Intended and unintended consequences of the implementation of minimum unit pricing of alcohol in Scotland: a natural experiment

Background

Scotland was the first country to implement minimum unit pricing for alcohol nationally. Minimum unit pricing aims to reduce alcohol-related harms and to narrow health inequalities. Minimum unit pricing sets a minimum retail price based on alcohol content, targeting products preferentially consumed by high-risk drinkers. This study comprised three components.

Objectives

This study comprised three components assessing alcohol consumption and alcohol-related attendances in emergency departments, investigating potential unintended effects of minimum unit pricing on alcohol source and drug use, and exploring changes in public attitudes, experiences and norms towards minimum unit pricing and alcohol use.

Design

We conducted a natural experiment study using repeated cross-sectional surveys comparing Scotland (intervention) and North England (control) areas. This involved comparing changes in Scotland following the introduction of minimum unit pricing with changes seen in the north of England over the same period. Difference-in-difference analyses compared intervention and control areas. Focus groups with young people and heavy drinkers, and interviews with professional stakeholders before and after minimum unit pricing implementation in Scotland allowed exploration of attitudes, experiences and behaviours, stakeholder perceptions and potential mechanisms of effect.

Setting

Four emergency departments in Scotland and North England (component 1), six sexual health clinics in Scotland and North England (component 2), and focus groups and interviews in Scotland (component 3).

Participants

Research nurses interviewed 23,455 adults in emergency departments, and 15,218 participants self-completed questionnaires in sexual health clinics. We interviewed 30 stakeholders and 105 individuals participated in focus groups.

Intervention

Minimum unit pricing sets a minimum retail price based on alcohol content, targeting products preferentially consumed by high-risk drinkers.

Results

The odds ratio for an alcohol-related emergency department attendance following minimum unit pricing was 1.14 (95% confidence interval 0.90 to 1.44; p = 0.272). In absolute terms, we estimated that minimum unit pricing was associated with 258 more alcohol-related emergency department visits (95% confidence interval –191 to 707) across Scotland than would have been the case had minimum unit pricing not been implemented. The odds ratio for illicit drug consumption following minimum unit pricing was 1.04 (95% confidence interval 0.88 to 1.24; p = 0.612). Concerns about harms, including crime and the use of other sources of alcohol, were generally not realised. Stakeholders and the public generally did not perceive price increases or changed consumption. A lack of understanding of the policy may have caused concerns about harms to dependent drinkers among participants from more deprived areas.

Limitations

The short interval between policy announcement and implementation left limited time for pre-intervention data collection.

Conclusions

Within the emergency departments, there was no evidence of a beneficial impact of minimum unit pricing. Implementation appeared to have been successful and there was no evidence of substitution from alcohol consumption to other drugs. Drinkers and stakeholders largely reported not noticing any change in price or consumption. The lack of effect observed in these settings in the short term, and the problem-free implementation, suggests that the price per unit set (£0.50) was acceptable, but may be too low. Our evaluation, which itself contains multiple components, is part of a wider programme co-ordinated by Public Health Scotland and the results should be understood in this wider context.

Future work

Repeated evaluation of similar policies in different contexts with varying prices would enable a fuller picture of the relationship between price and impacts.

Trial registration

Current Controlled Trials ISRCTN16039407.

Funding

This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 9, No. 11. See the NIHR Journals Library website for further project information.

Detection of the United States Neisseria meningitidis urethritis clade in the United Kingdom, August and December 2019 - emergence of multiple antibiotic resistance calls for vigilance

Since 2015 in the United States (US), the US Neisseria meningitidis urethritis clade (US_NmUC) has caused a large multistate outbreak of urethritis among heterosexual males. Its ‘parent’ strain caused numerous outbreaks of invasive meningococcal disease among men who have sex with men in Europe and North America. We highlight the arrival and dissemination of US_NmUC in the United Kingdom and the emergence of multiple antibiotic resistance. Surveillance systems should be developed that include anogenital meningococci.

Estimated glomerular filtration rate slopes on tenofovir alafenamide

OBJECTIVES

The aim of the study was to analyse and compare estimated glomerular filtration rate (eGFR) slopes during exposure to tenofovir disoproxil fumarate (TDF) and tenofovir alafenamide (TAF) in individuals who initiated TAF, regardless of prior regimen, before October 2016.

