Hotels as Noncongregate Emergency Shelters: An Analysis of Investments in Hotels as Emergency Shelter in King County, Washington During the COVID-19 Pandemic

This study analyzes the COVID-19 homelessness response in King County, Washington, in which people were moved out of high-density emergency shelters into hotel rooms. This intervention was part of a regional effort to de-intensify the shelter system and limit the transmission of the virus to protect vulnerable individuals experiencing homelessness. This study used quantitative and qualitative methods to describe the experiences of and outcomes on individuals who were moved from shelters to noncongregate hotel settings. The study highlights a new approach to shelter delivery that not only responded to the public health imperatives of COVID-19, but also indicated positive health and social outcomes compared to traditional congregate settings. The findings establish an evidence base to help inform future strategic responses to homelessness as well as to contribute to the broader policy conversations on our nation's response to homelessness.

Lessons Learned: Developing an Online Training Program for Cultural Sensitivity in an Academic Psychiatry Department

This column describes the development and impact of an innovative three-part online cultural sensitivity training program for faculty and staff of an academic medical center's psychiatry department. The goal of the training was to equip faculty and staff with skills to address issues of diversity in their clinical practice. Three online modules were offered. Evaluations after the second module suggested that participants felt most comfortable interacting with people of diverse backgrounds and least comfortable intervening after witnessing a microaggression. Participants found the modules to meet the learning objectives and the technology to be user friendly. Future directions include embedding cultural humility and antiracism frameworks within department practices and policies.

Depressed Chinese Americans present predominantly psychological symptoms: A new trend or different outcomes due to methodological differences?

People of Asian cultural origin have been reported to emphasize somatic rather than psychological symptoms when they are depressed. However, a recent study investigated 190 Chinese immigrants with depression in a primary care clinic and reported that they were more likely to report depressed mood, rather than physical symptoms. We performed a qualitative analysis of the chief complaint narratives of 57 Chinese immigrants with major depressive disorder who were referred to a behavioral health clinic. These patients' chief complaints included insomnia, sadness, anxiety, cognition issues, being irritated/annoyed, having low energy/motivation, and stress. Among this population, 70.18 % presented psychological symptoms, 5.26 % presented somatic symptoms, and the remaining 15.8 % presented only neutral symptoms (e.g. 'low energy', 'loss of appetite', and 'insomnia'). Our findings show that depressed Chinese Americans at outpatient clinics present predominantly psychological and not somatic symptoms. This may reflect a new trend of symptoms reporting among Asian Americans with depression.

A-28 Updated Baselines Show Improvement, Even When Athletes Sustain A Concussion Between Assessments

Objective

To explore change across repeated baseline assessments using raw scores and percentile scores, for athletes sustaining and not sustaining a concussion between baselines.

Method

Athletes (12–23 years) completed two valid, baseline neurocognitive test sessions using ImPACT. Participants were divided into independent groups based on having sustained a concussion between annual baselines (CONCUSSION; N = 269) or no concussion (NO CONCUSSION; N = 270) between baselines. Raw change scores were calculated between the first and follow-up baseline for both groups by subtracting the first baseline score from the updated baseline score on the four ImPACT composite scores. Age- and gender-based percentile scores were then applied for all participants, and percentile change scores were calculated in the same manner. Raw change scores and percentile change scores between groups were compared using 4 ANOVAs with a Bonferroni-corrected p-value of (p < .0125).

Results

Using raw scores ANOVAs revealed that athletes in the CONCUSSION group showed significantly greater improvement on follow-up testing than athletes in the NO CONCUSSION group on Verbal Memory (p < .001) and Visual Motor Speed (p = .001), but not on Visual Memory (p = .41) and Reaction Time (p = .04). Using percentile ranks, ANOVAs revealed significantly greater improvement in CONCUSSION group on Verbal Memory (p < .001), but not on Visual Memory (p = .34), Visual Motor Speed (p = .03), or Reaction Time (p = .014).

Conclusions

Athletes sustaining a concussion between annual baseline assessments show increases on Verbal Memory and Visual Motor Speed follow-up testing when using raw composite scores, but only on Verbal Memory when using age- and gender-based percentile ranks.

Exposure to Serial Post-Concussion Neurocognitive Testing Does not Affect Future “Updated” Baseline Neurocognitive Performance in Adolescent Athletes

Purpose

We investigated a dose response for serial post-concussion neurocognitive testing exposure on updated post-concussion baseline testing performance.

Methods

Athletes (13-18 yrs) that completed two, valid baseline neurocognitive testing (ImPACT) sessions approximately 1-3 years apart participated in this study. A sub-sample of athletes that sustained a SRC between baseline sessions were categorized into dose-response groups based on the number of serial, post-concussion neurocognitive tests completed following SRC: ONE (n=76), TWO (n=99), and THREE OR MORE (n=111). Athletes that did not sustain a SRC comprised the ZERO group (n=289). Change scores between the first to the second baseline were calculated for the ImPACT Composite and Symptom Scores and compared between the dose-response groups and controls with 5 ANOVAs, with a Bonferroni-corrected p-value of (p<.01). Baseline testing was administered using ImPACT stimuli within the “Baseline” administration, and all post-concussion ImPACT testing was administered using alternate-form associated with that specific post-injury assessment (Post-Injury1, Post-Injury2, etc).

Results

ANOVAs revealed no effect of number of post-concussion assessments (0, 1, 2, or 3+) on magnitude of the change between first and final baselines, for Verbal Memory (p=.08), Visual Memory (p=.96), Visual Motor Speed (p=.47), Reaction Time (p=.91), or Total Symptom Scores (p=.86).

Conclusion

Repeated exposure to neurocognitive testing has revealed improvements in Visual Motor Speed among normal controls, across test-retest intervals of 1-month, 1-year, and 2-years. However, in this study, exposure to post-concussion, serial neurocognitive testing had no effect on future performance on post-concussion baseline neurocognitive testing.

Microaggressions and Discrimination Relate to Barriers to Care Among Black Women Living with HIV

In the United States, black women living with HIV (BWLWH) represent the highest proportion of women living with HIV and dying from HIV-related illnesses when compared with women of other racial/ethnic groups. These disparities may be linked to social and structural factors faced by BWLWH, including race- and HIV-related discrimination, and gendered racial microaggressions (GRMs). GRMs are everyday insults that black women experience due to being both black and female (e.g., comments about their body). Commonly assessed barriers to HIV-related care (e.g., transportation, finance, community stigma) do not include personal experiences of race- and HIV-related discrimination and GRM. We present the cross-sectional associations between racial discrimination, HIV-related discrimination, GRM, and barriers to care. One hundred BWLWH in a large city in the Southeast United States completed baseline assessments as part of an intervention development study. At baseline assessments BWLWH completed measures on racial discrimination, HIV-related discrimination, GRM (frequency and appraisal), and barriers to care. Hierarchical multiple linear regressions controlling for age, education, and income indicated that higher race-related discrimination (β = 0.23, p < 0.05), higher HIV-related discrimination (β = 0.26, p < 0.01), and higher GRM (frequency: β = 0.31, p < 0.01; appraisal: β = 0.21, p < 0.05) significantly predicted higher total barriers to care. When all predictors were entered together GRMs contributed uniquely to total barriers to care and two subscales, while racial discrimination contributed uniquely toward one subscale. These findings further emphasize that for BWLWH interventions and policy efforts need to address racial discrimination, HIV-related discrimination, and GRM concurrently with other barriers to care, with special attention being given to daily GRM.

