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Study Type – Symptom prevalence (non-consecutive cohort) Level of Evidence 4 What’s known on the subject? and What does the study add? Obesity is a known risk factor for Urinary Incontinence. Non surgical weight loss has been shown to reduce Urinary Incontinence, but there is only limited evidence for surgically induced weight loss. This study aims to clarify the effects of surgically induced weight loss on urinary and erectile function. OBJECTIVE To investigate the effects of weight loss and time post laparoscopic gastric banding surgery (LGB) on urinary and sexual function. MATERIALS AND METHODS 653 females and 145 males who underwent LGB over the last 10 years at a single centre in Australia were contacted by post and asked to complete validated questionnaires. RESULTS The pre-surgery body-mass index (BMI) was higher in males than females (47.3 vs 43.5); 65% of the females and 24% of males previously had some degree of urinary incontinence (UI). There were significant weight and BMI losses in males and females (23.2 kg and 7.51 vs 22.7 kg and 8.28; P < 0.0001). In females there were significant improvements in the ICIQ-SF (P= 0.0008) and Quality of Life (P < 0.0001) scores. For each kilogram lost there was a 0.05 improvement in the ICIQ score (P= 0.03) in females. There were also postoperative improvements in all symptoms of UI and stress incontinence in females but urge incontinence worsened, when adjusted for weight loss. In males there was no improvement in UI with weight loss after LGB. There was no relationship with time and UI in either gender; 83.3% of males reported a degree of ED before LGB. There was improvement in the IIEF score in males post LGB but there was worsening of erectile index (P= 0.005) and orgasmic function (P= 0.002) when adjusted for time. More males had started using phosphodiesterase type 5 inhibitors, post-LGB. CONCLUSIONS Surgically induced weight loss by LGB improved overall UI, quality of life and stress incontinence in females but urge incontinence worsened. There was no improvement in UI with weight-loss or overall sexual function after LGB in males. However, erectile index and orgasmic function worsened when adjusted for time. Further evaluation is required by means of larger prospective studies involving urodynamic testing.

Background: Stroke is an Australian health priority area causing considerable levels of disability. We report 90-day outcomes for a cohort of acute stroke patients in New South Wales (NSW), Australia prior to randomization to a large cluster randomized controlled trial (CRCT), the Quality in Acute Stroke Care (QASC) trial. Aims: This paper describes prospectively collected, 90-day outcome data for a cohort of NSW stroke patients, providing pre-intervention data for the QASC trial. Methods: A consecutive sample of patients from acute stroke units in NSW was recruited. We measured patient death, disability (modified Rankin Score (mRS)), dependency (Barthel Index (BI)) and Health Status (Medical Outcomes Short-Form Health Survey (SF-36)) 90 days post-hospital admission. We also collected self-reported healthcare utilization and patient satisfaction with health professionals' advice and management to reduce risk of subsequent stroke. Results: Ninety-day outcome data were obtained for 687 patients, of which, 335 (49%) had an mRS ≥2; 44 patients (6.4%) had died. For the 643 surviving patients, the mean BI was 87.2 (SD 21.9) and the mean scores for SF-36 Physical Component Summary score and Mental Component Summary score were 46.2 (SD 10.1) and 46.3 (SD 12.6) respectively. Conclusions: In this pre-intervention cohort of selected acute stroke inpatients, stroke severity was mild to moderate and subsequent clinical outcomes were favourable in the majority. The findings from this study provide a comprehensive description of 90-day health outcomes of patients who have experienced a mild–moderate stroke managed in stroke care units across metropolitan NSW and provide valuable data to inform the subsequent cluster trial.

