Intensive pasture management alters the composition and structure of plant-pollinator interactions in Sibiu, Romania

Background

Land management change towards intensive grazing has been shown to alter plant and pollinator communities and the structure of plant-pollinator interactions in different ways across the world. Land-use intensification in Eastern Europe is shifting highly diverse, traditionally managed hay meadows towards intensive pastures, but few studies have examined how this influences plant-pollinator networks. We hypothesized that the effects of intensive grazing on networks will depend on how plant communities and their floral traits change.

Methods

We investigated plant and pollinator diversity and composition and the structure of plant-pollinator interactions near Sibiu, Romania at sites that were traditionally managed as hay meadows or intensive pastures. We quantified the identity and abundance of flowering plants, and used transect walks to observe pollinator genera interacting with flowering plant species. We evaluated the effects of management on diversity, composition and several indices of network structure.

Results

Pollinator but not plant diversity declined in pastures and both plant and pollinator taxonomic composition shifted. Functional diversity and composition remained unchanged, with rather specialized flowers having been found to dominate in both hay meadows and pastures. Apis mellifera was found to be the most abundant pollinator. Its foraging preferences played a crucial role in shaping plant-pollinator network structure. Apis mellifera thus preferred the highly abundant Dorycnium herbaceum in hay meadows, leading to hay meadows networks with lower Shannon diversity and interaction evenness. In pastures, however, it preferred less abundant and more generalized flower resources. With pollinators being overall less abundant and more generalized in pastures, we found that niche overlap between plants was higher.

Discussion

With both hay meadows and pastures being dominated by plant species with similar floral traits, shifts in pollinator preferences seem to have driven the observed changes in plant-pollinator interaction networks. We thus conclude that the effects of grazing on pollinators and their interactions are likely to depend on the traits of plant species present in different management types as well as on the effects of grazing on plant community composition. We thereby highlight the need for better understanding how floral abundance shapes pollinator visitation rates and how floral traits may influence this relationship.

Community Health Navigators for Cancer Screening Among Deaf, Deafblind, and Hard of Hearing Adults Who Use American Sign Language

Deaf, deafblind, and hard of hearing (DDBHH) individuals experience barriers to accessing cancer screening, including ineffective patient-physician communication when discussing screening recommendations. For other underserved communities, culturally and linguistically aligned community health navigators (CHNs) have been shown to improve cancer screening and care. A needs assessment study was conducted to identify barriers and gather recommendations for CHN training resources. A community-based participatory needs assessment was conducted from May 2022 to June 2022 using three focus groups. Eight were cancer survivors, six advocates/navigators, and three clinicians. All questions were semi-structured and covered screening barriers, observations or personal experiences, perceived usefulness of having a CHN to promote cancer screening adherence, and training resources that may be useful to American Sign Language (ASL)-proficient CHNs, who are also culturally and linguistically aligned. Out of 20 focus group participants, seven self-identified as persons of color. Data highlighted systemic, attitudinal, communication, and personal-level barriers as recurrent themes. The most frequently cited barrier was access to training that supports the role and competencies of CHNs, followed by cultural considerations, access to cancer guidelines in ASL, dialect diversity in sign language, and the health system itself. Unaddressed barriers can contribute to health disparities, such as lower preventive cancer screening rates amongst DDBHH individuals. The next step is to translate recommendations into actionable tasks for DDBHH CHN training programs. As a result, CHNs will be well-equipped to help DDBHH individuals navigate and overcome their unique barriers to cancer screening and healthcare access.

Guest Editorial - Pulmonary Embolism: the risk of what we don't yet know!

Pulmonary embolism (PE) is a common and potentially life-threatening condition encountered routinely in acute care. The diagnosis and management of PE has been the topic of National Institute of Health Care Excellence and European Cardiology Society guidelines. The recommendations within these guidelines have allowed standardisation of care and have facilitated the delivery of protocolised care pathways. Whilst some elements of care are determined by consensus view, there have been large randomised controlled trials and well-designed observational studies which have helped us understand the role of risk factors for PE, short term risk-stratification after initial diagnosis and treatment options in hospital as well as in the months after discharge from Acute Medicine. Few other conditions in acute care are informed by the same levels of evidence, yet there are many unresolved questions.

Society for Acute Medicine Benchmarking Audit 2021 (SAMBA21): assessing national performance of acute medicine services

INTRODUCTION

The Society for Acute Medicine Benchmarking Audit 2021 (SAMBA21) took place on 17th June 2021, providing the first assessment of performance against the Society for Acute Medicine's Clinical Quality Indicators (CQIs) within acute medical units since the start of the COVID-19 pandemic.

METHODS

All acute hospitals in the UK were invited to participate. Data were collected on unit structure, and for patients admitted to acute medicine services over a 24-hour period, with follow-up at 7 days.

RESULTS

158 units participated in SAMBA21, from 156 hospitals. 8973 patients were included. The number of admissions per unit had increased compared to SAMBA19 (Sign test p<0.005). An early warning score was recorded within 30 minutes of hospital arrival in 77.4% of patients. 87.4% of unplanned admissions were seen by a tier 1 clinician within 4 hours of arrival. Overall, the medical team performed the initial clinician assessment for 36.4% of unplanned medical admissions. More than a third of medical admissions had their initial assessment in Same Day Emergency Care (SDEC) in 25.4% of hospitals. 62.1% of unplanned admissions were seen by two other clinical decision makers prior to consultant review. Of those unplanned admissions requiring consultant review, 67.8% were seen within the target time. More than a third of unplanned admissions were discharged the same day in 41.8% of units.

CONCLUSION

Performance against the CQIs for acute medicine was maintained in comparison to previous rounds of SAMBA, despite increased admissions. There remains considerable variation in unit structure and performance within acute medical services.

Length of stay in Acute Medical Admissions: Analysis from the Society for Acute Medicine Benchmarking Audit

INTRODUCTION

Medical admissions to hospital represent a diverse range of patients, from those managed on ambulatory pathways through Same Day Emergency Care (SDEC) services, to those requiring prolonged inpatient admission. An understanding of current patterns of admission through acute medicine services and patient factors associated with longer hospital admission is needed to guide service planning and improvement.