The effectiveness of ω-3 polyunsaturated fatty acid interventions during pregnancy on obesity measures in the offspring: an up-to-date systematic review and meta-analysis

BACKGROUND

The potential role of ω-3 long chain polyunsaturated fatty acid (LCPUFA) supplementation during pregnancy on subsequent risk of obesity outcomes in the offspring is not clear and there is a need to synthesise this evidence.

OBJECTIVE

A systematic review and meta-analysis of randomised controlled trials (RCTs), including the most recent studies, was conducted to assess the effectiveness of ω-3 LCPUFA interventions during pregnancy on obesity measures, e.g. BMI, body weight, fat mass in offspring.

METHODS

Included RCTs had a minimum of 1-month follow-up post-partum. The search included CENTRAL, MEDLINE, SCOPUS, WHO's International Clinical Trials Reg., E-theses and Web of Science databases. Study quality was evaluated using the Cochrane Collaboration's risk of bias tool.

RESULTS

Eleven RCTs, from ten unique trials, (3644 children) examined the effectiveness of ω-3 LCPUFA maternal supplementation during pregnancy on the development of obesity outcomes in offspring. There were heterogeneities between the trials in terms of their sample, type and duration of intervention and follow-up. Pooled estimates did not show an association between prenatal intake of fatty acids and obesity measures in offspring.

CONCLUSION

These results indicate that maternal supplementation with ω-3 LCPUFA during pregnancy does not have a beneficial effect on obesity risk. Due to the high heterogeneity between studies along with small sample sizes and high rates of attrition, the effects of ω-3 LCPUFA supplementation during pregnancy for prevention of childhood obesity in the long-term remains unclear. Large high-quality RCTs are needed that are designed specifically to examine the effect of prenatal intake of fatty acids for prevention of childhood obesity. There is also a need to determine specific sub-groups in the population that might get a greater benefit and whether different ω-3 LCPUFA, i.e. eicosapentaenoic (EPA) vs. docosahexanoic (DHA) acids might potentially have different effects.

Effects of Mind⁻Body Movements on Balance Function in Stroke Survivors: A Meta-Analysis of Randomized Controlled Trials

Objective: We performed a systematic review with meta-analysis and meta-regression to determine if mind⁻body movements (MBM) could be effective in rehabilitating balance function among stroke survivors. Methods: A literature search was conducted using major Chinese and English electronic databases from an inception until January 2018. Randomized controlled studies were included in our meta-analysis. Data was independently extracted by two review authors using a pre-developed table and confirmed by a third party to reach a consensus. Pooled effect size (Hedge’s g) was computed while the random-effect model was set. Results: The meta-analytic results showed a significant benefit of the MBM intervention on increased balance function compared to the control groups (Hedge’s g = 1.59, CI 0.98 to 2.19, p < 0.001, I² = 94.95%). Additionally, the meta-regression indicated that the total number of sessions (β = 0.00142, 95% CI 0.0039 to 0.0244, p = 0.0067) and dose of weekly training (β = 0.00776, 95% CI 0.00579 to 0.00972, p = 0.00) had significantly positive effects on balance function. Conclusions: The study encouraging findings indicate the rehabilitative effect of a MBM intervention for balance function in stroke survivors. However, there were significant limitations in the design among several of the included trials. Additional studies with more robust methodologies are needed to provide a more definitive conclusion.

Comparison of nutrient intake in adolescents and adults with and without food allergies

BACKGROUND

Exclusion diets for the management of food allergy pose a risk of nutritional deficiencies and inadequate growth in children, yet less is known about their effect in adolescents and adults. The present study aimed to compare the dietary intake of adolescents and adults with food allergies with that of a control group.

METHODS

A food allergic and a control group were recruited from Portsmouth and the Isle of Wight in the UK. Participants were recruited from a food allergy charity, allergy clinics, a local school and university, and previous research studies. Macro and micronutrient intake data were obtained using a 4-day estimated food diary. Sociodemographic and anthropometric data was collected via a constructed questionnaire.

RESULTS

This cross-sectional study included 81 adolescents (48 food allergic and 33 controls) aged 11-18 years and 70 adults aged 19-65 years (23 food allergic and 47 controls). Overall, 19 (22.8%) adolescents and 19 (27.1%) adults took dietary supplements, with no difference according to food allergic status. Adolescents with food allergy had higher intakes of niacin and selenium than adolescents without (P < 0.05). This difference persisted when dietary supplements were removed from the analysis. Adults with food allergies had higher intakes of folate and zinc than those without (P < 0.05); however, this difference did not persist when dietary supplements were removed from the analysis. Across all participants, the intake of several micronutrients was suboptimal. There was no difference in protein or energy intake, or body mass index, according to food allergic status.

CONCLUSIONS

The dietary intake of food allergic participants was broadly similar and, in some cases, better than that of control participants. However, suboptimal intakes of several micronutrients were observed across all participants, suggesting poor food choices.

The accuracy of dietary recall of infant feeding and food allergen data

BACKGROUND

Research investigating the association of infant dietary factors with later health outcomes often relies on maternal recall. It is unclear what the effect of recall bias is on the accuracy of the information obtained. The present study aimed to determine the extent of recall bias on the accuracy of infant feeding and food allergen data collected 10 years later.

METHODS

Mothers were recruited from a prospective birth cohort from the Isle of Wight. When their child was 10 years of age (2011/2012), mothers were requested to complete a retrospective infant feeding questionnaire asking the same questions as those solicited in 2001/2002.

RESULTS

In total, 125 mothers participated. There was substantial agreement for recollection of any breastfeeding (κ = 0.79) and the duration of breastfeeding from 10 years earlier (r = 0.84). Some 94% of mothers recalled accurately that their child had received formula milk. The exact age at which formula milk was first given was reliably answered (r = 0.63). The brand of formula milk was poorly recalled. Recall of age of introduction of solid food was not reliable (r = 0.16). The age of introduction of peanuts was the only food allergen that was recalled accurately (86%).

CONCLUSIONS

The present study highlights the importance of maternal recall bias of infant feeding practices over 10 years. Recall related to breastfeeding and formula feeding were reliable, whereas recalls related to age of introduction of solid or allergenic foods, apart from peanut, were not. Caution should be applied when interpreting studies relying on dietary recall.

Taste preference, food neophobia and nutritional intake in children consuming a cows' milk exclusion diet: a prospective study

BACKGROUND

Taste exposure in infancy is known to predict food preferences later in childhood. This is particularly relevant in children with cows' milk allergy who consume a substitute formula and/or a cows' milk exclusion (CME) diet early in life. This prospective study aimed to show whether there is a long-term effect of consuming a substitute formula and CME diet on taste preferences and dietary intake.

