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Objective: To investigate the effectiveness of a school based intervention to increase physical activity, reduce sedentary behaviour, and increase fruit and vegetable consumption in children., Design: Cluster randomised controlled trial., Setting: 60 primary schools in the south west of England., Participants: Primary school children who were in school year 4 (age 8-9 years) at recruitment and baseline assessment, in year 5 during the intervention, and at the end of year 5 (age 9-10) at follow-up assessment., Intervention: The Active for Life Year 5 (AFLY5) intervention consisted of teacher training, provision of lesson and child-parent interactive homework plans, all materials required for lessons and homework, and written materials for school newsletters and parents. The intervention was delivered when children were in school year 5 (age 9-10 years). Schools allocated to control received standard teaching., Main Outcome Measures: The pre-specified primary outcomes were accelerometer assessed minutes of moderate to vigorous physical activity per day, accelerometer assessed minutes of sedentary behaviour per day, and reported daily consumption of servings of fruit and vegetables., Results: 60 schools with more than 2221 children were recruited; valid data were available for fruit and vegetable consumption for 2121 children, for accelerometer assessed physical activity and sedentary behaviour for 1252 children, and for secondary outcomes for between 1825 and 2212 children for the main analyses. None of the three primary outcomes differed between children in schools allocated to the AFLY5 intervention and those allocated to the control group. The difference in means comparing the intervention group with the control group was -1.35 (95% confidence interval -5.29 to 2.59) minutes per day for moderate to vigorous physical activity, -0.11 (-9.71 to 9.49) minutes per day for sedentary behaviour, and 0.08 (-0.12 to 0.28) servings per day for fruit and vegetable consumption. The intervention was effective for three out of nine of the secondary outcomes after multiple testing was taken into account: self reported time spent in screen viewing at the weekend (-21 (-37 to -4) minutes per day), self reported servings of snacks per day (-0.22 (-0.38 to -0.05)), and servings of high energy drinks per day (-0.26 (-0.43 to -0.10)) were all reduced. Results from a series of sensitivity analyses testing different assumptions about missing data and from per protocol analyses produced similar results., Conclusion: The findings suggest that the AFLY5 school based intervention is not effective at increasing levels of physical activity, decreasing sedentary behaviour, and increasing fruit and vegetable consumption in primary school children. Change in these activities may require more intensive behavioural interventions with children or upstream interventions at the family and societal level, as well as at the school environment level. These findings have relevance for researchers, policy makers, public health practitioners, and doctors who are involved in health promotion, policy making, and commissioning services. Trial registration Current Controlled Trials ISRCTN50133740., (© Kipping et al 2014.)

Objective: To investigate the effectiveness of facilitated physical activity as an adjunctive treatment for adults with depression presenting in primary care., Design: Pragmatic, multicentre, two arm parallel randomised controlled trial., Setting: General practices in Bristol and Exeter., Participants: 361 adults aged 18-69 who had recently consulted their general practitioner with symptoms of depression. All those randomised had a diagnosis of an episode of depression as assessed by the clinical interview schedule-revised and a Beck depression inventory score of 14 or more., Interventions: In addition to usual care, intervention participants were offered up to three face to face sessions and 10 telephone calls with a trained physical activity facilitator over eight months. The intervention was based on theory and aimed to provide individually tailored support and encouragement to engage in physical activity., Main Outcome Measures: The primary outcome was self reported symptoms of depression, assessed with the Beck depression inventory at four months post-randomisation. Secondary outcomes included use of antidepressants and physical activity at the four, eight, and 12 month follow-up points, and symptoms of depression at eight and 12 month follow-up., Results: There was no evidence that participants offered the physical activity intervention reported improvement in mood by the four month follow-up point compared with those in the usual care group; adjusted between group difference in mean Beck depression inventory score -0.54 (95% confidence interval -3.06 to 1.99; P=0.68). Similarly, there was no evidence that the intervention group reported a change in mood by the eight and 12 month follow-up points. Nor was there evidence that the intervention reduced antidepressant use compared with usual care (adjusted odds ratio 0.63, 95% confidence interval 0.19 to 2.06; P=0.44) over the duration of the trial. However, participants allocated to the intervention group reported more physical activity during the follow-up period than those allocated to the usual care group (adjusted odds ratio 2.27, 95% confidence interval 1.32 to 3.89; P=0.003)., Conclusions: The addition of a facilitated physical activity intervention to usual care did not improve depression outcome or reduce use of antidepressants compared with usual care alone., Trial Registration: Current Controlled Trials ISRCTN16900744.