METHODS

An observational cohort study was conducted at 11 clinics in the UK and Ireland. Mixed effects models with random intercept and time terms fitted were used to generate and compare eGFR slopes while participants were exposed to TDF and TAF, with adjustment for age, eGFR at TDF/TAF initiation, gender, ethnicity, and time-updated CD4 cell count and HIV RNA measurements.

RESULTS

Data were available for 357 subjects (median age 50 years; 80% male; 82% white/other ethnicity; 51% men who have sex with men; median nadir CD4 count 216 cells/µL). The median duration of exposure to TAF was 2.0 (interquartile range 1.6, 2.3) years. At TAF initiation, the median CD4 count was 557 cells/µL, the median eGFR was 80 mL/min/1.73 m², and 86% had suppressed HIV infection. The mean adjusted eGFR slope during TDF and TAF exposure was -2.08 [95% confidence interval (CI) -2.24, -1.92] and 1.18 (95% CI 0.20, 1.52) mL/min/1.73 m²/year, respectively (P < 0.001). Individuals who experienced rapid eGFR decline (> 3 or 5 mL/min/1.73 m²/year) while receiving TDF experienced significant eGFR recovery while on TAF (P < 0.001).

CONCLUSIONS

Significant improvement in eGFR slope was observed in patients who switched from TDF- to TAF-containing antiretroviral regimens. These data provide further support for the renal safety of TAF, and for switching those who experience progressive worsening of renal function from TDF to TAF.

Test of cure study: a feasibility study to estimate the time to test of cure (TOC) for Neisseria gonorrhoeae and Chlamydia trachomatis infections

OBJECTIVES

Test of cure (TOC) for Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT) infection is an important tool in the public health management of STIs. However, there are limited data about the optimal time to perform TOC using nucleic acid amplification tests (NAATs) for NG and CT infections. A study was performed to assess the feasibility of a larger study to determine the optimal time to TOC using NAATS.

METHODS

The Sexually Transmitted Bacteria Reference Unit at Public Health England undertook testing of gonococcal and chlamydial nucleic acids within neat urine stored in different conditions over 25 days to provide evidence of the stability of the nucleic acid prior to recruitment. Individuals diagnosed with uncomplicated NG or CT infection were recruited from three sexual health clinics. Individuals were asked to return nine self-taken samples from the site of infection over a course of 35 days. Survival analyses of time to first negative NAAT result for NG and CT infection and univariate regression analysis of factors that affect time to clearance were undertaken.

RESULTS

At room temperature, chlamydial DNA in urine is stable for up to 3 weeks and gonococcal DNA for up to 11 days. We analysed data for 147 infections (81 NG and 66 CT). The median time to clearance of infection was 4 days (IQR 2-10 days) for NG infection and 10 days (IQR 7-14 days) for CT infection. Vaginal CT infections took longer to clear (p=0.031). NG infection in men who have sex with men took longer to clear (p=0.052).

CONCLUSION

Chlamydial and gonococcal nucleic acids are stable in urine before addition of preservatives, longer than recommended by the manufacturer. The TOC results suggest that it may be possible to undertake TOC for NG and CT infections earlier than current guidelines suggest and that anatomical site of infection may affect time to clearance of infection.

Pattern of failure in anaplastic glioma patients with an IDH1/2 mutation

PURPOSE

The current study aimed to assess patterns of failure (PoF) in anaplastic glioma (AG) patients managed with intensity-modulated radiation therapy (IMRT) and their relationship to molecular subtype.

METHODS

The outcomes of AG patients managed between 2008 and 2014 and entered into a prospective database were assessed, including PoF. AG was initially defined using the WHO 2007 classification, but for analysis, patients were subsequently recategorised based on WHO 2016 as anaplastic oligodendroglioma (AOD), astrocytoma isocitrate dehydrogenase (IDH) mutant (AAmut) or astrocytoma IDH wildtype (AAwt). Management involved IMRT and temozolomide (TMZ), including from 2011 patients with an IDH mutation (IDHmut) planned with 18F-fluoroethyltyrosine (FET) and 18F-fluorodeoxyglucose (FDG) positron-emission tomography (PET). PoF was local, marginal or distant in relation to the IMRT volume. Relapse-free survival (RFS) was calculated from the start of IMRT.