METHODS

Children were predominantly recruited from two large birth cohort studies in the UK. Two groups were recruited: an experimental group of children who had consumed a CME diet during infancy and a control group who had consumed an unrestricted diet during infancy. Parents completed a food neophobia questionnaire and an estimated prospective food diary. Children completed a taste preference test and their growth was assessed.

RESULTS

One hundred and one children with a mean age of 11.5 years were recruited (28 CME and 73 controls). Children in the CME group had a significantly higher preference for bitter taste than those in the control group (P < 0.05). There were significant differences between the groups with respect to the intake of some micronutrients, including riboflavin, iodine, sodium and selenium. Food neophobia did not differ between groups. Some 28% of the CME group were overweight/obese compared to 15% of the control group; however, this difference was not statistically significant.

CONCLUSIONS

Consuming a substitute formula and/or a CME diet in infancy has a long-term effect on the preference for bitter taste. Differences exist with respect to the intake of some micronutrients, but not macronutrients. There was a nonsignificant trend towards being overweight and obese in children in the CME group.

Changing prevalence of wheeze, rhinitis and allergic sensitisation in late childhood: findings from 2 Isle of Wight birth cohorts 12 years apart

BACKGROUND

While the prevalence of asthma in children is decreasing or remaining the same, time trends in the prevalence of rhinitis in children are not known. Understanding sensitisation trends may help inform about trends in asthma and rhinitis prevalence.

OBJECTIVE

To assess time trends of wheeze, rhinitis and aero-allergen sensitisation prevalence at 10 years of age, we compared two birth cohorts established 12 years apart. To gain insight into differences in disease prevalence, we assessed association of family history, early life exposures and sensitisation with wheeze and rhinitis in each cohort.

METHODS

The IoW (Isle of Wight) and FAIR (Food Allergy and Intolerance Research) unselected birth cohorts were established in 1989 and 2001 respectively in IoW. Identical ISAAC questionnaire and skin prick test data were collected and compared at 10 years of age.

RESULTS

Over the 12-year period from 2001 to 2012, prevalence of lifetime wheeze, current wheeze and those ever treated for asthma decreased by 15.9% (45.5 vs. 29.6, P < 0.001), 3.9% (18.9 vs. 15, P = 0.020) and 8.2% (31.7 vs. 23.5, P = 0.001), respectively. Conversely, current rhinitis and lifetime rhinitis prevalence increased by 5.5% (22.6 vs. 28.1, P = 0.004) and 13% (18.6 vs. 31.7, P < 0.001), respectively. Atopic status remained stable; however, house dust mite (HDM) sensitisation decreased by 5.6% (19.2 vs. 13.6, P = 0.004) and grass sensitisation increased by 3.5% (12.9 vs. 16.4, P = 0.054). Male sex, parental history of asthma and HDM sensitisation were significantly associated with lifetime wheeze in both cohorts, while maternal smoking during pregnancy was a significant risk factor only in the earlier IoW cohort. Parental history of rhinitis and grass sensitisation was significantly associated with lifetime rhinitis in both cohorts, while HDM sensitisation was significant only for the IoW cohort.

CONCLUSION

Contrasting changes were noted with falling wheeze and HDM sensitisation but rising rhinitis and grass sensitisation prevalence. Changing prevalence of aero-allergen sensitisations may explain the different time trends observed in these cohorts.

Fussy eating and feeding difficulties in infants and toddlers consuming a cows' milk exclusion diet

BACKGROUND

Cows' milk allergy (CMA) is the most common infant food allergy in the United Kingdom, requiring a strict exclusion diet. Feeding difficulties and fussy eating are also very common problems in young children and can negatively influence feeding and dietary intake in an infant with CMA. The aim of this study was to compare the levels of fussy eating and feeding difficulties in two groups of young children: a group consuming an exclusion diet for CMA and a control group of children consuming an unrestricted diet.

METHOD

Participants were recruited from allergy and health visitor clinics on the Isle of Wight. Parents completed a number of questionnaires about their child's feeding behaviour.

RESULTS

One hundred and twenty-six participants (mean age 13 months) were recruited. Participants consuming an exclusion diet for CMA had significantly higher scores for both fussy eating and feeding difficulties (p < 0.05), although overall both groups were within the normal range. A number of symptoms were found to be positively moderately correlated with higher feeding difficulty score (p < 0.05). A higher consumption of milk/milk substitute consumed per day was positively correlated to both feeding difficulties and fussy eating (p < 0.05).

CONCLUSION

Participants consuming an exclusion diet for CMA have higher scores for feeding difficulties and fussy eating than those consuming an unrestricted diet; however, the majority of participants' scores were within the normal range and did not affect the growth.

Trends in cutaneous sensitization in the first 18 years of life: results from the 1989 Isle of Wight birth cohort study

BACKGROUND

Skin prick testing (SPT) is fundamental to the practice of clinical allergy identifying relevant allergens and predicting the clinical expression of disease. There are only limited data on the natural history of SPT results over childhood and adolescence.

OBJECTIVE

We aimed to describe the natural history of SPT and patterns of sensitization over childhood and adolescence.

METHODS

The 1989 Isle of Wight birth cohort (1456 participants) was followed up at 1, 2, 4, 10 and 18 years. SPT was undertaken from 4 years.

RESULTS

SPT was performed on 980 (80%), 1036 (75%) and 853 (65%) of participants at 4, 10 and 18 years. The prevalence of sensitization to any allergen at these time-points was 19.7%, 26.9% and 41.3% respectively. At each time-point, boys were significantly more likely to be sensitized (P < 0.016) and sensitization significantly increased over childhood and adolescence (average annual increase of 7%). Some children outgrew their sensitization. The rate of sensitization to most individual allergens increased over childhood and adolescence. A configural frequency analysis showed that whether an individual was sensitizated was relatively fixed over childhood and adolescence. Cluster analysis at 4 years demonstrated four major groups of individuals with similar co-sensitization to specific allergens. Children who were sensitized at age 4 years generally went onto become sensitized to additional allergens at 10 and 18 years.

CONCLUSIONS AND CLINICAL RELEVANCE

Allergic sensitization continues to increase over childhood into adolescence although the majority of children who were not sensitized at 4 years remain non-sensitized throughout childhood and adolescence. The presence of sensitization at 4 years predicted later sensitization to additional allergens.

Factors influencing food choices of food-allergic consumers: findings from focus groups

BACKGROUND

Up to 35% of the population modify their diet for adverse reactions to food. This study described the food choice behaviour of diagnosed food-allergic (DFA), self-reported food-allergic or intolerant (SFA) and nonfood-allergic (NFA) consumers, and explored differences between them.

METHODS

Six focus groups with adults (n = 44) were conducted. Data analysis was performed using thematic content analysis.

RESULTS

Compared to NFA participants, DFA consumers were deprived of satisfaction and pleasure from foods, experienced difficulties finding safe foods and had to be organized with eating. SFA participants faced similar problems, but to a lesser degree; their food choices were strongly influenced by emotional factors or health awareness.