Objective: To identify and quantify symptoms of ovarian cancer in women in primary care., Design: Case-control study, with coding of participants' primary care records for one year before diagnosis., Setting: 39 general practices in Devon, England., Participants: 212 women aged over 40 with a diagnosis of primary ovarian cancer, 2000-7; 1060 controls matched by age and general practice., Main Outcome Measures: Odds ratios and positive predictive values for symptoms from conditional logistic regression analyses., Results: Seven symptoms were associated with ovarian cancer in multivariable analysis. The univariable positive predictive values and multivariable odds ratios (with 95% confidence intervals) for these were 2.5% (1.2% to 5.9%) and 240 (46 to 1200) for abdominal distension; 0.5% (0.2% to 0.9%) and 24 (9.3 to 64) for postmenopausal bleeding; 0.6% (0.3% to 1.0%) and 17 (6.1 to 50) for loss of appetite; 0.2% (0.1% to 0.3%) and 16 (5.6 to 48) for increased urinary frequency; 0.3% (0.2% to 0.3%) and 12 (6.1 to 22) for abdominal pain; 0.2% (0.1% to 0.4%) and 7.6 (2.5 to 23) for rectal bleeding; and 0.3% (0.2% to 0.6%) and 5.3 (1.8 to 16) for abdominal bloating. In 181 (85%) cases and 164 (15%) controls at least one of these seven symptoms was reported to primary care before diagnosis. After exclusion of symptoms reported in the 180 days before diagnosis, abdominal distension, urinary frequency, and abdominal pain remained independently associated with a diagnosis of ovarian cancer., Conclusions: Women with ovarian cancer usually have symptoms and report them to primary care, sometimes months before diagnosis. This study provides an evidence base for selection of patients for investigation, both for clinicians and for developers of guidelines.

Objective: To estimate the cost to the NHS and to parents and carers of treating febrile preschool children with paracetamol, ibuprofen, or both, and to compare these costs with the benefits of each treatment regimen., Design: Cost consequences analysis and cost effectiveness analysis conducted as part of a three arm, randomised controlled trial., Participants: Children between the ages of 6 months and 6 years recruited from primary care and the community with axillary temperatures >or=37.8 degrees C and

Objective: To investigate whether paracetamol (acetaminophen) plus ibuprofen are superior to either drug alone for increasing time without fever and the relief of fever associated discomfort in febrile children managed at home., Design: Individually randomised, blinded, three arm trial., Setting: Primary care and households in England., Participants: Children aged between 6 months and 6 years with axillary temperatures of at least 37.8 degrees C and up to 41.0 degrees C., Intervention: Advice on physical measures to reduce temperature and the provision of, and advice to give, paracetamol plus ibuprofen, paracetamol alone, or ibuprofen alone., Main Outcome Measures: Primary outcomes were the time without fever (<37.2 degrees C) in the first four hours after the first dose was given and the proportion of children reported as being normal on the discomfort scale at 48 hours. Secondary outcomes were time to first occurrence of normal temperature (fever clearance), time without fever over 24 hours, fever associated symptoms, and adverse effects., Results: On an intention to treat basis, paracetamol plus ibuprofen were superior to paracetamol for less time with fever in the first four hours (adjusted difference 55 minutes, 95% confidence interval 33 to 77; P<0.001) and may have been as good as ibuprofen (16 minutes, -7 to 39; P=0.2). For less time with fever over 24 hours, paracetamol plus ibuprofen were superior to paracetamol (4.4 hours, 2.4 to 6.3; P<0.001) and to ibuprofen (2.5 hours, 0.6 to 4.4; P=0.008). Combined therapy cleared fever 23 minutes (2 to 45; P=0.025) faster than paracetamol alone but no faster than ibuprofen alone (-3 minutes, 18 to -24; P=0.8). No benefit was found for discomfort or other symptoms, although power was low for these outcomes. Adverse effects did not differ between groups., Conclusion: Parents, nurses, pharmacists, and doctors wanting to use medicines to supplement physical measures to maximise the time that children spend without fever should use ibuprofen first and consider the relative benefits and risks of using paracetamol plus ibuprofen over 24 hours., Trial Registration: Current Controlled Trials ISRCTN26362730.