Objectives: To explore whether a group programme for community-dwelling chronic stroke survivors and their carers is feasible in rural settings; to measure the impact of the programme on health-related quality of life and functional performance; and to determine if any benefits gained are maintained. Design: Randomized, assessor blind, cross-over, controlled trial. Setting: Rural outpatient. Subjects: Twenty-five community-dwelling, chronic stroke survivors and 17 carers of participant stroke survivors. Intervention: The intervention group undertook a once-a-week, seven-week group programme combining physical activity, education, self-management principles and a ‘healthy options’ morning tea. At completion, the control group crossed over to receive the intervention. Main measures: Stroke Impact Scale (stroke survivors), Health Impact Scale (carers), Six Minute Walk Test, Timed Up and Go, Caregiver Strain Index. Results: There were insufficient participants for results to reach statistical significance. However between-group trends favoured the intervention group in the majority of outcome measures for stroke survivors and carers. The majority of measures remained above baseline at 12 weeks post programme for stroke survivor participants. The programme was well attended. Of the seven sessions all participants attended four or more and 88% attended six or seven sessions. Conclusions: This novel programme incorporating physical activity, education and social interaction proved feasible to undertake by a stroke-specific multidisciplinary team in three rural Australian settings. This programme may improve and maintain health-related quality of life and physical functioning for chronic stroke survivors and their carers and warrants further investigation.

We hypothesized that pretreatment magnetic resonance imaging (MRI) diffusion-weighted imaging (DWI) and perfusion-weighted imaging (PWI) lesion volumes may have influenced clinical response to thrombolysis in the Echoplanar Imaging Thrombolytic Evaluation Trial (EPITHET). In 98 patients randomized to intravenous (IV) tissue plasminogen activator (tPA) or placebo 3 to 6 h after stroke onset, we examined increasing acute DWI and PWI lesion volumes (Tmax—with 2-sec delay increments), and increasing PWI/DWI mismatch ratios, on the odds of both excellent (modified Rankin Scale (mRS): 0 to 1) and poor (mRS: 5 to 6) clinical outcome. Patients with very large PWI lesions (most had internal carotid artery occlusion) had increased odds ratio (OR) of poor outcome with IV-tPA (58% versus 25% placebo; OR=4.13, P=0.032 for Tmax +2-sec volume >190 mL). Excellent outcome from tPA treatment was substantially increased in patients with DWI lesions 25 mL. In contrast, increasing mismatch ratios did not influence the odds of excellent outcome with tPA. Clinical responsiveness to IV-tPA, and stroke outcome, depends more on baseline DWI and PWI lesion volumes than the extent of perfusion–diffusion mismatch.

Background: The assessment of eosinophilic airway inflammation using induced sputum identifies a corticosteroid-responsive subtype that can be used to guide anti-inflammatory therapy. The stability of airway inflammation in asthma over time is not known, yet this information is crucial to inflammation-based patient management. Objective: The aim of this study was to determine the reproducibility of non-eosinophilic asthma. Methods: Participants with stable asthma (n = 26) underwent a sputum induction each month for 5 months. Sputum was dispersed and differential cell counts were performed. The reproducibility of inflammatory subtype with different eosinophil cut points (starting at 1% eosinophils) was examined and the minimum number of visits required to determine inflammatory subtype was calculated. Results: One hundred and twenty- two sputum samples were obtained (success 94%). All cut points greater than 2% eosinophils were reproducible and a 3% cut point resulted in the highest agreement with a κ statistic of 0.538. Specificity and sensitivity were high for determining inflammatory subtype after 1 or 3 sputum samples. Conclusions: A cut point of 3% eosinophils should be used to distinguish eosinophilic from non-eosinophilic airway inflammation in asthma. This allows a single sputum sample to be used to reliably determine the presence of eosinophilia.

Objective To show that an advanced diabetes education programme delivers sustained benefits to people with diabetes prescribed insulin and healthcare providers over and above those provided by basic diabetes education. Methods An historical cohort study of 68 people with Type 1 and 51 people with Type 2 diabetes on insulin who attended the 4-day Newcastle Empowerment programme in 2001 and 2002 compared with 71 people with Type 1 and 312 people with Type 2 diabetes who attended only the basic 4-day insulin education programme over the same period, followed until 2007. Primary outcome was all hospital admissions and emergency visits; secondary outcomes were the composite of first cardiac event or death and readmission for diabetes complications. Cox-proportional hazards regression was used to analyse Type 1 and Type 2 diabetes separately. Results The empowerment programme significantly delayed time to first hospital admission/visit for patients with Type 2 diabetes; the hazard ratio (HR) of 0.41 (P = 0.01) translates into a delay of almost 3 years; this was partly driven by a significant reduction in cardiovascular events and mortality (HR = 0.24, P = 0.01). These effects were not seen for people with Type 1 diabetes. Conclusions A one-time, advanced diabetes education programme teaching intensive insulin self-management with an empowerment style can lead to sustained improvement in patient outcomes and reduce use of hospital services for people with Type 2 diabetes on insulin.