RESULTS

A total of 156 patients were assessed, with median follow-up of 5.1 years. Of these patients, 75% were IDHmut, 44% were managed at first or later relapse and 73% received TMZ. Relapse occurred in 68 patients, with 6‑year RFS of 75.0, 48.8 and 2.5% for AOD, AAmut and AAwt, respectively (p < 0.001). There was a component of local relapse in 63%, of marginal relapse in 19% and of distant relapse in 37% of relapses. Isolated local, marginal and distant relapse was evident in 51, 9 and 22%, respectively. A distant relapse pattern was more frequent in IDHmut compared to IDHwt patients (26% vs. 45%, p = 0.005), especially within the first 2 years post-IMRT. In multivariate analysis, distant relapse remained associated with AAmut (p < 0.002) and delayed IMRT until the second relapse (p < 0.001).

CONCLUSION

Although patients with IDH-mutated AG have improved outcomes, there was a higher proportion of distant relapses occurring during the 2 years after IMRT.

Sexual behaviours and sexually transmitted infection outcomes in a cohort of HIV-negative men who have sex with men attending sexual health clinics in England

Men who have sex with men (MSM) attending sexual health (SH) clinics are at high risk for HIV acquisition and are disproportionately affected by sexually transmitted infections (STIs). We collected standardised behavioural data from MSM attending clinics to characterise sexual behaviours and identify predictors for HIV and STIs. In 2012–2013, HIV-negative MSM attending five SH clinics in England reported sexual behaviours in the previous three months via a self-administered questionnaire. Behaviours were linked to the individual’s clinical records using national surveillance. The prevalence and incidence of bacterial STIs (gonorrhoea, Chlamydia, lymphogranuloma venereum and syphilis) and incidence of HIV were calculated. Adjusted odds ratios and hazard ratios with 95% confidence interval (CI) were reported for significant predictors. Of 1278 HIV-negative MSM, 54% were of white ethnicity and UK-born and 43% were 25–34 years old. Almost all men reported at least one partner in the last three months. Half reported condomless anal sex and 36% condomless receptive anal intercourse (CRAI). Incidence of bacterial STIs was 46/100 (95%CI 39–54) person years (py) and of HIV was 3.1/100 (95%CI 1.7–5.6) py. A STI at baseline and CRAI with increasing numbers of partners were associated with both incident infections. In this cohort of MSM high-risk behaviours and STIs were prevalent. Engagement in CRAI increased the likelihood of subsequent infection, while men diagnosed with a bacterial STI were at increased risk of a future STI. Clinical and behavioural risk assessments to determine an individual’s risk of infection could allow a more nuanced prevention approach that has greater success in reducing transmission.

Acceptability of an open-label wait-listed trial design: Experiences from the PROUD PrEP study

BACKGROUND

PROUD participants were randomly assigned to receive pre-exposure prophylaxis (PrEP) immediately or after a deferred period of one-year. We report on the acceptability of this open-label wait-listed trial design.

METHODS

Participants completed an acceptability questionnaire, which included categorical study acceptability data and free-text data on most and least liked aspects of the study. We also conducted in-depth interviews (IDI) with a purposely selected sub-sample of participants.

RESULTS

Acceptability questionnaires were completed by 76% (415/544) of participants. After controlling for age, immediate-group participants were almost twice as likely as deferred-group participants to complete the questionnaire (AOR:1.86;95%CI:1.24,2.81). In quantitative data, the majority of participants in both groups found the wait-listed design acceptable when measured by satisfaction of joining the study, intention to remain in the study, and interest in joining a subsequent study. However, three-quarters thought that the chance of being in the deferred-group might put other volunteers off joining the study. In free-text responses, data collection tools were the most frequently reported least liked aspect of the study. A fifth of deferred participants reported 'being deferred' as the thing they least liked about the study. However, more deferred participants disliked the data collection tools than the fact that they had to wait a year to access PrEP. Participants in the IDIs had a good understanding of the rationale for the open-label wait-listed study design. Most accepted the design but acknowledged they were, or would have been, disappointed to be randomised to the deferred group. Five of the 25 participants interviewed reported some objection to the wait-listed design.

CONCLUSION

The quantitative and qualitative findings suggest that in an environment where PrEP was not available, the rationale for the wait-listed trial design was well understood and generally acceptable to most participants in this study.

Efficacy and safety of emtricitabine/tenofovir alafenamide (FTC/TAF) vs. emtricitabine/tenofovir disoproxil fumarate (FTC/TDF) as a backbone for treatment of HIV-1 infection in virologically suppressed adults: subgroup analysis by third agent of a randomized, double-blind, active-controlled phase 3 trial<sup/>

BACKGROUND

FTC/TAF was shown to be noninferior to FTC/TDF with advantages in markers of renal and bone safety.