METHODS

Data from the Society for Acute Medicine Benchmarking Audit (SAMBA) 2021 were analysed. Patients admitted to acute medicine services during a 24-hour period on 17th June 2021 were included, with data recording patient demographics, frailty score, acuity and follow-up of outcomes after seven days.

RESULTS

8101 unplanned medical admissions were included, from 156 hospitals. 31.6% were discharged without overnight admission; the median hospital performance was 30.1% (IQR 19.3-39.3%). 22.1% of patients remained in hospital for more than 7 days. Those remaining in hospital for more than 48 hours and for more than seven days were more likely to be aged over 70, to be frail, or to have a NEWS2 of 3 or more on arrival to hospital.

CONCLUSION

The proportion of acute medical attendances receiving overnight admission varies between hospitals. Length of stay is impacted by patient factors and illness acuity. Strategies to reduce inpatient service pressures must ensure effective care for older patients and those with frailty.

Point-of-care lung ultrasound in the assessment of COVID-19: results of a UK multicentre service evaluation

BACKGROUND

Coronavirus disease 2019 has had a dramatic impact on the delivery of acute care globally. Accurate risk stratification is fundamental to the efficient organisation of care. Point-of-care lung ultrasound offers practical advantages over conventional imaging with potential to improve the operational performance of acute care pathways during periods of high demand. The Society for Acute Medicine and the Intensive Care Society undertook a collaborative evaluation of point-of-care imaging in the UK to describe the scope of current practice and explore performance during real-world application.

METHODS

A retrospective service evaluation was undertaken of the use of point-of-care lung ultrasound during the initial wave of coronavirus infection in the UK. We report an evaluation of all imaging studies performed outside the intensive care unit. An ordinal scale was used to measure the severity of loss of lung aeration. The relationship between lung ultrasound, polymerase chain reaction for SARS-CoV-2 and 30-day outcomes were described using logistic regression models.

RESULTS

Data were collected from 7 hospitals between February and September 2020. In total, 297 ultrasound examinations from 295 patients were recorded. Nasopharyngeal swab samples were positive in 145 patients (49.2% 95%CI 43.5-54.8). A multivariate model combining three ultrasound variables showed reasonable discrimination in relation to the polymerase chain reaction reference (AUC 0.77 95%CI 0.71-0.82). The composite outcome of death or intensive care admission at 30 days occurred in 83 (28.1%, 95%CI 23.3-33.5). Lung ultrasound was able to discriminate the composite outcome with a reasonable level of accuracy (AUC 0.76 95%CI 0.69-0.83) in univariate analysis. The relationship remained statistically significant in a multivariate model controlled for age, sex and the time interval from admission to scan Conclusion: Point-of-care lung ultrasound is able to discriminate patients at increased risk of deterioration allowing more informed clinical decision making.

The coronavirus pandemic: Accessible technology for education, employment, and livelihoods

During the 2020 coronavirus pandemic, the use of technology to continue societal functions, maintain daily living, and gather information became near ubiquitous overnight. In the United States, universities moved to remote online education, non-essential personnel were asked to work from home, many businesses were forced to rapidly embrace online purchasing and even entertainers held concerts on social media platforms. Professional medical personnel, as well as state and local officials, held daily press briefings about the virus on television, radio, and social media. Disaster research has shown that often disasters exacerbate preexisting inequalities during all-hazards and therefore there are several populations likely to be more at risk, such as people with disabilities, and older adults. While complications from the coronavirus were more severe for older adults and those with preexisting health conditions, the preparedness and response efforts to contain the virus lessened the resiliency of other populations during the US outbreaks, potentially hampering their ability to recover at the same rate. For example, several press conferences from officials failed to include or display ASL interpreters. This would put some Americans at a disadvantage since they may have been unable to receive all of the pertinent information on how to keep safe. Furthermore, with nearly 22% of households without broadband internet access (per Pew Research Center), several individuals will not be able to take advantage of the rapid remote learning and work-from-home recommendations. Even when individuals have access to the Internet, older adults have been found to be less knowledgeable about privacy and security tools than younger adults.

Data Descriptor: Pacific Introduced Flora (PaciFLora)

Background

The Pacific Region has the highest density of naturalised plant species worldwide, which makes it an important area for research on the ecology, evolution and biogeography of biological invasions. While different data sources on naturalised plant species exist for the Pacific, there is no taxonomically and spatially harmonised database available for different subsets of species and islands. A comprehensive, accessible database containing the distribution of naturalised vascular plant species in the Pacific will enable new basic and applied research for researchers and will be an important information source for practitioners working in the Region.

New information

Here, we present PacIFlora, an updated and taxonomically standardised list of naturalised species, their unified nativeness, cultivation and invasive status and their distribution across the Pacific Ocean, including harmonised location denoination. This list is based on the two largest databases on naturalised plants for the Region, specifically the Pacific Island Ecosystems at Risk (PIER) and the Global Naturalised Alien Flora (GloNAF) databases. We provide an outlook for how this database can contribute to numerous research questions and conservation efforts.

EPICENTRE - Delivery of high quality acute medical care without transfer to hospital

The NHS Five Year Forward View focuses on expansion and development of community services and out-of-hospital care. Hospital at Home is a concept that provides acute active treatment that would traditionally be provided in an inpatient setting, involving nursing staff and therapists. As well as being financially favourable, it is important to acknowledge that often, for a multitude of reasons, people prefer to remain at home rather than be admitted to hospital for treatment. The COVID-19 pandemic has further reiterated that patients are at risk of nosocomial infection. More importantly Hospital at Home care has consistently been associated with greater satisfaction compared to acute hospital care for both patients and their family members.