Objectives: To determine the effects of two computer based decision aids on decisional conflict and mode of delivery among pregnant women with a previous caesarean section., Design: Randomised trial, conducted from May 2004 to August 2006., Setting: Four maternity units in south west England, and Scotland., Participants: 742 pregnant women with one previous lower segment caesarean section and delivery expected at >or=37 weeks. Non-English speakers were excluded., Interventions: Usual care: standard care given by obstetric and midwifery staff. Information programme: women navigated through descriptions and probabilities of clinical outcomes for mother and baby associated with planned vaginal birth, elective caesarean section, and emergency caesarean section. Decision analysis: mode of delivery was recommended based on utility assessments performed by the woman combined with probabilities of clinical outcomes within a concealed decision tree. Both interventions were delivered via a laptop computer after brief instructions from a researcher., Main Outcome Measures: Total score on decisional conflict scale, and mode of delivery., Results: Women in the information programme (adjusted difference -6.2, 95% confidence interval -8.7 to -3.7) and the decision analysis (-4.0, -6.5 to -1.5) groups had reduced decisional conflict compared with women in the usual care group. The rate of vaginal birth was higher for women in the decision analysis group compared with the usual care group (37% v 30%, adjusted odds ratio 1.42, 0.94 to 2.14), but the rates were similar in the information programme and usual care groups., Conclusions: Decision aids can help women who have had a previous caesarean section to decide on mode of delivery in a subsequent pregnancy. The decision analysis approach might substantially affect national rates of caesarean section. Trial Registration Current Controlled Trials ISRCTN84367722.

Objectives: To evaluate the effectiveness and acceptability of a lidocaine spray in reducing perineal pain during spontaneous vaginal delivery., Design: Randomised controlled trial., Setting: Consultant led obstetric unit., Participants: 185 women who had a spontaneous vaginal delivery without epidural analgesia., Interventions: Topically applied local anaesthetic spray (93 women) and placebo spray (92 women)., Main Outcome Measure: Primary outcome measure was pain during delivery (0-100 scale). The 16 secondary outcome measures included second degree perineal trauma during delivery, trauma of the genital tract, and dyspareunia by two months., Results: Lidocaine spray did not reduce pain during spontaneous vaginal delivery: mean 77 and 72 on a scale of 0-100 in the lidocaine and placebo groups, respectively (difference between means 4.8, 95% confidence interval -1.7 to 11.2). Lidocaine spray may reduce genital tract trauma during delivery, in particular second degree perineal trauma. The intervention was highly acceptable to the women and midwives., Conclusions: Although lidocaine spray applied to the perineum during spontaneous vaginal delivery did not reduce perineal pain, it was acceptable to both the women and the midwives., Trial Registration: Current controlled trials ISRCTN99732966 [controlled-trials.com].