It is unknown whether collateral vessel status, as seen on computed tomography angiography, can predict the fate of penumbral tissue identified on perfusion computed tomography and thereby influence clinical outcome. We tested this hypothesis in consecutive patients who underwent perfusion computed tomography/computed tomography angiography within 6 h of anterior circulation stroke, who also had repeat perfusion/infarct volume imaging at 24 h, and modified Rankin Scale at 3 months. Collateral status was graded as good or reduced depending on the extent of contrast visualized distal to the occlusion on computed tomography angiography. 'Perfusion computed tomography mismatch' ratio was calculated from the ratio of the mean transit time lesion/cerebral blood volume lesion. Of 92 patients with proximal intracranial vessel occlusion, good collateral status (51/92) was significantly associated with reduced infarct expansion and more favourable functional outcomes (modified Rankin Scale 0-2). Significant univariate predictors of favourable outcome were good collateral status, major reperfusion at 24 h, presence of perfusion computed tomography mismatch (for a range of ratios: > or = 1.2, > or = 2, > or = 3, > or = 3.5) and baseline National Institutes of Health Stroke Scale score. Notably, none of the 37 patients with a perfusion computed tomography mismatch ratio < 3.0 had a favourable outcome. In patients with perfusion computed tomography mismatch, significant independent predictors of favourable outcome were good collateral status, major reperfusion and baseline National Institutes of Health Stroke Scale score. There was also a strong interaction between major reperfusion and good collateral status in the regression models. In patients with proximal vessel occlusion, perfusion computed tomography mismatch is a prerequisite for a favourable clinical response, but good collateral status appears a critical determinant of ultimate outcome, particularly if major reperfusion occurs.

Clinical prediction of preterm delivery is largely ineffective, and the mechanism mediating progesterone (P) withdrawal and estrogen activation at the onset of human labor is unclear.Our objectives were to determine associations of rates of change of circulating maternal CRH in midpregnancy with preterm delivery, CRH with estriol (E3) concentrations in late pregnancy, and predelivery changes in the ratios of E3, estradiol (E2), and P.A cohort of 500 pregnant women was followed from first antenatal visits to delivery during the period 2000-2004 at John Hunter Hospital, New South Wales, Australia, a tertiary care obstetric hospital.Unselected subjects were recruited (including women with multiple gestations) and serial blood samples obtained.CRH daily percentage change in term and preterm singletons at 26 wk, ratios E3/E2, P/E3, and P/E2 and the association between E3 and CRH concentrations in the last month of pregnancy (with spontaneous labor onset) were assessed.CRH percentage daily change was significantly higher in preterm than term singletons at 26 wk (medians 3.09 and 2.73; P = 0.003). In late pregnancy, CRH and E3 concentrations were significantly positively associated (P = 0.003). E3/E2 increased, P/E3 decreased, and P/E2 was unchanged in the month before delivery (medians: E3/E2, 7.04 and 10.59, P0.001; P/E3, 1.55 and 0.98, P0.001; P/E2, 11.78 and 10.79, P = 0.07).The very rapid rise of CRH in late pregnancy is associated with an E3 surge and critically altered P/E3 and E3/E2 ratios that create an estrogenic environment at the onset of labor. Our evidence provides a rationale for the use of CRH in predicting preterm birth and informs approaches to delaying labor using P supplementation.