Acute care service performance during winter: report from the winter SAMBA 2020 national audit of acute care

The Winter Society for Acute Medicine Benchmarking Audit (SAMBA) provides the first comparison of performance within acute medicine against clinical quality indicators during winter, a time of increased pressure and demand on acute services. 105 hospitals participated in Winter SAMBA, collecting data over 24-hours on 30th January 2020. 5626 patients were included. Participating units saw a median of 48 patients (range 13-131). Comparison between Winter SAMBA and SAMBA19 found less patients had an early warning score within 30 minutes during winter (74.3% vs 78.9%) and less were seen by a clinical decision maker within four hours (84.9% vs 87.9%). Unplanned admissions represented a higher proportion of workload (92.5% vs 90.1%). Patients were more likely to have a NEWS2 score of 3 or higher (30.1% vs 25.7%). Performance is poorer in winter, and patients are more unwell, needing prompt treatment. Services should ensure high quality care can be maintained through times of increased pressure, including winter.

Gaps in point of care ultrasound provision and the cost of ultrasound equipment provision: results of a nationwide audit of acute medical units

INTRODUCTION

Advances in ultrasound technology have allowed an investigation previously restricted to the radiology department to be used more liberally in clinical decision making. Point-of-Care-Ultrasound (PoCUS) has superior diagnostic performance to traditional clinical examination across a range of pathologies in the hands of a suitably experienced practitioner. The utilisation of PoCUS has the potential to greatly influence the delivery of acute care, but little is known about the current level of resource provision within the acute medical setting.

METHODS

To establish the availability of ultrasound equipment and appropriately trained clinicians within Acute Medical Units (AMUs) in the United Kingdom (UK) we asked specific questions with an annual day of care survey, undertaken by the Society for Acute Medicine. We compared data across two years to assess interval changes.

RESULTS

58.1% (75/129) of AMUs had access to dedicated ultrasound equipment in SAMBA'19. This represents a small increase from SAMBA'18. Ultrasound expertise is concentrated across a small number of AMUs. Growth in the number of ultrasound trained clinicians is greatest units with established expertise.

CONCLUSION

The equipment to provide PoCUS is not present on all AMUs and appropriately trained clinicians are not distributed evenly across units. This is likely to affect individual AMUs ability to deliver bedside ultrasound to appropriate patients who may benefit. Bridging the gap to ensure all AMUs have the option to use PoCUS will require planning and investment.

Society for Acute Medicine Benchmarking Audit 2019 (SAMBA19): Trends in Acute Medical Care

INTRODUCTION

The eighth Society for Acute Medicine Benchmarking Audit (SAMBA19) took place on Thursday 27th June 2019. SAMBA gives a broad picture of acute medical care in the UK and allows individual units to compare their performance against their peers.

METHOD

All UK hospitals were invited to participate. Unit and patient level were collected. Data were analysed against published Clinical Quality indicators (CQI) and standards. This was the biggest SAMBA to date, with data from 7170 patients across 142 units in 140 hospitals.

RESULTS

84.5% of patients had an Early Warning Score measured within 30 minutes of arrival in hospital (SAMBA18 84.1%), 90.4% of patients were seen by a competent clinical decision maker within four hours of arrival in hospital (SAMBA18 91.4 %) and 68.6% of patients were seen by a consultant within the timeframe standard (SAMBA18 62.7%). Ambulatory Emergency Care is provided in 99.3% of hospitals. 61.8% of patients are initially seen in the Emergency Department (ED). Since SAMBA18 death rates and planned discharge rates, while the use of NEWS2 increased from 2.5% to 59.2% of hospitals.

CONCLUSION

SAMBA19 highlighted the evolving complexity of acute medical pathways for patients. The challenge now is to increase sample frequency, assess the impact of SAMBA open a broader debate to define optimal CQIs.

Point-of-care lung ultrasound in the assessment of suspected COVID-19: a retrospective service evaluation with a severity score

INTRODUCTION

Point-of-care lung ultrasound (POCUS) has been advocated as a tool to assess the severity of COVID19 and thereby aid risk stratification.

METHODS

We conducted a retrospective service evaluation between the 3rd March and the 5th May 2020 to describe and characterise the use of POCUS within an acute care pathway designed specifically for the assessment of suspected or confirmed COVID-19. A novel POCUS severity scale was formulated by assessing pleural and interstitial abnormalities within six anatomical zones (three for each lung). An aggregated score was calculated for each patient and evaluated as a marker of disease severity using standard metrics of discriminatory performance.

RESULTS

POCUS was performed in the assessment of 100 patients presenting with suspected COVID-19. POCUS was consistent with COVID-19 infection in 92% (n = 92) of the patients assessed. Severity, as assessed by POCUS, showed good discriminatory performance to predict all-cause inpatient mortality, death or critical care admission, and escalated oxygen requirements (AUC .80, .80, 82). The risk of all-cause mortality in patients with scores in lowest quartile was 2.5% (95%CI 0.12- 12.95) compared with 42.9% (95CI 15.8 - 75.0%) in the highest quartile. POCUS assessed severity correlated with length of stay and duration of supplemental oxygen therapy.

CONCLUSION

A simple aggregated score formed by the summating the degree of pleural and interstitial change within six anatomical lung zones showed good discriminatory performance in predicting a range of adverse outcomes in patients with suspected COVID-19.

The impact of restricting the use of e-cigarettes in public places: a systematic review

Background

We explored whether restrictions on using e-cigarettes in public places deter smokers from switching to e-cigarettes for harm reduction purposes. Secondary objectives looked at the ability to use e-cigarettes in public places as a reason for use and attitudes towards this among smokers.

Methods

Systematic review of the scientific and grey literature.

Results

No studies were found for the primary question. Twelve studies estimated the proportion of smokers citing the ability to use e-cigarettes in public places as a reason for use; estimates varied considerably but were typically higher for smokers than never smokers and lower for former than current smokers. Fourteen studies reported attitudes towards restrictions in public places. Smokers were significantly more likely to support the use of e-cigarettes in public places than never smokers and former smokers significantly less likely to support their use than current smokers.

Conclusions

There is a gap in the evidence base on whether restrictions on e-cigarettes in public places would deter smokers from switching for harm reduction purposes. The role that restrictions in public places play in smoker's choosing to vape, and the level of support for their use in public, is likely to vary between populations and by smoking status.

