement sets out the key principles to guide future best practice in PI&E with data-intensive health research. Conclusion/ImplicationsThe emergence of data intensive health research and the importance of the social contract upon which it relies, demands that we move beyond rhetorical commitments and engage anew with clearly stated principles to build PI\&E into data-intensive health research at all levels.

Public Preferences regarding Data Linkage for Health Research: A Discrete Choice Experiment

The potential for data collected in the public and private sector to be linked and used in research has led to increasing interest in public acceptability of data sharing and data linkage. The literature has identified a range of factors that are important for shaping public responses and in particular has noted that public support for research conducted through data linkage or data sharing is contingent on a number of conditions being met. In order to examine the relative importance of these conditions a Discrete Choice Experiment (DCE) was conducted via an online questionnaire among members of Ipsos MORI's online panel in Scotland. The survey was completed by 1,004 respondents. Overall the two most influential factors shaping respondents' preferences are: the type of data being linked; and, how profits are managed and shared. The type of data being linked is roughly twice as important as who the researchers are. There were slight differences across age groups and between genders and slight differences when comparing respondents with and without long term health conditions. The most notable differences between respondents were found when comparing respondents according to employment and working sector. This study provides much needed evidence regarding the relative importance of various conditions which may be essential for securing and sustaining public support for data-linkage in health research. This may be useful for indicating which factors to focus on in future public engagement and has important implications for the design and delivery of research and public engagement activities. The continuously evolving nature of the field means it will be necessary to revisit the key conditions for public support on an ongoing basis and to examine the contexts and circumstances in which these might change.

Public responses to the sharing and linkage of health data for research purposes: a systematic review and thematic synthesis of qualitative studies

Background

The past 10 years have witnessed a significant growth in sharing of health data for secondary uses. Alongside this there has been growing interest in the public acceptability of data sharing and data linkage practices. Public acceptance is recognised as crucial for ensuring the legitimacy of current practices and systems of governance. Given the growing international interest in this area this systematic review and thematic synthesis represents a timely review of current evidence. It highlights the key factors influencing public responses as well as important areas for further research.

Methods

This paper reports a systematic review and thematic synthesis of qualitative studies examining public attitudes towards the sharing or linkage of health data for research purposes. Twenty-five studies were included in the review. The included studies were conducted primarily in the UK and North America, with one study set in Japan, another in Sweden and one in multiple countries. The included studies were conducted between 1999 and 2013 (eight studies selected for inclusion did not report data collection dates). The qualitative methods represented in the studies included focus groups, interviews, deliberative events, dialogue workshops and asynchronous online interviews.

Results

Key themes identified across the corpus of studies related to the conditions necessary for public support/acceptability, areas of public concern and implications for future research. The results identify a growing body of evidence pointing towards widespread general—though conditional—support for data linkage and data sharing for research purposes. Whilst a variety of concerns were raised (e.g. relating to confidentiality, individuals’ control over their data, uses and abuses of data and potential harms arising) in cases where participants perceived there to be actual or potential public benefits from research and had trust in the individuals or organisations conducting and/or overseeing data linkage/sharing, they were generally supportive. The studies also find current low levels of awareness about existing practices and uses of data.

Conclusions

Whilst the results indicate widespread (conditional) public support for data sharing and linkage for research purposes, a range of concerns exist. In order to ensure public support for future research uses of data greater awareness raising combined with opportunities for public engagement and deliberation are needed. This will be essential for ensuring the legitimacy of future health informatics research and avoiding further public controversy.

Moving from trust to trustworthiness: Experiences of public engagement in the Scottish Health Informatics Programme

The Scottish Health Informatics Programme (SHIP) was a Scotland-wide research programme exploring ways of collecting, managing and analysing electronic patient records for health research. As part of the SHIP public engagement work stream, a series of eight focus groups and a stakeholder workshop were conducted to explore perceptions of the role, relevance and functions of trust (or trustworthiness) in relation to research practices. The findings demonstrate that the public's relationships of trust and/or mistrust in science and research are not straightforward. This paper aims to move beyond simple descriptions of whether publics trust researchers, or in whom members of the public place their trust, and to explore more fully the bases of public trust/mistrust in science, what trust implies and equally what it means for research/researchers to be trustworthy. This has important implications for public engagement in interdisciplinary projects.