Introduction Levels of hospital smoking cessation care are less than optimal. This study aimed to synthesize the evidence regarding the effectiveness of interventions in increasing smoking cessation care provision in hospitals. Methods A review identified relevant studies published between 1994 and 2006. A description of studies, including methodological quality, was undertaken. Intervention effectiveness in increasing smoking cessation care practices was examined for controlled studies using meta-analysis. Care practices examined were assessment of smoking status; advice to quit; counseling or assistance to quit; advising, offering, or providing nicotine replacement therapy (NRT); and follow-up or referral. Results Of the 25 identified studies, 18 were U.S. based and in inpatient settings. Of the 10 controlled trials, 4 addressed cardiac patients, 5 measured one smoking cessation care practice, and 9 implemented multistrategic interventions (e.g., combining educational meetings with reminders and written resources). The methodology described in these studies was generally of poor quality. Meta-analysis of controlled trials demonstrated a significant intervention effect for provision of assistance and counseling to quit (pooled risk difference = 16.6, CI = 4.9-28.3) but not for assessment of smoking status, advice to quit, or the provision or discussion of NRT. Statistical heterogeneity was indicated for all smoking cessation care practices. An insufficient number of studies precluded the use of meta-analysis for follow-up or referral for further assistance. Discussion Interventions can be effective in increasing the routine provision of hospital smoking cessation care. Future research should use more rigorous study design, examine a broader range of smoking cessation care practices, and focus on hospital-wide intervention implementation.

OBJECTIVE: To assess the effectiveness of the PAST (Pre-hospital Acute Stroke Triage) protocol in reducing pre-hospital and emergency department (ED) delays to patients receiving organised acute stroke care, thereby increasing access to thrombolytic therapy. DESIGN: Prospective cohort study using historical controls. SETTING: Hunter Region of New South Wales, September 2005 to March 2006 (pre-intervention) and September 2006 to March 2007 (post-intervention). PARTICIPANTS: Consecutive patients presenting with acute stroke to a regional, tertiary referral hospital. INTERVENTION: PAST protocol, comprising a pre-hospital stroke assessment tool for ambulance officers, an ambulance protocol for hospital bypass for potentially thrombolysis-eligible patients, and pre-hospital notification of the acute stroke team. MAIN OUTCOME MEASURES: Proportion of patients who received intravenous tissue plasminogen activator (tPA), process of care time points (symptom onset to ED arrival, ED arrival to tPA treatment, and ED transit time), and clinical outcomes of patients treated with tPA. RESULTS: The proportion of ischaemic stroke patients treated with tPA increased from 4.7% (pre-intervention) to 21.4% (post-intervention) (P < 0.001). Time point outcomes also improved, with a reduction in median times from symptom onset to ED arrival from 150 to 90.5 min (P = 0.004) and from ED arrival to stroke unit admission from 361 to 232.5 minutes (P < 0.001). Of those treated with tPA, 43% had minimal or no disability at 3 months. CONCLUSIONS: Organised pre-hospital and ED acute stroke care increases patient access to tPA treatment, which is proven to reduce stroke-related disability.

Aims Vitamin D deficiency has been linked to impaired glucose metabolism. We determined whether serum 25-hydroxyvitamin D (25OHD) is associated with glucose metabolism in pregnant women and the effect of ethnicity on this relationship. Methods We analysed serum 25OHD concentrations in 307 pregnant women attending a metropolitan obstetric clinic between October 2003 and May 2005. Measurements from 264 of the women were taken at the time of glucose tolerance testing at mid-gestation, a population therefore at increased risk for gestational diabetes. Pearson correlation analysis was used to test for univariate linear relationships between the natural log of serum 25OHD (ln-25OHD) and other variables. Multiple regression analysis was used to adjust for confounding factors. Results Mean serum 25OHD concentration was 53.8 ± 23.9 nmol/l (sd). Ln-25OHD was negatively correlated with serum parathyroid hormone as expected (r −0.24, confidence intervals −0.35 to −0.12). Ln-25OHD was also negatively correlated with fasting plasma glucose (r−0.20, −0.31 to −0.08), fasting insulin (r −0.20, −0.31 to −0.08) and insulin resistance as calculated by homeostatis model assessment (r −0.21, −0.32 to −0.09). The association between fasting glucose and log-transformed 25OHD concentration was of borderline significance after accounting for ethnicity, age and body mass index in multivariate analyses (−0.13, −0.26 to 0.01). The odds ratio of gestational diabetes in women with 25OHD