CONCLUSION

Food-allergic consumers' food choices are influenced by a number of factors that differ to those of NFA consumers. It is therefore important to offer people with food allergies or intolerances advice that goes beyond how to avoid allergens.

A multicentre randomised controlled trial and economic evaluation of ion-exchange water softeners for the treatment of eczema in children: the Softened Water Eczema Trial (SWET)

OBJECTIVES

To determine whether installation of an ion-exchange water softener in the home could improve atopic eczema in children and, if so, to establish its likely cost and cost-effectiveness.

DESIGN

An observer-blind, parallel-group randomised controlled trial of 12 weeks duration followed by a 4-week observational period. Eczema was assessed by research nurses blinded to intervention at baseline, 4 weeks, 12 weeks and 16 weeks. The primary outcome was analysed as intent-to-treat, using the randomised allocation rather than actual treatment received. A secondary per-protocol analysis excluded participants who failed to receive their allocated treatment and who were deemed to be protocol violators.

SETTING

Secondary and primary care referral centres in England (UK) serving a variety of ethnic and social groups and including children living in both urban and periurban homes.

PARTICIPANTS

Three hundred and thirty-six children (aged 6 months to 16 years) with moderate/severe atopic eczema, living in homes in England supplied by hard water (≥ 200 mg/l calcium carbonate).

INTERVENTIONS

Participants were randomised to either installation of an ion-exchange water softener plus usual eczema care (group A) for 12 weeks or usual eczema care alone (group B) for 12 weeks. This was followed by a 4-week observational period, during which water softeners were switched off/removed from group A homes and installed in group B homes. Standard procedure was to soften all water in the home, but to provide mains (hard) water at a faucet-style tap in the kitchen for drinking and cooking. Participants were therefore exposed to softened water for bathing and washing of clothes, but continued to drink mains (hard) water. Usual care was defined as any treatment that the child was currently using in order to control his or her eczema. New treatment regimens used during the trial period were documented.

MAIN OUTCOME MEASURES

Primary outcome was the difference between group A and group B in mean change in disease severity at 12 weeks compared with baseline, as measured using the Six Area, Six Sign Atopic Dermatitis (SASSAD) score. This is an objective severity scale completed by blinded observers (research nurses) unaware of the allocated intervention. Secondary outcomes included use of topical medications, night-time movement, patient-reported eczema severity and a number of quality of life measures. A planned subgroup analysis was conducted, based on participants with at least one mutation in the gene encoding filaggrin (a protein in the skin thought to be important for normal skin barrier function).

RESULTS

Target recruitment was achieved (n = 336). The analysed population included 323 children who had complete data. The mean change in primary outcome (SASSAD) at 12 weeks was -5.0 [standard deviation (SD) 8.8] for the water softener group (group A) and -5.7 (SD 9.8) for the usual care group (group B) [mean difference 0.66, 95% confidence interval (CI) -1.37 to 2.69, p = 0.53]. The per-protocol analysis supported the main analysis, and there was no evidence that the treatment effect varied between children with and without mutations in the filaggrin gene. No between-group differences were found in the three secondary outcomes that were assessed blindly (use of topical medications; night-time movement; proportion showing reasonable, good or excellent improvement). Small, but statistically significant, differences in favour of the water softener were found in three of the secondary outcomes that were assessed by participants [Patient-Oriented Eczema Measure (POEM); well-controlled weeks (WCWs); Dermatitis Family Index (DFI)]. The results of the economic evaluation, and the uncertainty surrounding them, suggest that ion-exchange water softeners are unlikely to be a cost-effective intervention for children with atopic eczema from an NHS perspective.

CONCLUSIONS

Water softeners provided no additional benefit to usual care in this study population. Small, but statistically significant, differences were found in some secondary outcomes as reported by parents, but it is likely that such improvements were the result of response bias. Whether or not the wider benefits of installing a water softener in the home are sufficient to justify the purchase of a softener is something for individual householders to consider on a case-by-case basis. This trial demonstrated overwhelming demand for non-pharmacological interventions for the treatment of eczema, and this is something that should be considered when prioritising future research in the field.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN71423189.

FUNDING

This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 15, No. 8. See the HTA programme website for further project information. Results of this trial are also published at www.plosmedicine.org.

Time trends in the prevalence of peanut allergy: three cohorts of children from the same geographical location in the UK

BACKGROUND

This article investigated the prevalence of peanut allergy in three cohorts of children born in the same geographical location, Isle of Wight, UK and seeks to determine whether the prevalence of peanut allergy has changed between 1994 and 2004.

METHODS

Three cohorts of children (age 3-4 years) born on the Isle of Wight, were assessed for peanut allergy and the outcomes compared: Cohort A: Born in 1989; reviewed at 4 years of age (n = 2181). Cohort B: Born between 1994 and 1996; reviewed between 3 and 4 years of age (n = 1273). Cohort C: Born between 2001 and 2002; reviewed at 3 years of age (n = 891).

RESULTS

Peanut sensitization increased significantly from 1.3% in Cohort A to 3.3% (P = 0.003) in Cohort B before falling back to 2.0% in Cohort C (P = 0.145). Similarly, clinical peanut allergy increased significantly from 0.5% in Cohort A to 1.4% (P = 0.023) in Cohort B, with a subsequent fall to 1.2% in Cohort C (P = 0.850).

CONCLUSIONS

Our data from three cohorts of 3- to 4-year-old children born in the same geographical area shows that peanut allergy prevalence has changed over time. Peanut sensitization and reported allergy in children born in 1994-1996 increased from 1989 but seems to have stabilized or slightly decreased since the late 1990s, although not significant.

Audiovisual distraction as an adjunct to pain and anxiety relief during minor surgery

BACKGROUND

Minor surgery for ingrown toenails can provoke anxiety and the anaesthetic injection can be acutely painful. Distraction techniques may reduce the associated pain and anxiety.

OBJECTIVE

To investigate an audiovisual distraction (Bedscapes) on pain and anxiety during minor surgery for the correction of ingrown toenail.

METHOD

In a randomised controlled trial, patients (N=152) with ingrown toenails requiring surgical correction under local anaesthesia were allocated to receive Bedscapes+standard care or standard care alone. Pain levels due to local anaesthetic injection were assessed post-procedure, and anxiety levels were assessed pre- and post-procedure in both groups. Follow-up focus groups were conducted with 14 patients allocated to the Bedscapes group, and one-to-one interviews were held with four podiatrists.

RESULTS

Participants with high pre-procedure anxiety scores experienced greater pain on injection, and older patients reported lower pain than younger patients, regardless of group allocation. Bedscapes did not reduce pain or anxiety, and was apparently no more effective than interpersonal interaction between podiatry staff and the patient.

CONCLUSIONS

Pain of injected anaesthesia correlates closely with pre-operative anxiety. Formal audiovisual distraction has no added benefit over interpersonal interaction in the alleviation of pain and anxiety in patients undergoing nail surgery.

Prevalence and cumulative incidence of food hypersensitivity in the first 3 years of life

BACKGROUND

Prevalence and incidence of food hypersensitivity (FHS) and its trends in early childhood are unclear.