A smartphone app to communicate child passenger safety: an application of theory to practice

Child passenger safety remains an important public health problem because motor vehicle crashes are the leading cause of death for children, and the majority of children ride improperly restrained. Using a mobile app to communicate with parents about injury prevention offers promise but little information is available on how to create such a tool. The purpose of this article is to illustrate a theory-based approach to developing a tailored, smartphone app for communicating child passenger safety information to parents. The theoretical basis for the tailoring is the elaboration likelihood model, and we utilized the precaution adoption process model (PAPM) to reflect the stage-based nature of behavior change. We created assessment items (written at ≤6th grade reading level) to determine the child's proper type of car seat, the parent's PAPM stage and beliefs on selected constructs designed to facilitate stage movement according to the theory. A message library and template were created to provide a uniform structure for the tailored feedback. We demonstrate how messages derived in this way can be delivered through new m-health technology and conclude with recommendations for the utility of the methods used here for other m-health, patient education interventions.

Reducing fluxes of faecal indicator compliance parameters to bathing waters from diffuse agricultural sources: the Brighouse Bay study, Scotland

The European Water Framework Directive requires the integrated management of point and diffuse pollution to achieve 'good' water quality in 'protected areas'. These include bathing waters, which are regulated using faecal indicator organisms as compliance parameters. Thus, for the first time, European regulators are faced with the control of faecal indicator fluxes from agricultural sources where these impact on bathing water compliance locations. Concurrently, reforms to the European Union (EU) Common Agricultural Policy offer scope for supporting on-farm measures producing environmental benefits through the new 'single farm payments' and the concept of 'cross-compliance'. This paper reports the first UK study involving remedial measures, principally stream bank fencing, designed to reduce faecal indicator fluxes at the catchment scale. Considerable reduction in faecal indicator flux was observed, but this was insufficient to ensure bathing water compliance with either Directive 76/160/EEC standards or new health-evidence-based criteria proposed by WHO and the European Commission.

Predicting the effect of livestock inputs of E. coli on microbiological compliance of bathing waters

Three alternative approaches to predicting delivery of faecal indicators from livestock sources to surface water in the catchment of the River Irvine, Ayrshire, Scotland, are described. These are a soil transport model which assumes all E. coli are transported through the soil, a regression model using observed E. coli concentrations in surface waters, and a distributed catchment model (PAMIMO). Each of these is linked to a simple group of equations describing inputs of E. coli from livestock to land, transport and inactivation in the river Irvine and mixing and inactivation in the sea. The models predict E. coli content of bathing water for Irvine beach. The regression model gives the best predictions of bathing water quality. The low values predicted by the soil transport model suggests that preventing surface runoff of faecal indicators from livestock would provide an adequate solution to the problem of bathing water contamination.

Low-risk persistent gestational trophoblastic disease treated with low-dose methotrexate: efficacy, acute and long-term effects

The aim of this study was to evaluate the efficacy and toxicity of low-dose methotrexate with folinic acid rescue in a large series of consecutively treated patients with low-risk persistent gestational trophoblastic disease. Between January 1987 and December 2000, 250 patients were treated with intramuscular methotrexate (50 mg on alternate days 1, 3, 5, 7) with folinic acid (7.5 mg orally on alternate days 2, 4, 6, 8) rescue. The overall complete response rate without recurrence was 72% for first-line treatment and 95% for those who required second-line chemotherapy. Eight women (3.2%) had recurrence following remission and two (0.8%) had new moles. Two women (0.8%) died of their disease giving an overall cure of 99%. Only 10 women (4%) experienced grade III/IV toxicity during the first course of treatment and 13 women (5.2%) subsequently. Toxicity included mucositis and stomatitis, pleuritic chest pain, thrombocytopenia, uterine bleeding, abdominal pain, liver function changes, rash and pericardial effusion. A total of 59 women (23.6%) required second-line chemotherapy; 48 women had methotrexate resistance, eight had methotrexate toxicity and an empirical decision to change therapy was made in three. In all, 11 women (4.4%) had a hysterectomy before, during or after treatment; 141 women (56.4%) became pregnant following treatment: in 128 (90.7%), the outcome was successful. Methotrexate with folinic acid rescue is an effective treatment for low-risk persistent trophoblastic disease. It has minimal severe toxicity, excellent cure rates and does not appear to affect fertility.