Hospitals are key settings for the provision of smoking cessation care. Limited data are available that describe the prevalence and type of such care delivered routinely in this setting. We reviewed studies conducted in hospitals and published between 1994 and 2005 that reported levels of smoking care delivery. This review describes the proportion of patients receiving, and the proportion of health professionals providing, various smoking cessation care practices. We used both descriptive and meta-analytic methods. According to the meta-analysis, smoking status was assessed in 60% of patients, 42% were advised or counseled to quit, 14% were provided with or advised to use nicotine replacement therapy (NRT), and 12% received referrals or follow-up. Significantly fewer patients received follow-up or referrals than were assessed for smoking status or received advice or counseling to quit. Some 81% of health professionals reported they assessed smoking status, 70% advised or counseled patients to quit, 13% provided NRT or advised its use, and 39% provided referrals or follow-up. Significantly fewer health professionals advised or prescribed NRT than assessed smoking status or advised or counseled patients to quit. Statistical heterogeneity was indicated for all smoking care practices. Levels of smoking cessation care are less than optimal in hospitals, and the levels of some important care practices are particularly low. Future research should identify effective methods for increasing smoking care provision in this setting. In addition, standardized measures of smoking care should be developed. Hospital organizations should enhance and continue to monitor their delivery of smoking care.

BACKGROUND: Obesity increases cardiovascular risk through effects on blood pressure, lipoproteins, coagulation factors and inflammatory cytokines, but in women variation in fat distribution complicates these relationships. Central (maletype or visceral) obesity confers greater risk than the more generalised (female) type. This is recognised by the metabolic syndrome which employs waist circumference rather than body mass index (BMI). We examined the relationships of several indices of fat distribution with cardiovascular risk factors in a large cohort of UK women. MATERIAL AND METHODS: 13,389 female department store employees aged 30–65 years not receiving exogenous hormones completed a health questionnaire. Their blood pressure, weight, height, waist and hip circumference, serum cholesterol low density lipoprotein cholesterol (LDL-C), high density lipoprotein cholesterol (HDL-C), triglycerides, C-reactive protein (CRP) and plasma fibrinogen were measured. RE-SULTS: There was a progressive rise in blood pressure, total cholesterol, LDL-C, triglycerides, fibrinogen and CRP with age. After adjustment for these age effects, BMI was most closely related to blood pressure, whereas the waist to height ratio (WHTR) correlated more closely with the other risk factors than BMI, waist circumference or waist to hip ratio (WHPR). CONCLUSIONS: Inclusion of height in the definition of metabolic syndrome will produce a clearer association between waist circumference and cardiovascular risk factors. Hypertension may be linked to the metabolic syndrome by its association with general obesity rather than specifically by central obesity.

Aortic pulse wave velocity (aPWV), a noninvasive measure of vascular stiffness, is an independent predictor of cardiovascular disease both before and in overt vascular disease. Its characteristics in early life and its relationship to maternal factors have hardly been studied. To test the hypothesis that infant aPWV was positively related to maternal anthropometry and blood pressure (BP) at 28 weeks gestation, after adjusting for neonatal anthropometry and BP, 148 babies born in Manchester were measured 1 to 3 days after birth. A high reproducibility of aPWV, assessed in 30 babies within 3 days of birth, was found with a mean difference between occasions of −0.04 m/s (95% CI: −0.08 to 0.16 m/s). Contrary to our hypothesis, a significant inverse relation was found between neonatal aPWV (mean: 4.6 m/s) and maternal systolic BP (mean: 108.9 mm Hg; r =−0.57; 95% CI: −0.67 to −0.45) but not maternal height nor weight. Neonatal aPWV was positively correlated with birth length, birth weight, and systolic BP. In multiple regression, neonatal aPWV remained significantly inversely associated with maternal systolic BP (adjusted β coefficient: −0.032; 95% CI: −0.040 to −0.024; P