Clinical measures of balance in people with type two diabetes: A systematic literature review

Approximately 422 million people have diabetes mellitus worldwide, with the majority diagnosed with type 2 diabetes mellitus (T2DM). The complications of diabetes mellitus include diabetic peripheral neuropathy (DPN) and retinopathy, both of which can lead to balance impairments. Balance assessment is therefore an integral component of the clinical assessment of a person with T2DM. Although there are a variety of balance measures available, it is uncertain which measures are the most appropriate for this population. Therefore, the aim of this study was to conduct a systematic review on clinical balance measures used with people with T2DM and DPN. Databases searched included: CINAHL plus, MEDLINE, SPORTDiscus, Dentistry and Oral Sciences source, and SCOPUS. Key terms, inclusion and exclusion criteria were used to identify appropriate studies. Identified studies were critiqued using the Downs and Black appraisal tool. Eight studies were included, these studies incorporated a total of ten different clinical balance measures. The balance measures identified included the Dynamic Balance Test, balance walk, tandem and unipedal stance, Functional Reach Test, Clinical Test of Sensory Interaction and Balance, Berg Balance Scale, Tinetti Performance-Oriented Mobility Assessment, Activity-Specific Balance Confidence Scale, Timed Up and Go test, and the Dynamic Gait Index. Numerous clinical balance measures were used for people with T2DM. However, the identified balance measures did not assess all of the systems of balance, and most had not been validated in a T2DM population. Therefore, future research is needed to identify the validity of a balance measure that assesses these systems in people with T2DM.

Development of a conceptual model of cancer caregiver health literacy

Caregivers play a vital role in caring for people diagnosed with cancer. However, little is understood about caregivers' capacity to find, understand, appraise and use information to improve health outcomes. The study aimed to develop a conceptual model that describes the elements of cancer caregiver health literacy. Six concept mapping workshops were conducted with 13 caregivers, 13 people with cancer and 11 healthcare providers/policymakers. An iterative, mixed methods approach was used to analyse and synthesise workshop data and to generate the conceptual model. Six major themes and 17 subthemes were identified from 279 statements generated by participants during concept mapping workshops. Major themes included: access to information, understanding of information, relationship with healthcare providers, relationship with the care recipient, managing challenges of caregiving and support systems. The study extends conceptualisations of health literacy by identifying factors specific to caregiving within the cancer context. The findings demonstrate that caregiver health literacy is multidimensional, includes a broad range of individual and interpersonal elements, and is influenced by broader healthcare system and community factors. These results provide guidance for the development of: caregiver health literacy measurement tools; strategies for improving health service delivery, and; interventions to improve caregiver health literacy.

Correlations between physical and chemical defences in plants: tradeoffs, syndromes, or just many different ways to skin a herbivorous cat?

Most plant species have a range of traits that deter herbivores. However, understanding of how different defences are related to one another is surprisingly weak. Many authors argue that defence traits trade off against one another, while others argue that they form coordinated defence syndromes. We collected a dataset of unprecedented taxonomic and geographic scope (261 species spanning 80 families, from 75 sites across the globe) to investigate relationships among four chemical and six physical defences. Five of the 45 pairwise correlations between defence traits were significant and three of these were tradeoffs. The relationship between species' overall chemical and physical defence levels was marginally nonsignificant (P = 0.08), and remained nonsignificant after accounting for phylogeny, growth form and abundance. Neither categorical principal component analysis (PCA) nor hierarchical cluster analysis supported the idea that species displayed defence syndromes. Our results do not support arguments for tradeoffs or for coordinated defence syndromes. Rather, plants display a range of combinations of defence traits. We suggest this lack of consistent defence syndromes may be adaptive, resulting from selective pressure to deploy a different combination of defences to coexisting species.

Contrasting Beliefs About Screening for Mental Disorders Among Uk Military Personnel Returning from Deployment to Afghanistan

Objective

The objective of the study was to elicit beliefs and experiences of the value of a screening programme for mental illness among UK military personnel.

Method

Three months after returning from Afghanistan 21 army personnel participated in a qualitative study about mental health screening. One-to-one interviews were conducted and recorded. Data-driven thematic analysis was used. Researchers identified master themes represented by extracts of text from the 21 complete transcripts.

Results

Participants made positive remarks on the advantages of screening. Noted barriers to seeking help included: unwillingness to receive advice, a wish to deal with any problems themselves and a belief that military personnel should be strong enough to cope with any difficulties. Participants believed that overcoming barriers to participating in screening and seeking help would be best achieved by making screening compulsory.

Conclusions

Although respondents were positive about a screening programme for mental illness, the barriers to seeking help for mental illness appear deep rooted and reinforced by the value ascribed to hardiness.

Putting plant resistance traits on the map: a test of the idea that plants are better defended at lower latitudes

• It has long been believed that plant species from the tropics have higher levels of traits associated with resistance to herbivores than do species from higher latitudes. A meta-analysis recently showed that the published literature does not support this theory. However, the idea has never been tested using data gathered with consistent methods from a wide range of latitudes. • We quantified the relationship between latitude and a broad range of chemical and physical traits across 301 species from 75 sites world-wide. • Six putative resistance traits, including tannins, the concentration of lipids (an indicator of oils, waxes and resins), and leaf toughness were greater in high-latitude species. Six traits, including cyanide production and the presence of spines, were unrelated to latitude. Only ash content (an indicator of inorganic substances such as calcium oxalates and phytoliths) and the properties of species with delayed greening were higher in the tropics. • Our results do not support the hypothesis that tropical plants have higher levels of resistance traits than do plants from higher latitudes. If anything, plants have higher resistance toward the poles. The greater resistance traits of high-latitude species might be explained by the greater cost of losing a given amount of leaf tissue in low-productivity environments.

Resistance patterns of multidrug-resistant tuberculosis in Western Province, Papua New Guinea

Few data are available on tuberculosis (TB) drug resistance patterns in Papua New Guinea (PNG) due to the lack of facilities for mycobacterial culture. Many patients from the Western Province seek care in Queensland health clinics in the Torres Strait. Since 2000, we have treated 161 TB cases from PNG, of whom 40 proved to have multidrug-resistant TB (MDR-TB; two human immunodeficiency virus positive). Drug susceptibility testing (DST) shows high levels of resistance to other drugs in the MDR-TB cases (streptomycin 93%, ethionamide 87%, ethambutol 18%, pyrazinamide 10%). No extensively drug-resistant TB (XDR-TB) has been identified. MDR-TB seems to be highly prevalent in the Western Province of PNG, and unless treatment is guided by DST, the risk of XDR-TB emerging is high.