Objective: To carry out an economic evaluation of a general practitioner with special interest service for non-urgent skin problems compared with hospital outpatient care., Design: Cost effectiveness analysis and cost consequences analysis alongside a randomised controlled trial., Setting: General practitioner with special interest dermatology service covering 29 general practices in Bristol., Participants: Adults referred to a hospital dermatology clinic who were potentially suitable for management by a general practitioner with special interest., Interventions: Participants were randomised 2:1 to receive either care by general practitioner with special interest service or usual hospital outpatient care., Main Outcome Measures: Costs to NHS, patients, and companions, and costs of lost production. Cost effectiveness, using the two primary outcomes of dermatology life quality index scores and improved patient perceived access, was assessed by incremental cost effectiveness ratios and cost effectiveness acceptability curves. Cost consequences are presented in relation to all costs and both primary and secondary outcomes from the trial., Results: Costs to the NHS for patients attending the general practitioner with special interest service were 208 pounds sterling (361 dollars; 308 euro) compared with 118 pounds sterling for hospital outpatient care. Based on analysis with imputation of missing data, costs to patients and companions were 48 pounds sterling and 51 pounds sterling, respectively; costs of lost production were 27 pounds sterling and 34 pounds sterling, respectively. The incremental cost effectiveness ratios for general practitioner with special interest care over outpatient care were 540 pounds sterling per one point gain in the dermatology life quality index and 66 pounds sterling per 10 point change in the access scale., Conclusions: The general practitioner with special interest service for dermatology is more costly than hospital outpatient care, but this additional cost needs to be weighed against improved access and broadly similar health outcomes.

Objectives: To assess the association between elective caesarean section and postnatal depression compared with planned vaginal delivery and whether emergency caesarean section or assisted vaginal delivery is associated with postnatal depression compared with spontaneous vaginal delivery., Design: Prospective population based cohort study., Setting: ALSPAC (the Avon longitudinal study of parents and children)., Participants: 14,663 women recruited antenatally with a due date between 1 April 1991 and 31 December 1992., Main Outcome Measure: Edinburgh postnatal depression scale score > or = 13 at eight weeks postnatal on self completed questionnaire., Results: Albeit with wide confidence intervals, there was no evidence that elective caesarean section altered the odds of postnatal depression compared with planned vaginal delivery (adjusted odds ratio 1.06, 95% confidence interval 0.66 to 1.70, P = 0.80). Among planned vaginal deliveries there was similarly little evidence of a difference between women who have emergency caesarean section or assisted vaginal delivery and those who have spontaneous vaginal delivery (1.17, 0.77 to 1.79, P = 0.46, and 0.89, 0.68 to 1.18, P = 0.42, respectively)., Conclusions: There is no reason for women at risk of postnatal depression to be managed differently with regard to mode of delivery. Elective caesarean section does not protect against postnatal depression. Women who plan vaginal delivery and require emergency caesarean section or assisted vaginal delivery can be reassured that there is no reason to believe that they are at increased risk of postnatal depression.

Objectives: To evaluate the impact of an intervention based in general practice on the incidence of repeat episodes of deliberate self harm., Design: Cluster randomised controlled trial in which 98 general practices were assigned in equal numbers to an intervention or a control group. The intervention comprised a letter from the general practitioner inviting the patient to consult, and guidelines on assessment and management of deliberate self harm for the general practitioner to use in consultations. Control patients received usual general practitioner care., Setting: General practices within Avon, Wiltshire, and Somerset Health Authorities, whose patients lived within the catchment area of four general hospitals in Bristol and Bath., Participants: 1932 patients registered with the study practices who had attended accident and emergency departments at one of the four hospitals after an episode of deliberate self harm., Main Outcome Measures: Primary outcome was occurrence of a repeat episode of deliberate self harm in the 12 months after the index episode. Secondary outcomes were number of repeat episodes and time to first repeat., Results: The incidence of repeat episodes of deliberate self harm was not significantly different for patients in the intervention group compared with the control group (odds ratio 1.2, 95% confidence interval 0.9 to 1.5). Similar findings were obtained for the number of repeat episodes and time to first repeat. Subgroup analyses indicated that there was no differential effect of the intervention according to patient's sex (P=0.51) or method used to cause deliberate self harm (P=0.64). The treatment seemed to be beneficial for people with a history of deliberate self harm, but it was associated with an adverse effect in people for whom the index episode was their first episode (interaction P=0.017)., Conclusions: An invitation to consult, sent by the general practitioner of patients who have deliberately harmed themselves, and the use of management guidelines during any subsequent consultation did not reduce the incidence of repeat self harm. A subgroup analysis that indicated that patients who had previously harmed themselves benefited from the intervention was inconsistent with previous evidence and should be treated with caution. More research is needed on how to manage patients who deliberately harm themselves, to reduce the incidence of repeat episodes.