The primary aim of this study was to evaluate the effectiveness of an intervention to increase the implementation of healthy eating and physical activity policies and practices by centre-based childcare services. The study also sought to determine if the intervention was effective in improving child dietary intake and increasing child physical activity levels while attending childcare. A parallel group, randomised controlled trial was conducted in a sample of 128 childcare services. Intervention strategies included provision of implementation support staff, securing executive support, staff training, consensus processes, academic detailing visits, tools and resources, performance monitoring and feedback and a communications strategy. The primary outcome of the trial was the proportion of services implementing all seven healthy eating and physical activity policies and practices targeted by the intervention. Outcome data were collected via telephone surveys with nominated supervisors and room leaders at baseline and immediately post-intervention. Secondary trial outcomes included the differences between groups in the number of serves consumed by children for each food group within the Australian Guide to Healthy Eating and in the proportion of children engaged in sedentary, walking or very active physical activity assessed via observation in a random subsample of 36 services at follow-up. There was no significant difference between groups for the primary trial outcome (p = 0.44). Relative to the control group, a significantly larger proportion of intervention group services reported having a written nutrition and physical activity policy (p = 0.05) and providing adult-guided activities to develop fundamental movement skills (p = 0.01). There were no significant differences between groups at follow-up on measures of child dietary intake or physical activity. The findings of the trial were equivocal. While there was no significant difference between groups for the primary trial outcome, the intervention did significantly increase the proportion of intervention group services implementing two of the seven healthy eating and physical activity policies and practices. High levels of implementation of a number of policies and practices at baseline, significant obesity prevention activity in the study region and higher than previously reported intra-class correlation of child behaviours may, in part, explain the trial findings. Australian Clinical Trials Registry (reference ACTRN12612000927820 ).

In December 1999, New Zealand lowered the alcohol minimum purchasing age from 20 to 18 years. We tested hypotheses that this change was associated with long-term increases in traffic injury attributable to alcohol-impaired driving among 18- to 19-year-olds (target age group) and 15- to 17-year-olds (affected by 'trickle-down').We undertook a controlled before-and-after comparison of rates of fatal and non-fatal traffic injury to persons of any age attributable to impaired drivers aged 18-19 years and 15-17 years, versus 20- to 21-year-olds. Crash data including assessment of driver alcohol impairment were recorded by New Zealand Police. The pre-change period was 1996-1999. Post-change periods were 2000-2003, 2004-2007 and 2008-2010. Outcomes were population-based and vehicle travel-based rates.Compared with the change in injury rates attributable to alcohol-impaired 20- to 21-year-old male drivers, injuries attributable to 18- to 19-year-old male drivers increased in all post-change periods and significantly so in the second post-change period (incidence rate ratio [IRR] 1.3, 95% confidence interval [CI] 1.1 to 1.5). For 15- to 17-year-old male drivers, rates increased in all post-change periods compared with 20- to 21-year-olds, and more so in the second (IRR 1.2, 95% CI 1.1 to 1.4) and third (IRR 1.2, 95% CI 1.1 to 1.4) periods. There was a short-term relative increase in harm attributable to 18- to 19-year-old female drivers (IRR 1.5; 1.1 to 2.0). Results were similar for vehicle travel-based rates.Reducing the alcohol minimum purchasing age was followed by long-term increases in the incidence of traffic injury attributable to male 15- to 19-year-old alcohol-impaired drivers. [Kypri K, Davie G, McElduff P, Langley J, Connor J. Long-term effects of lowering the alcohol minimum purchasing age on traffic crash injury rates in New Zealand. Drug Alcohol Rev 2017;36:178-185].