METHODS

A birth cohort born on the Isle of Wight (UK) between 2001 and 2002 was followed-up prospectively. Children were clinically examined and skin prick tested at set times and invited for food challenges when indicated.

RESULTS

Nine hundred and sixty-nine children were recruited and 92.9%, 88.5% and 91.9% of them respectively were assessed at 1, 2 and 3 years of age. Prevalence of sensitization to foods was 2.2%, 3.8% and 4.5% respectively at these ages. Cumulatively, 5.3% [95% confidence interval (CI): 3.9-7.1] children were sensitized to a food. Using open food challenge and a good clinical history, the cumulative incidence of FHS was 6.0% (58/969, 95% CI: 4.6-7.7). Based on double-blinded, placebo-controlled, food challenge (DBPCFC) and a good clinical history, the cumulative incidence was 5.0% (48/969, 95% CI: 3.7-6.5). There is no evidence to suggest that the incidence of FHS has increased, comparing these results with previous studies. Overall, 33.7% of parents reported a food-related problem and of these, 16.1% were diagnosed with FHS by open challenge and history and 12.9% by DBPCFC and history. Main foods implicated were milk, egg and peanut.

CONCLUSIONS

By the age of 3 years, 5-6% of children suffer from FHS based on food challenges and a good clinical history. There were large discrepancies between reported and diagnosed FHS. Comparing our data with a study performed in the USA more than 20 years ago, there were no significant differences in the cumulative incidence of FHS.

Comparison of open and double-blind placebo-controlled food challenges in diagnosis of food hypersensitivity amongst children

BACKGROUND

Correct diagnosis of food hypersensitivity (FHS) is important to ensure appropriate patient care and to accurately establish the population prevalence and incidence. Food challenges play a very important role in the diagnosis of FHS, but it is unclear when open food challenges (OFCs) opposed to double-blind placebo-controlled food challenges (DBPCFCs) should be used. This study investigated the use of OFCs and DBPCFCs when diagnosing FHS.

METHODS

Children with a reported history of FHS or with sensitization to a food without known previous consumption were invited to undergo food challenges. Children of consenting parents underwent an OFC and those with a positive OFC were approached to undergo a DBPCFC. Food challenges were either performed as 1-day or 1-week challenges depending on sensitization status and clinical history.

RESULTS

Forty-one children underwent both OFCs and DBPCFCs. The positive predictive values for 1-day and 1-week OFCs were 73% (8/11; 95% CI: 39-94%) and 57% (20/35; 95% CI: 39-74%) respectively. There was no evidence to indicate that the younger children were more likely to have a positive OFC confirmed by a DBPCFC compared to older children (Fisher's exact P = 0.53). In the 1-day challenges parents indicated a preference for OFC rather than DBPCFC. By contrast, in the 1-week challenge parents indicated a preference for DBPCFC (P = 0.0192).

CONCLUSION

Open food challenge may be suitable for diagnosing immediate objective symptoms, whereas DBPCFC may be needed for the diagnosis of delayed and mainly subjective symptoms, irrespective of the child's age.

Government advice on peanut avoidance during pregnancy--is it followed correctly and what is the impact on sensitization?

BACKGROUND

In 1998, the UK government issued precautionary advice that pregnant or breast-feeding women with a family history of atopy, may wish to avoid eating peanuts during pregnancy and lactation. This study aimed to assess the compliance with this recommendation and investigate its impact upon peanut sensitization.

METHODS

A total of 858 children born immediately after the advice were followed for 2 years and assessed for peanut sensitization. A standardized questionnaire was used to ascertain history of atopy and maternal exposure to peanuts during pregnancy. Following parental consent children were skin prick tested to assess sensitization to peanuts.

RESULTS

Sixty-five per cent of mothers had avoided peanuts during pregnancy. Forty-two per cent of the mothers had heard about the government advice, and half modified their diet as a consequence. Neither maternal nor family history of atopy had any significant effect on peanut consumption. Parity did play a role, and mothers having their first child were twice as likely to change their diet (P<0.001). Mothers of 77% of the children sensitized to peanuts had avoided peanuts during pregnancy. In this cohort study maternal consumption of peanut during pregnancy was not associated with peanut sensitization in the infant.

CONCLUSIONS

The majority of mothers in this cohort avoided peanut consumption during pregnancy. It is likely that either the government advice is misunderstood by mothers, or that those who communicate the advice have not fully explained who it is targeted at.

Randomized, double-blind comparison of patient-controlled epidural infusion vs nurse-administered epidural infusion for postoperative analgesia in patients undergoing colonic resection

BACKGROUND

There is little published evidence of the analgesic efficacy of patient-controlled epidural analgesia (PCEA) for postoperative pain relief. The aim of this study was to compare the analgesic efficacy of epidural infusion of bupivacaine 0.125% and fentanyl 4 microg ml(-1) administered by either PCEA with a background infusion or nurse-administered continuous epidural infusion (CEI) after major intra-abdominal surgery.

METHODS

In a double-blind, randomized clinical trial, 205 adult patients undergoing colonic resection by laparotomy received either PCEA or CEI. Pain scores were recorded via a four-point verbal rating scale at 1, 2, 3, 4, 8, 12, 24, 48, and 72 h after surgery. The administration of epidural top-ups and systemic analgesia over the same period was also recorded, and patient satisfaction questionnaires completed.

RESULTS

The median area under the curve of pain against time was significantly lower in the PCEA group (2 vs 24, P<0.001) as were median summary pain scores on movement (0.67 vs 1.33, P<0.001). Significantly fewer patients in the PCEA group received one or more epidural top-ups (13 vs 36%, P = 0.0002) or any systemic analgesics (41 vs 63%, P = 0.0021). Patients in the PCEA group were significantly more likely to be very satisfied than in the CEI group (76 vs 43%, P<0.0001).

CONCLUSIONS

PCEA provides greater analgesic efficacy than CEI for postoperative analgesia after major intra-abdominal surgery, and a decreased requirement for physician or nurse intervention.

Eicosapentaenoic acid (EPA, an omega-3 fatty acid from fish oils) for the treatment of cancer cachexia

BACKGROUND

Cancer cachexia is a distressing weight loss syndrome commonly seen in advanced cancer patients. It is associated with reduced quality of life and shorter survival time. Eicosapentaenoic acid (EPA) is a long chain polyunsaturated fatty acid found naturally in some fish which has been used to decrease weight loss, promote weight gain and increase survival times in patients affected with cancer cachexia.

OBJECTIVES

To evaluate the effectiveness and safety of EPA in relieving symptoms associated with the cachexia syndrome in patients with advanced cancer.

SEARCH STRATEGY

Studies were sought through an extensive search of a range of electronic databases. Hand searching was conducted on selected journals and reference lists as well as contact made with investigators, manufacturers and experts. The most recent electronic search was conducted in February 2005.

SELECTION CRITERIA

Studies were included in the review if they assessed oral EPA compared with placebo or control in randomised controlled trials of patients with advanced cancer and either a clinical diagnosis of cachexia or self-reported weight loss of 5% or more.