OBJECTIVE

To evaluate the efficacy and safety of switching to FTC/TAF from FTC/TDF by third agent (boosted protease inhibitor [PI] vs. unboosted third agent).

METHODS

We conducted a 48-week subgroup analysis based on third agent from a randomized, double blind study in virologically suppressed adults on a FTC/TDF-containing regimen who switched to FTC/TAF vs. continued FTC/TDF while remaining on the same third agent.

RESULTS

We randomized (1:1) 663 participants to either switch to FTC/TAF (N = 333) or continue FTC/TDF (N = 330), each with baseline third agent stratifying by class of third agent in the prior treatment regimen (boosted PI 46%, unboosted third agent 54%). At week 48, significant differences in renal biomarkers and bone mineral density were observed favoring FTC/TAF over FTC/TDF (p < 0.05 for all), with similar improvements in the FTC/TAF arm in those who received boosted PI vs. unboosted third agents. At week 48, virologic success rates were similar between treatment groups for those who received a boosted PI (FTC/TAF 92%, FTC/TDF 93%) and for those who received an unboosted third agent (97% vs. 93%).

CONCLUSIONS

In virologically suppressed patients switching to FTC/TAF from FTC/TDF, high rates of virologic suppression were maintained, while renal and bone safety parameters improved, regardless of whether participants were receiving a boosted PI or an unboosted third agent. FTC/TAF offers safety advantages over FTC/TDF and can be an important option as an NRTI backbone given with a variety of third agents.

An analysis of baseline data from the PROUD study: an open-label randomised trial of pre-exposure prophylaxis

Background

Pre-exposure prophylaxis (PrEP) has proven biological efficacy to reduce the sexual acquisition of the human immunodeficiency virus (HIV). The PROUD study found that PrEP conferred higher protection than in placebo-controlled trials, reducing HIV incidence by 86 % in a population with seven-fold higher HIV incidence than expected. We present the baseline characteristics of the PROUD study population and place the findings in the context of national sexual health clinic data.

Methods

The PROUD study was designed to explore the real-world effectiveness of PrEP (tenofovir-emtricitabine) by randomising HIV-negative gay and other men who have sex with men (GMSM) to receive open-label PrEP immediately or after a deferral period of 12 months. At enrolment, participants self-completed two baseline questionnaires collecting information on demographics, sexual behaviour and lifestyle in the last 30 and 90 days. These data were compared to data from HIV-negative GMSM attending sexual health clinics in 2013, collated by Public Health England using the genitourinary medicine clinic activity database (GUMCAD).

Results

The median age of participants was 35 (IQR: 29–43). Typically participants were white (81 %), educated at a university level (61 %) and in full-time employment (72 %). Of all participants, 217 (40 %) were born outside the UK. A sexually transmitted infection (STI) was reported to have been diagnosed in the previous 12 months in 330/515 (64 %) and 473/544 (87 %) participants reported ever having being diagnosed with an STI. At enrolment, 47/280 (17 %) participants were diagnosed with an STI. Participants reported a median (IQR) of 10 (5–20) partners in the last 90 days, a median (IQR) of 2 (1–5) were condomless sex acts where the participant was receptive and 2 (1–6) were condomless where the participant was insertive. Post-exposure prophylaxis had been prescribed to 184 (34 %) participants in the past 12 months. The number of STI diagnoses was high compared to those reported in GUMCAD attendees.

Conclusions

The PROUD study population are at substantially higher risk of acquiring HIV infection sexually than the overall population of GMSM attending sexual health clinics in England. These findings contribute to explaining the extraordinary HIV incidence rate during follow-up and demonstrate that, despite broad eligibility criteria, the population interested in PrEP was highly selective.

Trial registration

Current Controlled TrialsISRCTN94465371. Date of registration: 28 February 2013.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-016-1286-4) contains supplementary material, which is available to authorized users.

Pre-exposure prophylaxis to prevent the acquisition of HIV-1 infection (PROUD): effectiveness results from the pilot phase of a pragmatic open-label randomised trial

BACKGROUND

Randomised placebo-controlled trials have shown that daily oral pre-exposure prophylaxis (PrEP) with tenofovir-emtricitabine reduces the risk of HIV infection. However, this benefit could be counteracted by risk compensation in users of PrEP. We did the PROUD study to assess this effect.