Objective: To examine the impact on sexual function of treatments for lower urinary tract symptoms in men., Design: Multicentre pragmatic randomised controlled trial of standard surgery (transurethral resection of the prostate), non-contact laser therapy, and conservative management (no active intervention)., Setting: Three clinical centres in the United Kingdom., Participants: 340 men aged between 48 and 90 years with lower urinary tract symptoms related to benign prostatic enlargement., Main Outcome Measures: ICSsex questionnaire items concerned with erectile stiffness, ejaculatory volume, pain or discomfort on ejaculation, whether sex life was spoilt by urinary symptoms., Results: Erectile and ejaculatory dysfunction were common (70%) and problematic at baseline and showed the expected trends with ageing. After treatment, reduced ejaculation was reported in all groups but was not significantly worse after standard surgery than after laser therapy. Erectile function was significantly improved after standard surgery; no significant difference was found between standard surgery and laser therapy (odds ratio 0.70, 95% confidence interval 0.36 to 1.38). Standard surgery was significantly better at relieving pain or discomfort on ejaculation than either conservative management (0.06, 0.007 to 0.49) or laser therapy (0.09, 0.01 to 0.73)., Conclusions: Compared with laser therapy standard surgery for lower urinary tract symptoms has a beneficial effect on aspects of sexual function-particularly in improving erectile function and reducing reported pain or discomfort on ejaculation. Older men who need treatment and want to retain or improve sexual function may thus want to consider standard surgery rather than non-contact laser therapy.

Objective: To compare routine speech and language therapy in preschool children with delayed speech and language against 12 months of "watchful waiting.", Design: Pragmatic randomised controlled trial., Setting: 16 community clinics in Bristol., Participants: 159 preschool children with appreciable speech or language difficulties who fulfilled criteria for admission to speech and language therapy., Main Outcome Measures: Four quantitative measures of speech and language, assessed at 6 and 12 months; a binary variable indicating improvement, by 12 months, on the trial entry criterion., Results: Improvement in auditory comprehension was significant in favour of therapy (adjusted difference in means 4.1, 95% confidence interval 0.5 to 7.6; P=0.025). No significant differences were observed for expressive language (1.4, -2.1 to 4.8; P=0.44); phonology error rate (-4.4, -12.0 to 3.3; P=0.26); language development (0.1, -0.4 to 0.6; P=0.73); or improvement on entry criterion (odds ratio 1.3, 0.67 to 2.4; P=0.46). At the end of the trial, 70% of all children still had substantial speech and language deficits., Conclusions: This study provides little evidence for the effectiveness of speech and language therapy compared with watchful waiting over 12 months. Providers of speech and language therapy should reconsider the appropriateness, timing, nature, and intensity of such therapy in preschool children. Continued research into more specific provision to subgroups of children is also needed to identify better treatment methods. The lack of resolution of difficulties for most of the children suggests that further research is needed to identify effective ways of helping this population of children.