DATA COLLECTION AND ANALYSIS

Both methodological quality evaluation of potential trials and data extraction were conducted by two independent review authors.

MAIN RESULTS

Five trials (involving 587 patients) met the inclusion criteria. Three trials compared EPA at different doses with placebo with two outcomes, nutritional status and adverse events comparable across two of the three included trials. In addition, two trials compared different doses of EPA with an active matched control. It was possible to compare the outcomes of weight, quality of life and adverse events across these two trials. There were insufficient data to define the optimal dose of EPA.

AUTHORS' CONCLUSIONS

There were insufficient data to establish whether oral EPA was better than placebo. Comparisons of EPA combined with a protein energy supplementation versus a protein energy supplementation (without EPA) in the presence of an appetite stimulant (Megestrol Acetate) provided no evidence that EPA improves symptoms associated with the cachexia syndrome often seen in patients with advanced cancer.

The diagnosis of Brazil nut allergy using history, skin prick tests, serum-specific immunoglobulin E and food challenges

BACKGROUND

Allergy to Brazil nut is a relatively common nut allergy and can be fatal. However, the evidence is lacking regarding the best approach to its diagnosis.

OBJECTIVE

We sought to determine the relative merits of history, skin prick testing, measurement of serum-specific IgE and challenge in the diagnosis of Brazil nut allergy.

METHODS

Fifty-six children and adults with a history of an allergic reaction to Brazil nut or evidence of sensitization were investigated by questionnaire (n=56), skin prick tests (SPTs) (n=53), measurement of serum-specific IgE to Brazil nut (n=54) and double-blind, placebo-controlled labial, and if necessary oral, challenges (n=19).

RESULTS

Brazil nut allergy occurred in highly atopic individuals of any age with a strong family history of atopy. In 24 of 56 (43%), the history of an immediate reaction was sufficient to make a diagnosis with confidence and an oral challenge was considered unsafe. Of the 19 subjects undertaking the 'gold standard' test of a double-blind, placebo-controlled, food challenge, all six subjects with a SPT of at least 6 mm had a positive challenge and all three subjects with a SPT of 0 mm had a negative challenge. In the remaining 10 (53%) subjects, where SPT was between 1 and 5 mm and serum-specific IgE was less than 3.5 kU/L, an oral challenge was performed resulting in three positive and seven negative challenges.

CONCLUSION

A combination of history, SPT and serum-specific IgE was adequate in achieving a diagnosis in the majority (77%) patients with suspected Brazil nut allergy. However, a doubtful history with SPT between 1 and 5 mm, or a serum-specific IgE less than 3.5 kU/L may require an oral challenge to help determine the risk of a Brazil nut allergic reaction.

Reliability and validity of a maternal food frequency questionnaire designed to estimate consumption of common food allergens

BACKGROUND

Maternal food intake during pregnancy may influence the development of food hypersensitivity (FHS) in the child. A food frequency questionnaire estimating the frequency with which some of the mains food allergens are consumed was designed and validated.

MATERIALS AND METHODS

Pregnant women were recruited at the ante-natal clinic of St. Mary's Hospital, Isle of Wight, UK. A food frequency questionnaire was developed and validated by comparing responses to information recorded in 7 days food diaries. The reliability of the food frequency questionnaire was evaluated by asking women to complete the questionnaire on two separate occasions at 30 and 36 weeks gestation.

RESULTS

Fifty-seven women completed the validity study and 91 women completed the reliability study. For both validity and reliability, questions with dichotomous response categories showed the highest level of agreement. Frequency of intake of foods commonly "hidden" in foods produced the lowest validity and reliability scores. In the validity study responses to the food frequency questionnaire identically matched information recorded in the food diaries 80% of the time, on average. In the reliability study, responses were identical on both questionnaires 85% of the time on average.

CONCLUSION

In this study a food frequency questionnaire estimating the frequency with which some of the main food allergens are consumed during pregnancy was designed and validated. This food frequency questionnaire could be used in future studies to assess the role of maternal food intake in the development of FHS in the infant.

Teaching evidence-based practice: A survey of UK's higher education provision

Evidence-based practice (EBP) ensures that clinical health management decisions are based on valid, reliable and relevant evidence determined by sound research and evaluation. It is a key element of both the clinical governance and clinical effectiveness agendas. Clearly, there is a need to provide adequate educational and professional attributes to meet this increasing demand.

The aim of this research was to identify and map all UK postgraduate courses that focus on EBP within health- and social-care services. Electronic searching of internet databases and all UK postgraduate electronic prospectuses using the broad term ‘evidence based’ was undertaken. Course details and prospectuses were obtained and reviewed, where available.

In total, 12 postgraduate courses were identified. These could be broadly categorized into two distinct groups: five courses focused on health-care sciences designed for multidisciplinary health professionals and seven targeted clinical specialities. UK universities therefore provide relatively few courses in EBP. Two models of EBP education appear to be developing, which either specifically target EBP as a separate component of the curriculum or integrate into existing subjects. Further evaluation is needed to determine the relative merits of each.

The effects of a double blind, placebo controlled, artificial food colourings and benzoate preservative challenge on hyperactivity in a general population sample of preschool children

AIMS

To determine whether artificial food colourings and a preservative in the diet of 3 year old children in the general population influence hyperactive behaviour.

METHODS

A sample of 1873 children were screened in their fourth year for the presence of hyperactivity at baseline (HA), of whom 1246 had skin prick tests to identify atopy (AT). Children were selected to form the following groups: HA/AT, not-HA/AT, HA/not-AT, and not-HA/not-AT (n = 277). After baseline assessment, children were subjected to a diet eliminating artificial colourings and benzoate preservatives for one week; in the subsequent three week within subject double blind crossover study they received, in random order, periods of dietary challenge with a drink containing artificial colourings (20 mg daily) and sodium benzoate (45 mg daily) (active period), or a placebo mixture, supplementary to their diet. Behaviour was assessed by a tester blind to dietary status and by parents' ratings.

RESULTS

There were significant reductions in hyperactive behaviour during the withdrawal phase. Furthermore, there were significantly greater increases in hyperactive behaviour during the active than the placebo period based on parental reports. These effects were not influenced by the presence or absence of hyperactivity, nor by the presence or absence of atopy. There were no significant differences detected based on objective testing in the clinic.

CONCLUSIONS

There is a general adverse effect of artificial food colouring and benzoate preservatives on the behaviour of 3 year old children which is detectable by parents but not by a simple clinic assessment. Subgroups are not made more vulnerable to this effect by their prior levels of hyperactivity or by atopy.

Azathioprine as an oral corticosteroid sparing agent for asthma

BACKGROUND

For the majority of chronic asthmatics, symptoms are best controlled by using inhaled steroids. However, for a small group of asthmatics, symptoms can only be controlled by high doses of oral steroids. Continuous use of oral steroid is associated with severe side-effects, but it has been suggested that azathioprine, an immunosuppressive anti-metabolite, often used to reduce the immune response in chronic active hepatitis and severe rheumatoid arthritis, could be useful as an oral steroid sparing agent. There is a need to systematically evaluate the evidence regarding its use to reduce or eliminate oral corticosteroid usage.