METHODS

PROUD is an open-label randomised trial done at 13 sexual health clinics in England. We enrolled HIV-negative gay and other men who have sex with men who had had anal intercourse without a condom in the previous 90 days. Participants were randomly assigned (1:1) to receive daily combined tenofovir disoproxil fumarate (245 mg) and emtricitabine (200 mg) either immediately or after a deferral period of 1 year. Randomisation was done via web-based access to a central computer-generated list with variable block sizes (stratified by clinical site). Follow-up was quarterly. The primary outcomes for the pilot phase were time to accrue 500 participants and retention; secondary outcomes included incident HIV infection during the deferral period, safety, adherence, and risk compensation. The trial is registered with ISRCTN (number ISRCTN94465371) and ClinicalTrials.gov (NCT02065986).

FINDINGS

We enrolled 544 participants (275 in the immediate group, 269 in the deferred group) between Nov 29, 2012, and April 30, 2014. Based on early evidence of effectiveness, the trial steering committee recommended on Oct 13, 2014, that all deferred participants be offered PrEP. Follow-up for HIV incidence was complete for 243 (94%) of 259 patient-years in the immediate group versus 222 (90%) of 245 patient-years in the deferred group. Three HIV infections occurred in the immediate group (1·2/100 person-years) versus 20 in the deferred group (9·0/100 person-years) despite 174 prescriptions of post-exposure prophylaxis in the deferred group (relative reduction 86%, 90% CI 64-96, p=0·0001; absolute difference 7·8/100 person-years, 90% CI 4·3-11·3). 13 men (90% CI 9-23) in a similar population would need access to 1 year of PrEP to avert one HIV infection. We recorded no serious adverse drug reactions; 28 adverse events, most commonly nausea, headache, and arthralgia, resulted in interruption of PrEp. We detected no difference in the occurrence of sexually transmitted infections, including rectal gonorrhoea and chlamydia, between groups, despite a suggestion of risk compensation among some PrEP recipients.

INTERPRETATION

In this high incidence population, daily tenofovir-emtricitabine conferred even higher protection against HIV than in placebo-controlled trials, refuting concerns that effectiveness would be less in a real-world setting. There was no evidence of an increase in other sexually transmitted infections. Our findings strongly support the addition of PrEP to the standard of prevention for men who have sex with men at risk of HIV infection.

FUNDING

MRC Clinical Trials Unit at UCL, Public Health England, and Gilead Sciences.

Narratives of HIV: measuring understanding of HIV and the law in HIV-positive patients

OBJECTIVE

This study aimed to identify the understanding of people living with HIV and AIDS (PLWHA) regarding the application of the law around transmission of HIV in England and Wales.

DESIGN

A questionnaire was designed to prompt participants attending a large HIV department to discuss their understanding of the law with reference to HIV transmission. The design focused on qualitative analysis as there were insufficient data available to inform a metric reflecting quantitative data on PLWHA's understanding of the legal implications of transmission.

METHODS

The data were collected from PLWHA attending their HIV outpatient appointment to ensure relevance of population to the analysis. The answers were analysed using grounded theory and thematic analysis to identify key themes and theories for further testing.

RESULTS

Analysis demonstrated that understanding of legal obligations and outcomes of prosecutions was poor and patchy, with behavioural restrictions often overstated. There was a strong theme of ownership of responsibility amongst PLWHA, and of reference to principles of morality beyond legal restrictions.

CONCLUSIONS

PLWHA remain at risk of prosecution through poor understanding of the law. Clinical services and advocacy agencies should strive to increase understanding in order to enable PLWHA to comprehend the law and negotiate it successfully. This information should be shared as a process, not an isolated event.

Should we screen heterosexuals for extra-genital chlamydial and gonococcal infections?

Neisseria gonorrhoeae (GC) and Chlamydia trachomatis (CT) are two of the most prevalent bacterial sexually transmitted infections in the UK. Although the high burden of extra-genital infections with GC and CT in men who have sex with men has been well established, a significant number of extra-genital site infections with CT and GC could similarly be present in heterosexual women. For this reason we started to routinely offer extra-genital site testing for GC and CT in all patients attending our sexual health clinic who reported having had receptive anal sex and/or giving oral sex. This followed a review of current evidence by the clinical team and a change in local testing policy. This study not only confirmed a large reservoir of extra-genital infection amongst men who have sex with men, but also demonstrates that a comparable reservoir of extra-genital infection is present amongst heterosexual women. Our study adds to the mounting evidence that extra-genital site testing in heterosexual women should occur when oral or anal sexual activity is reported.