Long-term follow-up of coeliac disease--what do coeliac patients want?

BACKGROUND

Coeliac disease affects up to 1% of the population and the British Society of Gastroenterology recommends long-term follow-up of these patients, although the absolute risk of complications is small.

AIM

To determine what proportion of patients with coeliac disease remain under specialist follow-up and to examine patients' perspectives on the long-term management of coeliac disease.

METHODS

A questionnaire was sent to 183 patients who had a duodenal biopsy between July 1994 and July 2004 which was consistent with coeliac disease.

RESULTS

A total of 126 (69%) patients returned their questionnaire. Patients had on average been diagnosed with coeliac disease 5.4 years earlier. Eighty-eight percentage were trying to follow a strict gluten-free diet. Sixty-two percentage of patients were under regular follow-up although this varied between hospital clinic (doctor/dietitian, 92%) and General Practitioner (8%). Most patients found at least one aspect of the hospital out-patient clinic very useful. The preferred method of coeliac disease follow-up was to see a dietitian with a doctor being available (P < 0.05 vs. all other options).

CONCLUSIONS

Respondents to this study showed great variation in follow-up of their coeliac disease -38% were under no active follow-up. Patients would prefer to see a dietitian for long-term follow-up.

Sphygmomanometers in use in general practice: an overlooked aspect of quality in patient care

OBJECTIVES

To assess the condition, accuracy and safety of mercury and anaeroid sphygmomanometers in use in general practice and to pilot a scheme for sphygmomanometer maintenance within the district.

DESIGN

Instruments were checked on site according to set protocols which related to established guidelines and standards and data were entered into a specially designed database. Mercury sphygmomanometers were removed to the laboratory for servicing. Practices received written feedback on the condition of each instrument checked, repairs undertaken and advice, where necessary, for further work required. Participant views on the scheme were sought.

MATERIALS AND METHODS

A total of 472 instruments (75.4% mercury) located in 86 general practices (87.8% of practices participated) in a health district in the West Midlands. Instruments were checked against 28 (mercury) and 25 (anaeroid) quality standards and (for mercury instruments) against British Hypertension Society guidelines.

RESULTS

69.1% of mercury and 95.7% of anaeroid instruments checked, had no service records. Of the remainder, only 29 mercury (8.1%) and one anaeroid (0.9%) had a record of a check or service within the previous 12 months. None of the instruments met all of the relevant quality standards and 14 (3.9%) mercury and seven (6.1%) anaeroid instruments met less than half. A large proportion of mercury sphygmomanometers tested had defects likely to affect recommended measurement technique. Only two-thirds were accurate at all pressure levels tested. Only 38.8% of anaeroid instruments were accurate at all test pressure levels.

CONCLUSIONS

The level of defects noted could have an impact on diagnosis and monitoring of hypertension.

Patient education and emergency room visits

Patients visit emergency rooms for urgent and non-urgent care. Because emergency room visits are more costly than visits to primary care clinics and are less likely to involve preventive care, third party payers and institutions have always tried to shift patients away from the emergency room and towards primary care clinics where appropriate. Hypothesizes that an intervention based in an adult primary care clinic might enable this, especially if it involved patients who used both the clinic and the emergency room. Surveys patients to determine why they used the emergency room and to identify barriers to using the primary care clinic instead. Based on the survey results, an intervention was developed to facilitate use of the primary care clinic. Discusses the methodology used in the survey and analyses results. Concludes that it is difficult to change patient behaviour to fit the demands of the health care system. Possibly, it would be better to change the system to fit the behaviour patterns of the patients.

Observed changes in the lipid profile and calculated coronary risk in patients given dietary advice in primary care

BACKGROUND

Dietary advice is usually the first-line treatment for increased blood cholesterol in primary care with a reduction in levels as the expected response. In practice, the diet adopted by the patient may lead to changes in blood lipids characterised by a greater decrease in high-density lipoprotein (HDL) than total cholesterol. The ratio of total cholesterol to HDL cholesterol is an important factor in calculated coronary risk using the Framingham model, from which most risk tables currently in use have been derived. This suggests that either coronary risk may increase after dietary advice or that risk should always be assessed on measurements made before any intervention has taken place.

AIM

To report observed changes in blood lipids and calculated coronary risk following dietary advice in primary care.

METHOD

Subjects with at least one coronary risk factor and baseline cholesterol above 5.2 mmol/l from an inner-city general practice had cardiovascular risk factors, including fasting lipids, recorded before receiving dietary advice. At follow-up several months later, risk factor measurements were repeated. Ten-year coronary risk was calculated using the Framingham model. Lipid levels and coronary risk at baseline and follow-up were compared.

RESULTS

There was a significant decrease in both total cholesterol and HDL cholesterol in both sexes. However, in 56% of subjects, HDL decreased by a greater proportion than the total cholesterol. These subjects showed a highly significant increase in the total cholesterol/HDL cholesterol ratio (median = 0.8 [semi-interquartile range = 1.5], P < 0.001, which was correlated with a change in triglycerides (rs = 0.309, P < 0.001). In those who had an increase in the total cholesterol/HDL cholesterol ratio, calculated coronary risk increased from 5.45% (13.2) at baseline to 7.25% (15.5) (P < 0.001). In all subjects, the change in calculated coronary risk associated with dietary advice ranged from -15% to 15%.

CONCLUSIONS

Low fat dietary advice in this primary care setting was frequently associated with undesirable changes in the lipid profile. The majority of subjects showed an increase in the total cholesterol/HDL cholesterol ratio, owing primarily to a decrease in HDL. Consequently, calculated coronary risk increased in over one-half of the subjects. Owing to our incomplete understanding of HDL metabolism, it is unclear whether the fall in HDL is actually detrimental; however, it seems prudent to give dietary advice to patients to avoid excess simple carbohydrate as a fat substitute. This helps avoid a rise in triglycerides, which appears to be associated with an increase in the ratio. These results confirm that coronary risk should always be calculated using measurements made before intervention.