Objective: To investigate the impact of patients' preferences for the treatment of atrial fibrillation, by using individualised decision analysis combining probability and utility assessments into a decision tree., Design: Observational study based on interviews with patients., Setting: Eight general practices in Avon., Participants: 260 randomly selected patients aged 70-85 years with atrial fibrillation., Main Outcome Measures: Patients' treatment preferences regarding anticoagulation treatment (warfarin) after individualised decision analysis; comparison of these preferences with treatment guidelines on the basis of comorbidity and absolute risk and compared with current prescription., Results: Of 195 eligible patients, 97 participated in decision making using decision analysis. Among these 97, the decision analysis indicated that 59 (61%; 95% confidence interval 50% to 71%) would prefer anticoagulation treatment-considerably fewer than those who would be recommended treatment according to guidelines. There was marked disagreement between the decision analysis and guideline recommendations (kappa=0.25 or less). Of 38 patients whose decision analysis indicated a preference for anticoagulation, 17 (45%) were being prescribed warfarin; on the other hand, 28 (47%) of 59 patients were not being prescribed warfarin although the results of their decision analysis suggested they wanted to be., Conclusions: In the context of shared decision making, individualised decision analysis is valuable in a sizeable proportion of elderly patients with atrial fibrillation. Taking account of patients' preferences would lead to fewer prescriptions for warfarin than under published guideline recommendations. Decision analysis as a shared decision making tool should be evaluated in a randomised controlled trial.

Objectives: To investigate the effect of a computer based clinical decision support system and a risk chart on absolute cardiovascular risk, blood pressure, and prescribing of cardiovascular drugs in hypertensive patients., Design: Cluster randomised controlled trial., Setting: 27 general practices in Avon., Participants: 614 patients aged between 60 and 79 years with high blood pressure., Interventions: Patients were randomised to computer based clinical decision support system plus cardiovascular risk chart; cardiovascular risk chart alone; or usual care., Main Outcome Measures: Percentage of patients in each group with a five year cardiovascular risk >/=10%, systolic blood pressure, diastolic blood pressure, prescribing of cardiovascular drugs., Results: Patients in the computer based clinical decision support system and chart only groups were no more likely to have cardiovascular risk reduced to below 10% than patients receiving usual care. Patients in the computer based clinical decision support group were more likely to have a cardiovascular risk >/=10% than chart only patients, odds ratio 2.3 (95% confidence interval 1.1 to 4.8). The chart only group had significantly lower systolic blood pressure compared with the usual care group (difference in means -4.6 mm Hg (95% confidence interval -8.4 to -0.8)). Reduction of diastolic blood pressure did not differ between the three groups. The chart only group were twice as likely to be prescribed two classes of cardiovascular drugs and over three times as likely to be prescribed three or more classes of drugs compared with the other groups., Conclusions: The computer based clinical decision support system did not confer any benefit in absolute risk reduction or blood pressure control and requires further development and evaluation before use in clinical care can be recommended. Use of chart guidelines are associated with a potentially important reduction in systolic blood pressure.

Objectives: To compare the self reported health of a group of individuals living in an area contaminated by chromium (chromium group) with a group living in an uncontaminated area (control group), and to assess the effects of perception of risk from exposure to chromium on health., Design: Cross sectional study using the SF-36 validated quality of life questionnaire. Further questions were added to examine the relations between perceptions about living on or near land contaminated with chromium and the effects on self reported health., Setting: An area contaminated with chromium (Cambuslang, Carmyle, and Rutherglen) and a control area (Barrmulloch and Pollok)., Participants: Residents of an area containing chromium landfill and residents of an uncontaminated control area., Main Outcome Measures: Scores on SF-36., Results: Little difference was found in health scores between the two groups, and only for general health was there a significantly higher score in the chromium group. Health scores for the chromium group were significantly worse across all dimensions for those who believed that chromium adversely affected health. Most of the chromium group (68%) would prefer money to be spent on improving amenities rather than on chromium remediation., Conclusions: Similar self reported health among residents of the chromium and control groups indicates that there is no evidence of harm to health from exposure to chromium in this setting. Noticeably lower scores in participants who believed chromium to be harmful to health point to the potential importance of perception and possible anxiety. Given the overall greater desire for better amenities rather than remedial action, policy makers and planners should discuss with residents how best to spend resources before instigating expensive cleaning up programmes.