Risk factors for chlamydial infection in chlamydia contacts: a questionnaire-based study

BACKGROUND AND METHODOLOGY

Treatment of individuals with chlamydial infection and their sexual partners is an important aspect of reproductive health care. Partners of infected individuals are currently offered 'epidemiological treatment', which means that they are offered antibiotic treatment at their first visit without waiting for the result of their chlamydia test. We carried out a study to identify the risk factors for chlamydial infection in partners of infected individuals. Individuals attending a genitourinary clinic as chlamydia contacts were identified and asked to complete a questionnaire about their relationship with the index case and their prior sexual history. The result of their chlamydia test was then analysed against those variables.

RESULTS

A total of 115 chlamydia contacts were analysed in this study; 60 (52%) were found to be positive for chlamydial infection. In a multivariate analysis, young age, more than one episode of sexual intercourse with the infected partner and a greater total number of sexual partners were associated with a positive chlamydia result. A prediction model for chlamydial infection using these risk factors had a discriminatory ability quantified by an area under the curve (AUC) of 0.76 (95% CI 0.66-0.85).

DISCUSSION AND CONCLUSIONS

The risk factors identified can be used when discussing epidemiological treatment with individuals who attend sexual health services as chlamydia contacts, or to target clinic resources to a higher-risk group. Larger studies will be necessary to assess the benefits and risks of changing to a policy of offering epidemiologic treatment to 'high-risk' contacts only, identified using a predictive model such as the one described here.

Cervical surveillance in HIV-positive women: a genitourinary medicine clinic experience

BACKGROUND

The prevalence of cervical intraepithelial neoplasia (CIN) is increased in HIV infection. The UK National Health Service Cervical Screening Programme (NHSCSP) guidelines therefore provide specific recommendations for HIV-positive women. An audit of cervical surveillance in HIV-positive women who attend the genitourinary medicine (GUM) department at the Leicester Royal Infirmary, Leicester, UK was conducted. The objectives were to assess adherence to UK and local screening guidelines, prevalence of cervical pathology and appropriate referral for colposcopy.

METHODS

A retrospective case note review of 130 HIV-infected women attending the GUM department between January 2000 and December 2005 was undertaken.

RESULTS

Results showed that 76.2% of patients had cervical cytology within a year of HIV diagnosis and 42.4% of patients had abnormal cytology. All patients with dyskaryosis were referred for colposcopy according to local and national guidelines. Cytology results were consistent with histological findings and the prevalence of CIN was 15.2%. CD4 counts at presentation were significantly lower in those with dyskaryosis compared with those without dyskaryosis (p = 0.038). Twenty-two patients were lost to follow-up after initial cytology.

DISCUSSION AND CONCLUSIONS

A designated health advisor in the GUM department co-ordinates cervical surveillance in HIV-positive women. This, together with an increasingly integrated service with family planning services, may contribute to relatively successful surveillance. Overall, patients are carefully monitored to ensure that surveillance is adequate. Extra vigilance is, however, required and further cost-effective measures in future may include more active involvement of general practitioners.

The Internet as a diagnostic aid: the patients' perspective

A questionnaire-based cross-sectional study was conducted in order to determine how frequently patients attending a genitourinary (GU) medicine clinic use the Internet to diagnose their own symptoms, and to assess the accuracy of their diagnosis. Out of 223 symptomatic patients attending a GU clinic, 101 (45.3%) looked up their symptoms on the Internet. The age difference between those who looked up their symptoms and those who did not was not statistically significant ( P = 0.77). Twenty (19.8%) out of 101 patients diagnosed their own symptoms, and 14 (13.9%) patients made the correct diagnosis. Ninety-one (90.1%) patients used the Google® search engine as the starting point for their search.

Although the Internet plays an important role in providing health information, the variable quality of health information available limits its use as a diagnostic tool by patients.

An elimination diet for chronic urticaria of childhood

Twenty-three children with chronic urticaria were treated with an elimination diet for two weeks. Eighteen completed the period of dietary elimination; in seven of the 18 children there was a marked remission of the urticaria during the second week of the diet. The administration of challenge capsules provoked an exacerbation of urticaria in five of the 14 (36%) children given aspirin. The incidence of reactions to tartrazine, sodium benzoate and yeast (7%) was not significantly different from those to the lactose placebo (9%). In selected cases, elimination diets with controlled reintroduction of foods have a role in the management of chronic urticaria in childhood.