Rethinking public health: new training for new times

The new public health agenda will require major changes in the way health authorities, local authorities, Trusts and Primary Care Groups organise and manage their activities. The requirement is for inter-agency co-ordination and inter-professional and inter-sectoral working to a shared agenda, yet the human and resources development planning to achieve these goals has not been done. This paper summarises the key training issues and argues for a collaborative, decentralised and quality assured approach to multidisciplinary public health management education and training. Only with such a joined up human resources plan can Our Healthier Nation succeed where The Health of the Nation signally failed.

Tuberculosis in Far North Queensland, Australia

SETTING

Regional thoracic clinic in tropical Australia.

OBJECTIVE

To document recent experience with tuberculosis in Far North Queensland, Australia, with particular reference to tuberculosis in indigenous people.

METHODS

Retrospective survey of all cases of tuberculosis in Far North Queensland between January 1993 and December 1997.

RESULTS

There were 87 cases of tuberculosis; 54 were pulmonary, of which 67% were sputum smear-positive. Crude annual incidence of tuberculosis in indigenous people was 35.9/100,000 population compared to 2.32/ 100,000 in non indigenous people. There were 15 deaths, seven of which were felt to be avoidable. Nine of 11 relapses of previously treated disease occurred in Aboriginals. There were six cases of initial drug resistance, of which four were imported from overseas. Contact tracing identified four active cases of tuberculosis and 102 recently infected contacts. Preventive treatment in infected contacts was completed in only 41%, largely because of poor compliance related to alcohol consumption.

CONCLUSION

Tuberculosis remains common in Far North Queensland, with excess cases observed mainly in the indigenous population. Aboriginals are at high risk of both death from and relapse of tuberculosis. Tuberculosis control in indigenous people scattered over such a vast area remains challenging, and the results at present are sub-optimal.

Treatment of malnutrition with 1.1% amino acid peritoneal dialysis solution: results of a multicenter outpatient study

A peritoneal dialysis (PD) solution containing 1.1% amino acids as the osmotic agent was evaluated in a 3-month randomized, prospective, open-label study in malnourished PD patients. Patients in the treatment group (DAA) received one or two exchanges daily with the amino acid solution, depending on tolerance, in place of glucose solutions. Controls (DD) received their usual therapy with glucose dialysate. Fifty-four DAA and 51 DD patients completed the study. In DAA, but not in DD patients, there was a significant increase at month 3 in serum insulin-like growth factor-1 (IGF-1) levels and significant decreases in serum potassium (all 3 months) and inorganic phosphorus levels (months 1 and 3), indicating a general anabolic response. Prealbumin and transferrin levels were significantly increased in DAA but not in DD patients at month 1, but the groups did not differ at months 2 and 3. In patients with baseline albumin levels less than 3.5 g/dL (bromcresol green [BCG] method), DAA patients showed increases in albumin, transferrin (months 1 and 2), and prealbumin levels (all 3 months) relative to baseline values, whereas these serum protein levels were unchanged in DD patients, although the changes from baseline did not differ between groups. In this subgroup, midarm muscle circumference (MAMC) did not change in DD or DAA patients. In patients with baseline albumin levels of 3.5 g/dL or greater, DD patients had decreases in albumin and total protein levels at all 3 months and in prealbumin levels at months 1 and 2, relative to baseline. In DAA patients, there were fewer changes in serum proteins. MAMC increased significantly from baseline in DAA but not in DD patients, although changes from baseline did not differ between DAA and DD groups. DAA patients showed no changes in peritoneal membrane transport characteristics. The results indicate that treatment with one or two exchanges daily of this amino acid-based PD solution is safe and provides nutritional benefit for malnourished PD patients.

Enteral glutamine supplementation for very low birth weight infants decreases morbidity

Glutamine, described as a "conditionally essential" amino acid for critically ill patients, has not been routinely added to parenteral amino acid formulations for critically ill neonates and is provided in only small quantities by the enteral route when enteral intake is low. We conducted a blinded, randomized study of enteral glutamine supplementation in 68 very low birth weight neonates randomly assigned to receive glutamine-supplemented premature formula versus premature formula alone between days 3 and 30 of life. Primary end points consisted of hospital-acquired sepsis, tolerance to subsequent enteral feedings (days with no oral intake), and duration of hospital stay. Hospital acquired sepsis was 30% (control group) and 11% (glutamine group). Logistic regression with birth weight as a covariate showed that: (1) feeding group was significant (p = 0.048) in determining the probability of developing proven sepsis over the course of hospitalization and (2) the estimated odds of developing sepsis were 3.8 times higher for infants in the control group than for those treated with glutamine. Glutamine-supplemented infants had better tolerance to enteral feedings as measured by percent of days on which feedings needed to be withheld (mean percentage of 8.8 vs 23.8, p = 0.007). Analysis of T cells demonstrated a blunting of the rise in HLA-DR+ and CD16 subsets in glutamine-supplemented infants. There were no differences in growth; in serum ammonia, urea, liver transaminase, or prealbumin concentrations; or in mean hospital stay. This study provides evidence for decreased morbidity in very-low-birth-weight neonates who receive enteral glutamine supplementation.

Morphometric evaluation of lower cervical pedicle and its projection

STUDY DESIGN

This study evaluated the lower cervical pedicle from C3 to C6 to provide information for accurate transpedicular screw fixation in this region.

OBJECTIVES

To measure the dimensions of the lower cervical pedicle and to determine the correct location of the pedicle axis on the posterior aspect of the lateral mass.

SUMMARY OF BACKGROUND DATA

Several anatomic studies and clinical applications of transpedicular screw fixation in the cervical spine have been documented, but little quantitative data concerning the lower cervical pedicle and its projection are available.

METHODS

Forty dry cervical specimens from C3 to C6 (160 cervical vertebrae) were used for this study. Anatomic evaluation included pedicle height, width, effective length, and anguli. The distances from the projection point of the pedicle axis to reference lines related to the lateral edge of the lateral mass (vertical) and the inferior edge of the superior facet (horizontal) also were measured. The means, ranges, and standard deviations were calculated for all of the specimens and separately for male and female spines.