Objective: To compare effectiveness and acceptability of early discharge to a hospital at home scheme with that of routine discharge from acute hospital., Design: Pragmatic randomised controlled trial., Setting: Acute hospital wards and community in north of Bristol, with a catchment population of about 224 000 people., Subjects: 241 hospitalised but medically stable elderly patients who fulfilled criteria for early discharge to hospital at home scheme and who consented to participate., Interventions: Patients' received hospital at home care or routine hospital care., Main Outcome Measures: Patients' quality of life, satisfaction, and physical functioning assessed at 4 weeks and 3 months after randomisation to treatment; length of stay in hospital and in hospital at home scheme after randomisation; mortality at 3 months., Results: There were no significant differences in patient mortality, quality of life, and physical functioning between the two arms of the trial at 4 weeks or 3 months. Only one of 11 measures of patient satisfaction was significantly different: hospital at home patients perceived higher levels of involvement in decisions. Length of stay for those receiving routine hospital care was 62% (95% confidence interval 51% to 75%) of length of stay in hospital at home scheme., Conclusions: The early discharge hospital at home scheme was similar to routine hospital discharge in terms of effectiveness and acceptability. Increased length of stay associated with the scheme must be interpreted with caution because of different organisational characteristics of the services.

Objective: To compare, from the viewpoints of the NHS and social services and of patients, the costs associated with early discharge to a hospital at home scheme and those associated with continued care in an acute hospital., Design: Cost minimisation analysis., Setting: Acute hospital wards and the community in the north of Bristol (population about 224 000)., Subjects: 241 hospitalised but medically stable elderly patients who fulfilled the criteria for early discharge to a hospital at home scheme and who consented to participate., Main Outcome Measures: Costs to the NHS, social services, and patients over the 3 months after randomisation., Results: The mean cost for hospital at home patients over the 3 months was 2516 pounds, whereas that for hospital patients was 3292 pounds. Under all the assumptions used in the sensitivity analysis, the cost of hospital at home care was less than that of hospital care. Only when hospital costs were assumed to be less than 50% of those used in the initial analysis was the difference equivocal., Conclusions: The hospital at home scheme is less costly than care in the acute hospital. These results may be generalisable to schemes of similar size and scope, operating in a similar context of rising acute admissions.

Objective: To examine the relation between energy intake in childhood and adult mortality from cancer., Study Design: Cohort study., Setting: 16 rural and urban centres in England and Scotland., Subjects: 3834 people who took part in Lord Boyd Orr's Carnegie survey of family diet and health in prewar Britain between 1937 and 1939 who were followed up with the NHS, central register. Standardised methods were used to measure household dietary intake during a one week period., Main Outcome Measures: Cancer mortality., Results: Significant associations between childhood energy intake and cancer mortality were seen when the confounding effects of social variables were taken into account in proportional hazards models (relative hazard for all cancer mortality 1.15 (95% confidence interval 1.06 to 1.24), P = 0.001, for every MJ increase in adult equivalent daily intake in fully adjusted models). This effect was essentially limited to cancers not related to smoking (relative hazard 1.20; 1.07 to 1.34; P = 0.001), with similar effects seen in men and women., Conclusion: This positive association between childhood energy intake and later cancer is consistent with animal evidence linking energy restriction with reduced incidence of cancer and the association between height and human cancer, implying that higher levels of energy intake in childhood increase the risk of later development of cancer. This evidence for long term effects of early diet confirm the importance of optimal nutrition in childhood and suggest that the unfavourable trends seen in the incidence of some cancers may have their origins in early life.

Objectives: To investigate and quantify the extent to which variations in guidelines influence assessment of control of hypertension., Design: Cross sectional study. Selected patients had hypertension assessed as controlled or uncontrolled with guidelines from New Zealand, Canada, the United States, Britain, and the World Health Organisation., Setting: 18 general practices in Oxfordshire., Subjects: 876 patients with diagnosed hypertension and taking antihypertensive drugs., Main Outcome Measures: Proportion of patients with controlled hypertension according to each set of guidelines., Results: The proportion of patients with controlled hypertension varied from 17.5% to 84.6% with the different guidelines after adjustment for the sampling method. All five sets of guidelines agreed on the classification for 31% (277) of the patients. The New Zealand guidelines calculate an absolute risk of a cardiovascular event. When this was taken as the standard half of the patients with uncontrolled hypertension by the United States criteria would be treated unnecessarily and 31% of those classified as having controlled hypertension by the Canadian guidelines would be denied beneficial treatment., Conclusions: Hypertension guidelines are inconsistent in their recommendations and need to make clear the absolute benefits and risks of treatment.