Continuous quality improvement: educating towards a culture of clinical governance

The National Health Service in England and Wales has recently adopted a policy aimed at embedding continuous quality improvement (CQI) at all levels and across all services. The key goal is to achieve changes in practice which improve patient outcomes. This paper describes the use of a training course for multiprofessional groups of participants tailored to offer them relevant knowledge, management and team working skills, and approaches to personal and career development. These were intended to assist them in changing their practice for the benefit of patients. The participants rated the course highly in fulfilling its objectives. One cohort followed up for 6 months named changes in practice which related specifically to learning from the course. This paper shows the important contribution of multiprofessional learning to CQI and presents a useful method of evaluating links between learning and performance.

Continuous quality improvement: educating towards a culture of clinical governance

The National Health Service in England and Wales has recently adopted a policy aimed at embedding continuous quality improvement (CQI) at all levels and across all services. The key goal is to achieve changes in practice which improve patient outcomes. This paper describes the use of a training course for multiprofessional groups of participants tailored to offer them relevant knowledge, management and team working skills, and approaches to personal and career development. These were intended to assist them in changing their practice for the benefit of patients. The participants rated the course highly in fulfilling its objectives. One cohort followed up for 6 months named changes in practice which related specifically to learning from the course. This paper shows the important contribution of multiprofessional learning to CQI and presents a useful method of evaluating links between learning and performance.

Informed consent and the preregistration house officer

A survey of preregistration house officers demonstrated that less than a third had never felt compelled to obtain consent from patients for procedures they themselves did not understand. This had occurred frequently for over a fifth of respondents. Learning how to obtain informed consent is an important part of the education and training of a doctor. The wrong lessons will be learned if they feel compelled to do this when ill-equipped with relevant information about risks and alternatives.

Pediatric injuries resulting from use of all-terrain vehicles

Annually, 20,000 children are injured while operating all-terrain vehicles (ATVs). The purpose of this paper was to review child-ATV injuries in Arkansas and identify any areas in need of further investigation. An analysis of emergency-medical-service transports was done for children 0-19 years who had ATV-related injuries in Arkansas from 1998 to 1999. Prehospital-reported child-ATV emergencies were identified, separated by county, and emergency encounter rates were calculated. Our results indicate that emergency medical services (EMS) transported 319 children in Arkansas from 1998 to 1999. ATV injury information is limited in Arkansas, but available data indicate high injury rates existed for many rural counties.

Trainee satisfaction before and after the Calman reforms of specialist training: questionnaire survey

OBJECTIVES

To evaluate the impact of the Calman reforms of higher specialist training on trainee satisfaction.

DESIGN

Questionnaire surveys using portable electronic survey units, two years apart.

SETTING

Postgraduate, teaching, district general, and community NHS trusts in North Thames. North Thames deanery includes London north of the Thames, Essex, and Hertfordshire.

PARTICIPANTS

Trainees in all grades and all specialties: 3078 took part in the first survey and 3517 in the second survey.

MAIN OUTCOME MEASURES

Trainees' satisfaction with training in their current post, including educational objectives, training agreements, induction, consultant feedback, hands on experience acquired, use of log books, consultant supervision, and overall satisfaction with the post.

RESULTS

In the second survey respondents were more likely to have discussed educational objectives with their consultant, used a log book, and had useful feedback from their consultant. They were more likely to give high ratings to induction, consultant supervision, and hands on experience acquired in the post. Each of these elements was associated with increased satisfaction with the post overall. Improvements were most noticeable at the level of specialist registrar, but changes in the same direction were also seen in more junior grades.

CONCLUSIONS

After the reforms of specialist training, trainees in all grades reported greater satisfaction with their current posts. The changes required extra training time and effort from consultants.