RESULTS

Statistically significant differences in dimensions of males and females were found in one linear and one angular measurement, which included the pedicle height of C6 and the pedicle sagittal angle of C4. The greatest variation for males and females was found in the pedicle sagittal angle, with a range of 4.3-9.8 degrees. The distances from the projection point to the horizontal line did not show any real pattern of change from C3 to C6, whereas the distances from the projection point to the vertical line consistently increased from cephalad to caudad.

CONCLUSIONS

Taking into consideration some variations between individuals, this information, combined with evaluation of results of preoperative axial computed tomography and conventional radiography, may enhance the safety of transpedicular screw fixation in the lower cervical spine.

Is Helicobacter pylori transmitted from cats to humans?

BACKGROUND

Subsequent to the isolation of Helicobacter pylori from domestic cats, it has been suggested that the organism might be transmitted from cats to humans. This hypothesis has already gained considerable media attention.

MATERIALS AND METHODS

In a previous study of risk factors for H. pylori infection, 447 factory workers from Stoke on Trent in the UK had provided blood samples for H. pylori serological workup. They had also completed a detailed questionnaire concerning their living conditions, including the possession of any household pets, in childhood. Logistic regression was used to assess the association between cat ownership in childhood and H. pylori seropositivity.

RESULTS

After adjustment for potential confounders, it was found that subjects who had owned a pet as a child were slightly more likely to be H. pylori seropositive than subjects who had not. There was, however, no difference between subjects who had owned a cat and those with other pets.

CONCLUSIONS

These data do not support the hypothesis that H. pylori infection might be transmitted from cats to humans.

Helicobacter pylori transmission: evidence from a comparison with hepatitis A virus

OBJECTIVE

To assess the possibility that faecal-oral contact might play a role in the transmission of Helicobacter pylori.

DESIGN

A cross-sectional comparison of the patterns of hepatitis A and H. pylori seropositivity.

METHODS

At interview, blood samples and questionnaire data were collected from a group of 467 male volunteers, aged 18-65, from Stoke-on-Trent, UK. Serum samples from each subject were then analysed for anti-H. pylori and anti-hepatitis A antibodies.

RESULTS

Overall, 100 of 175 H. pylori seropositive subjects (57.1%) and 113 of 292 H. pylori seronegative subjects (38.7%) were hepatitis A seropositive (chi 2 = 15.0, P < 0.001). This difference was not statistically significant after adjustment for age group and father's occupation, as a surrogate for socioeconomic status in childhood (P = 0.15). The seroprevalence of hepatitis A increased with age at a rate of 2.3% per year, compared to only 1.0% per year for H. pylori (P = 0.015).

CONCLUSION

These data suggest that the case for faecal-oral transmission of H. pylori, in a manner similar to the spread of hepatitis A, is not proven and that other modes of transmission, for instance through oral-oral contact, should also be considered.

Helicobacter pylori gastritis and serum pepsinogen levels in a healthy population: development of a biomarker strategy for gastric atrophy in high risk groups

This study aimed to estimate the prevalence and type of chronic gastritis in an asymptomatic working population and to determine whether a combination of serum pepsinogen levels and Helicobacter pylori serology could be used to identify a subgroup with atrophic gastritis at elevated risk of gastric carcinoma. A 10% subsample of 544 male volunteer factory workers aged 18-63 years and participating in a larger study underwent endoscopy and biopsy. Of these men, 29 were seropositive for Helicobacter pylori; all but three (89.7%) had chronic gastritis. Serum pepsinogen A levels increased with progression from a corpus predominant pattern of gastritis through pangastritis to an antral predominant pattern. Nine subjects had corpus atrophy, which was in most cases accompanied by fasting hypochlorhydria and hypergastrinaemia. A combination of pepsinogen A below 80 ng ml-1 and Helicobaceter pylori seropositivity detected corpus atrophy with sensitivity 88.9% and specificity 92.3%. A second screening stage, using a pepsinogen A/C ratio of below 2.5 as a cut-off, resulted in a reduction in numbers requiring further investigation but with some loss of sensitivity (77.8%). Application of this two-stage screening programme to the original sample of 544 workers would have resulted in 11 (2.2%) men being selected for follow-up, excluding 25 (5.1%) false negatives. Our results suggest that a combination of serum pepsinogen levels and Helicobacter pylori serology could be useful as a biomarker strategy for detection of individuals at increased risk of gastric carcinoma and for non-invasive investigation of the natural history of Helicobacter pylori gastritis.

Variability in serum pepsinogen levels in an asymptomatic population

OBJECTIVE

To investigate the variability in serum pepsinogen levels in an asymptomatic population.

DESIGN

Cross-sectional survey of 420 men aged 18-63 years, without symptoms or a history of gastric disease, recruited from four factories in Stoke-on-Trent.

METHODS

During an interview, data on history of gastric health, 'lifestyle' and occupation were collected, blood samples were taken for measurement of serum pepsinogen and anti-Helicobacter pylori antibody levels and height and weight were measured.

RESULTS

Extreme (low/high) levels of pepsinogens A and C, indicative of chronic gastritis, were found in 24 (5.7%) and 61 (14.5%) of the participants, respectively. Low A-C ratios, indicative of moderate or severe gastric atrophy, were found in 13 (3.1%) participants. Of the variables examined, Helicobacter pylori serology had the strongest influence on serum pepsinogen levels. Serum pepsinogen A and C levels were significantly higher in the 33.6% of participants who were seropositive. The effect was more marked for pepsinogen C; thus, A-C ratios were lower in seropositive individuals. In seronegative participants, both pepsinogen A and pepsinogen C levels increased with increasing age; pepsinogen A levels increased with increasing height and were higher in smokers, but decreased with increasing weight. The effect of smoking on pepsinogen A levels was also detectable in seropositive individuals, but was considerably less marked. Among seronegative participants, those employed on the 'shop-floor' in manual jobs had higher serum pepsinogen C levels and lower A-C ratios than office-based workers.