Introduction Maintaining adequate nutrition for Head and Neck Cancer (HNC) patients is challenging due to both the malignancy and the rigours of radiation treatment. As yet, health behaviour interventions designed to maintain or improve nutrition in patients with HNC have not been evaluated. The proposed trial builds on promising pilot data, and evaluates the effectiveness of a dietitian-delivered health behaviour intervention to reduce malnutrition in patients with HNC undergoing radiotherapy: Eating As Treatment (EAT). Methods and analysis A stepped-wedge cluster randomised design will be used. All recruitment hospitals begin in the control condition providing treatment as usual. In a randomly generated order, oncology staff at each hospital will receive 2 days of training in EAT before switching to the intervention condition. Training will be supplemented by ongoing supervision, coaching and a 2-month booster training provided by the research team. EAT is based on established behaviour change counselling methods, including motivational interviewing, cognitive–behavioural therapy, and incorporates clinical practice change theory. It is designed to improve motivation to eat despite a range of barriers (pain, mucositis, nausea, reduced or no saliva, taste changes and appetite loss), and to provide patients with practical behaviour change strategies. EAT will be delivered by dietitians during their usual consultations. 400 patients with HNC (nasopharynx, hypopharynx, oropharynx, oral cavity or larynx), aged 18+, undergoing radiotherapy (>60 Gy) with curative intent, will be recruited from radiotherapy departments at 5 Australian sites. Assessments will be conducted at 4 time points (first and final week of radiotherapy, 4 and 12 weeks postradiotherapy). The primary outcome will be a nutritional status assessment. Ethics and dissemination Ethics approval from all relevant bodies has been granted. Study findings will be disseminated widely through peer-reviewed publications and conference presentations. Trial registration number ACTRN12613000320752.

In view of proposed screening for presymptomatic Alzheimer's disease (AD) with advanced imaging, and blood and cerebral spinal fluid analysis, we aimed to establish levels, and associations, of acceptance of AD testing modalities by general practice patients.A cross-sectional questionnaire-based study of consecutive patients (aged 50 years and over) of general practices of an Australian practice-based research network was used. The questionnaire elicited demographic data and attitudes to screening for other diseases and included the screening acceptance domain of the Perceptions Regarding Investigational Screening for Memory in Primary Care (PRISM-PC) instrument. This assesses receptivity to modalities of testing for AD: short questionnaire, blood test, cerebral imaging, and annual physician examination. Reflecting speculation of possible future AD diagnostic methods, an item regarding testing cerebral spinal fluid was also included. Associations of PRISM-PC scores were analyzed with multiple linear regression.Of 489 participants (response rate 87%), 66.2% would like to know if they had AD. Participants were more accepting of testing modalities that were noninvasive or familiar (questionnaire, physician's examination, and blood test) as opposed to cerebral imaging or lumbar puncture. Attitudes to AD testing are influenced by a positive attitude to disease screening in general. Patients with a self-perceived higher risk of AD were less accepting of testing, as were participants with an educational level of junior high school (10 school years) or less.This study demonstrates that a majority of patients would like to know if they have AD. Acceptability of testing modalities, however, varies. Noninvasive, familiar methods are more acceptable.

Background: The Quality in Acute Stroke Care (QASC) Trial 1 determined that a multidisciplinary supported, nurse-initiated, evidence-based intervention involving supported implementation of clinical protocols to manage fever, hyperglycaemia and swallowing (FeSS protocols) following stroke decreased death and dependency by 16% (p=0.002); reduced temperatures (p=0.001) and glucose levels (p=0.02); and improved swallowing management (p= Aim: To implement the FeSS protocols from the QASC Trial in all 36 stroke services in NSW, Australia. Method: Our 14 month translational project replicated the intervention from the original QASC Trial. We conducted barrier and enabler assessments and an educational workshop, engaged local opinion leaders, used reminders, and provided ongoing site champion support. Participating sites audited 40 pre-, and 40 post- implementation medical records using the National Stroke Foundation clinical audit web-based tool. Results: All (n=36, 100%) sites participated in the medical record audit (100% response rate) providing data for a total of 2144 patients (pre-implementation: n= 1062; post-implementation: n=1082). Significantly increased proportions of patients received care according to the fever (pre: 69%; post: 78%; p=0.0031), hyperglycaemia (pre: 23%; post: 34%; p=0.0085), and swallowing (pre: 42%; post: 51%; p=0.0331) protocols post-implementation. Conclusion: Our results provide rare evidence of successful research translation of Class 1 Level B evidence across an entire state in a short time-frame and in the real world of clinical practice.