Ectopic bone formation via rhBMP-2 delivery from porous bioabsorbable polymer scaffolds

Drug delivery devices have received considerable interest in the field of tissue engineering due to the advent of proteins that can induce proliferation and differentiation of various cells to form specific tissues and organs, for example, bone morphogenetic protein (BMP-2) for osteogenesis. In this work the delivery of a clinically relevant bioactive factor, recombinant human rhBMP-2, was tested in vivo in a rat ectopic bone induction assay. Contact radiography and radiomorphometry showed significantly more radiopacity (1798+/-183 mm2 versus. 784+/-570 mm2 radiopaque area/g scaffold) in the BMP scaffolds than controls (p < 0.002). De novo woven bone and abundant osteoid formation were confirmed from histological sections while controls contained minimal amounts of tissue. Histomorphometry revealed significantly more bone (124+/-93 mm2 versus 7+/-12 mm2) and osteoid (72+/-43 mm2 versus 20+/-21 mm2) in the BMP implants (p < 0.001). These scaffolds demonstrated the ability to deliver viable rhBMP-2 and to induce bone formation in an ectopic site.

Prevalence of clinical sinusitis in young children followed up by primary care pediatricians

OBJECTIVE

To determine the proportion of young children seen in primary care pediatric practices who meet clinical criteria for the diagnosis of sinusitis, and variations in the management of these patients' conditions.

DESIGN

Observational cohort study.

SETTINGS

Pediatric practices in the Seattle, Wash, area participating in the Puget Sound Pediatric Research Network, a regional practice-based research organization.

PATIENTS

Children, 1 to 5 years old, presenting for any reason to participating practices.

METHODS

Parents of all 1307 eligible children completed a survey specifically detailing the presence of nasal congestion or discharge and daytime cough, the duration of these symptoms, and whether the symptoms were improving. For patients meeting clinical criteria for sinusitis (nasal congestion and daytime cough persisting for > 9 days without improvement), the pediatrician recorded the presence/severity of other signs and symptoms, and the treatment prescribed. Severity of symptoms was reassessed using telephone interviews with parents at 48 to 72 hours, and again at 10 to 14 days, after the office visit. Study data were collected during 1-week to 3-week blocks at each office site during the winter months.

RESULTS

Data were collected on 1307 children; 121 had persistent respiratory symptoms meeting criteria for a diagnosis of sinusitis (9.3%, 95% confidence interval, 7.7%-10.9%). Patients who presented with cold/cough symptoms were significantly more likely to meet criteria for sinusitis than those who came for any other reason (17.3% vs 4.2%, respectively, P < .001). A physician study form was completed on 87 children with persistent symptoms; antibiotics were prescribed for 68 (78%) of these patients. Antibiotic-treated patients were more likely to have symptoms lasting longer than 29 days (P = .004) and to have purulent nasal discharge (P = .03), and were judged to be sicker at enrollment (P = .001) than untreated children. A concurrent otitis media was diagnosed in 40 (46%) of 87 patients; if the proportion of children with otitis media is excluded, 5% of children 1 to 5 years old who are seen in primary care pediatrics might be expected to receive antibiotics exclusively for a diagnosis of sinusitis. At 24 to 48 hours and at 10 to 14 days after the clinic visit, a trend was noted toward more rapid improvement among those children who were treated with antibiotics.

CONCLUSION

When the criteria are strictly adhered to, only a small proportion of young children seen during the winter months in primary care pediatric practices will be diagnosed with sinusitis.

Cartilage protective agent (CPA) Ro 32-3555, a new matrix metalloproteinase inhibitor for the treatment of rheumatoid arthritis

CPA was well tolerated at all dose levels (10-150 mg) following single oral dose administration to healthy male volunteers. There was no relationship between the intensity, duration and number of adverse events reported and the dose of CPA. There was a dose-related increase in exposure as measured by AUC0-infinity and Cmax. Administration of 10 mg CPA following food resulted in a delayed tmax, and a significant decrease in Cmax but not AUC0-infinity.

Prevention of injuries to children and adolescents

Injury prevention is one of the most important preventive health challenges for pediatricians worldwide. A science of injury control has developed. Matching a child's skill and development age is needed for anticipatory guidance. Poor children living in rural areas are at greatest risk and require continuous reinforcement. Family function relates closely to injuries and recovery from injury. Prevention involves education, legislation, environmental modification, and engineering techniques.