CONCLUSION

H. pylori serology was a major source of variation in serum pepsinogen levels, but causes of gastritis other than H. pylori were indicated. Independent of these effects, serum pepsinogen levels may also vary with age, height and weight. Screening of serum pepsinogen levels in the general population may identify 5-15% who require further investigation. Other 'filters' may be required in conjunction with serum pepsinogen levels to identify those needing investigation for significant gastric pathology.

Relation between infection with Helicobacter pylori and living conditions in childhood: evidence for person to person transmission in early life

OBJECTIVES

To relate the prevalence of infection with Helicobacter pylori in adults to their living conditions in childhood to identify risk factors for infection.

DESIGN

Prevalence study of IgG antibodies to H pylori (> 10 micrograms IgG/ml, determined by enzyme linked immunosorbent assay (ELISA)) and reported living conditions and other socioeconomic factors in childhood.

SETTING

Three factories in Stoke on Trent.

SUBJECTS

471 male volunteers aged 18 to 65 years.

MAIN OUTCOME MEASURES

Seroprevalence and variables in childhood.

RESULTS

Seroprevalence of H pylori increased with age (22/74 (29.7%) at < 30 years v 29/46 (63%) at 55-65 years; P < 0.001 for trend) and was related to manual occupation (14/65 (21.5%) for non-manual v 162/406 (39.9%) for manual; P = 0.003). After data were adjusted for age and occupation subjects from large families, whose childhood homes were crowded or who regularly shared a bed in childhood, were significantly more likely to be seropositive (adjusted odds ratio (95% confidence interval) 2.15 (1.41 to 3.30) for crowding and 2.13 (1.38 to 3.30) for sharing a bed), but there was no relation with possession of a bathroom, inside toilet, refrigerator, or household pets in childhood.

CONCLUSIONS

Close person to person contact in childhood is an important determinant of seroprevalence of H pylori in adulthood, suggesting that the infection is transmitted directly from one person to another and may be commonly acquired in early life.

Ethnic differences in risk markers for heart disease in Bradford and implications for preventive strategies

OBJECTIVES

To assess and compare the prevalence of established risk markers for ischaemic heart disease in a sample of Asian and non-Asian men and to relate these observations to preventive strategies.

SETTING

Two factories in the textile industry in Bradford, West Yorkshire, UK. Subjects--288 male manual workers aged 20 to 65 years.

DESIGN

Cross sectional study within one occupational/social class stratum.

MEASUREMENTS AND MAIN RESULTS

Age, body mass index, plasma lipids, fibrinogen and serum insulin values, blood pressure, smoking habits, alcohol consumption, and exercise routines were recorded. Plasma total cholesterol concentrations were significantly lower in Asian than non-Asian men (5.3 mmol/l v 5.8 mmol/l respectively, p < 0.0001), as were low density lipoprotein cholesterol concentrations (3.4 mmol/l v 3.7 mmol/l, p = 0.0150), and high density lipoprotein (HDL) cholesterol (1.1 mmol/l v 1.3 mmol/l, p < 0.0001). Hypercholesterolaemia (concentration > 6.5mM) was present in nearly one quarter of non-Asians but less than one eighth of Asian men. Triglyceride values were not significantly higher in Asians. Smoking rates were high in non-Asians (43.8%) and only slightly lower in Asians (39.1%). Asian smokers smoked fewer cigarettes per day on average (9.3 v 16.1, p = 0.0001). Almost a quarter of non-Asian men (23.1%) and 26.6% of Asian men had raised blood pressure. Systolic pressures were higher in non-Asian men (138.3 mmHg v 133.0 mmHg, p = 0.0070), but diastolic pressures showed no ethnic differences. Diabetes was more prevalent in Asian men (10.9% v 4.4% p < 0.05), who also showed higher serum insulin concentrations after glucose loading (22.3 mU/l v 10.2 mU/l, p < 0.0001). Plasma fibrinogen values were higher in non-Asian men (2.9 g/l v 2.6 g/l, p < 0.0001) and these were associated with smoking. Nearly all non-Asians (92.5%) consumed alcohol at some time whereas 62.5% of Asians habitually abstained from alcohol consumption. Among the drinkers, non-Asian men consumed on average, 23.9 units per week and Asian men 18.4 units per week (p = 0.083). The mean body mass index for Asian men was 24.5 kg/m2 which was not significantly different to the mean in non-Asian men (25.2 kg/m2). The frequency of exercise in leisure time was low in both groups with 44.4% of non-Asian and 21.1% of Asian men taking moderate exercise weekly, and even fewer, regular strenuous exercise (16.3% and 8.6% respectively).

CONCLUSIONS

The plasma cholesterol and fibrinogen concentrations, prevalence of hypertension, smoking habits, alcohol intakes, and infrequency of exercise in leisure time in these non-Asian men in Bradford were consistent with an increased risk of heart disease. The pattern of risk markers was clearly different in Asian men. Only their lower HDL cholesterol concentrations, marginally higher triglyceride values, higher prevalence of diabetes, and very low frequency of exercise in leisure time would be consistent with a higher risk of heart disease compared with non-Asians. The implications of these observations for heart disease preventive strategies are discussed.

Periodic posture stimulation of the baroreceptors and the local vasomotor reflexes

In a supine subject, lowering of the foot from heart level to 50 cm below is known to stimulate the local reflex response and the baroreceptor outflow. We lowered and raised the leg of a supine subject periodically, with the leg stationary between movements (square wave). The Traube-Hering-Mayer wave (THM congruent to 0.1 Hz) was captured by or locked on to the leg movement over a certain frequency range, this is usually called the entrainment range. Square wave periodic leg movement in this manner on 10 male subjects, mean age 22 years, demonstrated that the THM frequency can be entrained. The lower limit of the entrainment bandwidth is 0.0841 (SD 0.0030) Hz and the upper limit is 0.1176 (SD 0.0013) Hz. Further examination showed that this phenomenon is independent of the breathing input. Comparison with the Traube-Hering-Mayer entrainment techniques of breathing and periodic neck suction using the Eckberg collar which stimulates the baroreceptors showed similar results. This work supports the hypothesis that the local reflex response and the baroreceptor outflow entrain the THM frequency.