Objective: To assess whether the way in which the results of a randomised controlled trial and a systematic review are presented influences health policy decisions., Design: A postal questionnaire to all members of a health authority within one regional health authority., Setting: Anglia and Oxford regional health authorities., Subjects: 182 executive and non-executive members of 13 health authorities, family health services authorities, or health commissions., Main Outcome Measures: The average score from all health authority members in terms of their willingness to fund a mammography programme or cardiac rehabilitation programme according to four different ways of presenting the same results of research evidence--namely, as a relative risk reduction, absolute risk reduction, proportion of event free patients, or as the number of patients needed to be treated to prevent an adverse event., Results: The willingness to fund either programme was significantly influenced by the way in which data were presented. Results of both programmes when expressed as relative risk reductions produced significantly higher scores when compared with other methods (P < 0.05). The difference was more extreme for mammography, for which the outcome condition is rarer., Conclusions: The method of reporting trial results has a considerable influence on the health policy decisions made by health authority members.

Objective: To examine the relations between parasuicide, suicide, psychiatric inpatient admissions, and socioeconomic deprivation., Design: Ecological analysis with data from routine information systems and the 1991 census., Setting: 24 localities in the area covered by the Bristol and District Health Authority (population 817,000), consisting of aggregations of neighbouring wards, with an average population of 34,000., Subjects: 6089 subjects aged over 10 years admitted to hospital after parasuicide between April 1990 and March 1994; 997 suicides occurring 1982-91; 4763 subjects aged 10-64 years admitted with acute psychiatric illness between April 1990 and March 1994., Results: Localities varied significantly in standardised admission ratios for parasuicide and standardised mortality ratios for suicide (P < 0.001). Spearman's rank correlation coefficient between the standardised mortality ratio for suicide and standardised admission ratio for parasuicide was 0.73 (95% confidence interval 0.46 to 0.88). Correlation between parasuicide and Townsend score was 0.86 (0.70 to 0.94) and between suicide and Townsend score 0.73 (0.46 to 0.88). The partial correlation coefficient between suicide and parasuicide after the Townsend score was adjusted for was 0.29 (-0.13 to 0.62). The correlation between standardised admission ratio for parasuicide and standardised admission ratio for psychiatric illness was 0.76 (0.51 to 0.89) and between standardised mortality ratio for suicide and standardised admission ratio for psychiatric illness was 0.72 (0.45 to 0.87)., Conclusion: A strong ecological association exists between suicide and parasuicide, with socioeconomic deprivation accounting for much of this relation. This strong association provides supporting evidence for the importance of social policy measures in attaining Health of the Nation targets on mental health.

Objective: To investigate the role of genetically determined differences in the enzymes of alcohol metabolism in susceptibility to liver damage from misusing alcohol., Design: Use of pADH36 probe to study PVU II restriction length fragment polymorphism in alcohol dehydrogenase 2 gene in white alcohol misusers and controls., Setting: Teaching hospital referral centres for liver disease and alcohol misuse., Subjects: 45 white alcohol misusers (38 with alcoholic liver disease) and 23 healthy controls., Main Outcome Measures: Alcohol misuse, the presence and severity of alcoholic liver disease, alcohol dependency, and family history of alcohol misuse., Results: A two allele polymorphism (A and B) was identified. In control subjects the allele frequencies were 85% for A and 15% for B compared with 37% and 63% respectively in alcohol misusers (p < 0.001). B allele was significantly associated with severe liver damage (p < 0.05) as well as alcohol dependency and family history of alcohol misuse compared with controls., Conclusion: Inherited variation in enzymes of ethanol metabolism may contribute to the pathogenesis of alcohol induced liver damage. This supports the presence of a genetic component in alcohol misuse.