OBJECTIVES

The objective of this review is to assess the efficacy of adding azathioprine in patients with stable asthma who are dependent on oral corticosteroids with the intention of eventually minimizing or eliminating the use of these steroids.

SEARCH STRATEGY

Searches of the Cochrane Airways Group asthma and wheeze trials register were undertaken with predefined search terms. Searches were current as of February 2003

SELECTION CRITERIA

Only studies with a randomised placebo-controlled design met the inclusion criteria for the review.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed studies for suitability for inclusion in the review. Data were extracted and entered into RevMan 4.2.2.

MAIN RESULTS

Two small trials recruiting 23 participants met the inclusion criteria for the review. Participants may have been suffering from comorbid lung disease. No data on oral steroid consumption were reported. No significant differences were observed in the studies for FEV(1), FVC, PaO(2) and symptoms. One study reported a statistically significant difference in SGaw, but the clinical importance of this is uncertain. Due to concerns over the small sample sizes and methodological shortcomings in terms of inadequate washout in one study, and methods used in outcome assessment for both studies, the findings of the studies are not generalisable to the issue of steroid tapering.

REVIEWER'S CONCLUSIONS

Currently there is a clear lack of evidence to support the use of azathioprine in the treatment of chronic asthma as a steroid sparing-agent. Large, long-term studies with pre-defined steroid reducing protocols are required before recommendations for clinical practice can be made.

Unusual complication of sternotomy: bone fragment induced right ventricular rupture after mitral valve replacement surgery

Major surgical complications following open cardiac procedures via median sternotomy are infrequent but potentially devastating events. We report on a unique, fatal complication of median sternotomy. A 44-year-old woman underwent mitral valve replacement for endocarditis related to intravenous drug abuse. Twenty days after the surgery, she presented to the emergency department in acute distress, and died of cardiac tamponade soon after admission. Postmortem examination revealed a defect in the right ventricular wall caused by a bone fragment resulting from the median sternotomy.

Colchicine as an oral corticosteroid sparing agent for asthma

BACKGROUND

Oral corticosteroids are used as a treatment for asthma, but they are often associated with serious side effects. Colchicine is an anti-inflammatory, immuno modulating agent, which could potentially have a beneficial effect in the treatment of asthma as well as act as a steroid-sparing agent.

OBJECTIVES

To determine the effectiveness of colchicine as an oral corticosteroid sparing agent for in the treatment of chronic asthma.

SEARCH STRATEGY

We searched the Cochrane Airways Group trials register (November 2002), SIGLE (1980 to 2001) and reference lists of potential articles. We also contacted researchers in the field.

SELECTION CRITERIA

Randomised controlled trials investigating the addition of colchicine compared to placebo in stable steroid dependent asthmatics.

DATA COLLECTION AND ANALYSIS

No trials were found that met the inclusion criteria.

MAIN RESULTS

We were unable to perform any meta-analyses. Two small studies have assessed the efficacy of colchicine subsequent to inhaled steroid withdrawal and as a tapering agent in inhaled steroids. Both studies failed to detect a significant difference between colchicine and placebo.

REVIEWER'S CONCLUSIONS

No relevant trials have been published, so there is no evidence to indicate that colchicine is beneficial or otherwise in the management of steroid-dependent asthmatic patients. There is a need for well designed randomised controlled trials to be performed.

Chloroquine as a steroid sparing agent for asthma

BACKGROUND

For the majority of chronic asthmatics, symptoms are best controlled using inhaled steroids, but for a small group of asthma sufferers, symptoms cannot be controlled using inhaled steroids and instead continuous use of high dosage oral steroids (corticosteroids) are required. However, using high dosage oral steroids for long periods is associated with severe side effects. Steroid-sparing treatments have been sought and one of these is chloroquine. Chloroquine is an anti-inflammatory agent, also used in the treatment of malarial infection and as a second-line therapy in the treatment of rheumatoid arthritis, sarcoidosis and systemic lupus erythematosus. All these diseases are associated with immunologic abnormalities hence the speculation that chloroquine might be used to control severe, poorly controlled bronchial asthma. There is a need to systematically evaluate the evidence regarding its use to reduce or eliminate oral corticosteroid use in asthma.

OBJECTIVES

The object of this review was to assess the efficacy of adding chloroquine to oral corticosteroids in patients with chronic asthma who are dependent on oral corticosteroids with the intention of minimising or eventually eliminating the use of these oral steroids.

SEARCH STRATEGY

Searches of the Cochrane Airways Group asthma and wheeze trials register were undertaken with predefined search terms in February 2003.

SELECTION CRITERIA

Only studies with a randomised placebo-controlled design met the inclusion criteria for the review.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed studies for suitable in the review. Data were extracted and entered into RevMan 4.2.2

MAIN RESULTS

One small study was included in the review. No significant findings were reported.

REVIEWER'S CONCLUSIONS

There is insufficient evidence to support the use of chloroquine as an oral steroid-sparing agent in chronic asthma. Further trials should optimise oral steroid dosage before addition of the steroid-sparing agent.

Care home versus hospital and own home environments for rehabilitation of older people

BACKGROUND

Rehabilitation for older people has acquired an increasingly important profile for both policy-makers and service providers within health and social care agencies. This growing demand for rehabilitation services has generated an increased interest in the use of alternative care environments, for example care home environments, for older persons' rehabilitation. At a time when there is pressure for policy decision-makers and service providers to explore the use of such care settings for the provision of rehabilitation for older people, there appears limited evidence on which to base decisions.

OBJECTIVES

The objective of this review is to compare the effects of care home environments (e.g. nursing home, residential care home and nursing facilities) versus hospital environments and own home environments in the rehabilitation of older people.

SEARCH STRATEGY

The following databases were searched. The Cochrane Effective Practice and Organisation of Care Specialised Register, the Cochrane Rehabilitation Specialist Register; Cochrane Controlled Trials Register (CCTR); MEDLINE (1966-2000); EMBASE (1980-2000), Cumulative Index to Nursing and Allied Health Literature (CINAHL) (1982-2000): Science Citation Index (1982-2000); Social Science Citation Index (1982-2000); Best Evidence (1991-2000); HMIC (1979-2000); PsycINFO(1967-2000); ASSIA (1987-2000); Ageline (1978-2000); AgeInfo (1971-2000); Sociological Abstracts (1963-2000); System for Information on Grey Literature (SIGLE) (1980-2000); UK National Research Registers Project Database( Issue 1 2001); Architecture Publication Index (1977-2000). The following Journals were hand searched: Disability and Rehabilitation (1992-2000); Disability and Society (1986-2000); Archives of Physical Medicine and Rehabilitation (1985-2000); Journal of the American Geriatric Society (1980-2000); International Journal of Rehabilitation Research (1980-2000); American Journal of Physical Medicine and Rehabilitation (1980-2000) and: Clinical Rehabilitation (1992-2000). The reviewers also consulted subject area experts and obtained full text review articles and forward tracked any references from these sources.

SELECTION CRITERIA

Randomised controlled trials (RCTs), controlled clinical trials (CCTs), controlled before and after studies (CBAs) and interrupted time series (ITS) that compared rehabilitation outcomes for persons 60 years or older who received rehabilitation whilst residing in a care home with those for persons 60 years or older who received rehabilitation in hospital or own home environments. Primary outcomes included functional outcomes using activities of daily living measurement (both personal and instrumental). Secondary outcomes included subjective health status; quality of life measures; return to place of usual residency; all cause mortality; adverse effects; readmission to an acute care facility; patient and carer satisfaction; number of days in facility and number of days receiving rehabilitation.

DATA COLLECTION AND ANALYSIS

One reviewer (DW) completed the initial search and identified potential papers for inclusion. Abstracts for these papers were independently scrutinised by two reviewers (DW/MS) to assess their eligibility. Full text versions of potentially eligible papers were independently assessed by two reviewers (DW/MS). Papers that fulfilled the comparison inclusion criteria were then independently scrutinised by all reviewers to assess whether they met EPOC methodological criteria for inclusion.

MAIN RESULTS

The total yield from the initial search strategy was 19,457. A total of 1,247 abstracts were independently scrutinised by two reviewers (DW/MS) to assess their eligibility. Full text papers for 99 studies were obtained to assess if they fulfilled the review's comparison inclusion criteria. This process resulted in 12 papers being assessed further for methodological validity. However, none of these studies met the inclusion criteria.

REVIEWER'S CONCLUSIONS

There is insufficient evidence to compare the effects of care home environments, hospital environments and own home environments on older persons rehabilitation outcomes. Although the authors acknowledge that absence of effect is not no effect. There are three main reasons; the first is that the description and specification of the environment is often not clear; secondly, the components of the rehabilitation system within the given environments are not adequately specified and; thirdly, when the components are clearly specified they demonstrate that the control and intervention sites are not comparable with respect to the methodological criteria specified by Cochrane EPOC group (Cochrane 1998). The combined effect of these factors resulted in the comparability between intervention and control groups being very weak. For example, there were differences in the services provided in the intervention and control arms, due possibly to differences in dominant remuneration systems, nature of the rehabilitation transformation, patient characteristics, skill mix and academic status of the care environment.

Prevention of sensitization to house dust mite by allergen avoidance in school age children: a randomized controlled study

BACKGROUND

Sensitization to dust mites predisposes to asthma and allergic rhinitis, and prevention of this sensitization might reduce the rising prevalence of these disorders.

OBJECTIVE

To test the effectiveness of dust mite avoidance measures on the development of sensitization to dust mites in children.

METHODS

As part of a multicentre study (Study of Prevention of Allergy in Children of Europe), 242 children, aged 5-7 years, in three European countries (United Kingdom, Greece and Lithuania), were randomized to prophylactic group (n = 127) and control group (n = 115). At randomization these children were required to have a family history of atopy and positive skin test to an aeroallergen but not to house dust mite. Children in the prophylactic group were provided with dust mite impermeable mattress covers and advice on environmental measures to reduce exposure to dust-mite allergen. Control group children were given non-specific advice. After 12 months a standardized questionnaire was completed and skin prick tests were performed.

RESULTS

Ten children in the prophylactic group and 19 in the control group were lost to follow-up. Three of 117 (2.56%) children in the prophylactic group and nine of 96 (9.38%) in the control group developed sensitization to dust mites. Logistic regression analysis confirmed an independent effect of prophylactic measures (adjusted odds ratio (OR): 0.14, 95% confidence interval (CI): 0.03-0.79, P = 0.03). Fifteen children need to be treated to prevent sensitization in one child.

CONCLUSION

Dust mite sensitization can be reduced in school age children with simple mite avoidance measures.

Association of allergy-related symptoms with sensitisation to common allergens in an adult European population

BACKGROUND

Atopy is an important risk factor for asthma and allergic diseases. However, the relationship between atopy and allergic symptoms is not fully understood, and may not be the same for different allergy related symptoms and in differing environmental conditions.

OBJECTIVE

To study the differences in the association of allergy-related symptoms and atopy, in an adult population from five European countries.

METHODS

A prospective, multi-national study was conducted. Centres included Isle of Wight (UK), Vienna (Austria), Freiburg (Germany), Athens (Greece), and Kaunas (Lithuania). We used five questions derived from the ISAAC (International Study of Asthma and Allergy in Children) and other validated questionnaire, to evaluate the presence of allergic symptoms in a selected adult population. Atopy was assessed by SPT or IgE measurement to 3 core allergens (dust mite, cat and grass pollen) in all centres and 1-2 additional allergens relevant to each area (parietaria, olive, birch pollen, tree pollen mix, dog).

RESULTS

Of 3985 subjects, 2478 (62%) responded positively to one or more core ISAAC questions. Sensitisation rate was high in Austria and UK and relatively low in Greece. Dust mite and cat were important allergens for asthma, odds ratio (OR): 2.24, 95% confidence interval (CI): 1.63-3.08 and OR: 2.31, CI: 1.69-3.14, respectively. Grass pollen was strongly associated with hay fever in all centres (OR: 3.62 CI: 2.81-4.66) and with birch pollen in Austria (OR: 3.57, CI: 2.09-6.09) and with parietaria in Greece (4.61 (2.99-7.12). In the comparative analysis, using UK as a reference, Lithuanians had a 10-20-fold reduced risk of asthma and hay fever, but were twice more likely to report chronic itching. The risk of dust mite allergy was 3- and 10-fold lower in Lithuania and Greece, respectively, whereas the risk of cat and grass pollen allergy was one and half times higher in Austria.

CONCLUSION

The risk of allergic symptoms and sensitisation and their association vary widely in different European countries.

Dapsone as an oral corticosteroid sparing agent for asthma

BACKGROUND

Oral corticosteroids are used as a treatment for asthma, however they are often associated with serious side effects. Dapsone is a sulfone with anti-inflammatory properties, therefore it may have a beneficial effect in the treatment of asthma and act as a corticosteroid-sparing agent.

OBJECTIVES

The objective of this review is to assess the safety and efficacy of adding dapsone to oral corticosteroids in adults with stable asthma who are dependent on oral corticosteroids with the intention of eventually minimizing or eliminating the use of these steroids.

SEARCH STRATEGY

The Cochrane Airways group trials register and reference lists of potential articles were searched.

SELECTION CRITERIA

Randomised controlled trials investigating the addition of dapsone compared to placebo in stable corticosteroid dependent asthmatics.

DATA COLLECTION AND ANALYSIS

No trials were found that met the selection criteria.

MAIN RESULTS

No meta-analyses could be performed.

REVIEWER'S CONCLUSIONS

No randomised controlled trials have been published, so there is no reliable evidence to show whether dapsone is beneficial or otherwise in the management of steroid-dependent asthmatic patients. There is a need for well designed randomised controlled trials to be performed. These must be carried out double-blind, since oral corticosteroid reduction requires a judgement on the part of the physician, who may be open to bias if the treatment allocation is known.