Objective: To compare national and international recommendations for statin treatment in the primary prevention of cardiovascular disease (CVD) in middle-aged men. Design: Application of the current American, British and European recommendations to results of a prospective study. Participants: Men aged 49–65 years (n = 1653) who participated in the Caerphilly Prospective Study. Main outcome measures: Proportion of patients who would receive statin treatment, the number needed to treat (NNT) to prevent one first CVD event (myocardial infarction or stroke) over 10 years and the potential number of events prevented over 10 years in the whole population (population impact) by the use of statins in accordance with each set of guidelines, assuming a reduction of risk in the range 10–50% from the observed events and baseline risk factors. Results: 212 events were noted. For an anticipated reduction in first CVD events of 30% with statin treatment, the NNT was 26.0, if the whole population was treated. The lowest NNT was 12.1 for the National Service Framework, achieved when only 14% of the men received a statin. This prevented the lowest number of events (19.2/212), however, and had the smallest population impact on CVD incidence (−9.1%). The American and earlier Joint British Societies guidelines, although giving NNTs of around 21, prevented more events and had a greater population impact of −21.6% to −23.3%. They did, however, target about 60% of the male population. The British Hypertension Society guidelines and new Joint British Societies recommendations achieved the greatest population impact of −27% while maintaining the NNT at 22.2. They did, however, target three quarters of this population. Conclusion: Even effective preventive treatment will have little impact in preventing disease if patients at typical risk are not treated. Whether cholesterol lowering on such a scale should be attempted with drugs raises philosophical, psychological and economic considerations, particularly in view of the high likelihood of individual benefit from statin treatment. More effective nutritional policies to reduce serum cholesterol on a population level and reduce the requirement for statins in primary prevention should also be considered.

Objectives: To examine recent time trends in blood pressure (BP), total cholesterol, body mass index (BMI) and current smoking among people in the UK of different deprivation groups. Design: Repeatable survey. Setting: Primary care-based UK cardiovascular risk factor screening programme (58 Stockport general practices). Participants: 37 161 women and 33 977 men aged 35–60 years responding to a screening invitation and with a first screening episode during 1989–99. Results: There were significant decreasing trends in total cholesterol (−0.06 mmol/l/year, 95% confidence interval (CI) −0.07 to −0.06 for women, −0.07 mmol/l/year, 95% CI −0.07 to −0.06 for men), with a significantly faster drop in more deprived groups (−0.005 mmol/year/increasing deprivation group, 95% CI −0.01 to −0.001 for both sexes). There were decreasing trends in current smoking prevalence (odds ratio (OR) 0.97/year, 95% CI 0.96 to 0.97 for women, OR 0.96/year, 95% CI 0.95 to 0.96 for men) with a significantly slower drop in the more deprived groups (OR 1.01/year/increasing deprivation group, 95% CI 1.00 to 1.01 for both sexes). There were significant increasing trends in BMI (0.11 kg/m 2 /year in women, 95% CI 0.09 to 0.13, 0.10 kg/m 2 /year in men, 95% CI 0.08 to 0.11), with a significantly slower increase in the more deprived groups among men only (−0.02 kg/m 2 /year/increasing deprivation group, 95% CI −0.01 to −0.03). Inequality in BP narrowed among men but widened among women. Conclusion: Inequalities in risk factors between different deprivation groups may be both widening (smoking, BP in women) and narrowing (total cholesterol, BMI and BP in men). Given baseline inequalities in risk factors levels, these trends suggest that inequalities in cardiovascular disease are likely to persist in the future.

Context: Adiponectin is a recognized protective risk marker for cardiovascular disease in adults and is associated with an optimal lipid profile. The role of adiponectin at birth is not well understood, and its relationship with the neonatal lipid profile is unknown. Because ethnic disparities in cardiovascular risk have been attributed to low adiponectin and its associated low high-density lipoprotein cholesterol (HDL-C), investigation at birth may help determine the etiology of these risk patterns. Objective: Our objective was to investigate the relationship between neonatal adiponectin and lipid profile at birth in two ethnic groups in cord blood. Design, Setting, and Participants: Seventy-four healthy mothers and their newborns of South Asian and White European origin were studied in this cross-sectional study at St. Mary’s Hospital, Manchester, United Kingdom. Main Outcome Measures: Serum adiponectin, total cholesterol, HDL-C, low-density lipoprotein cholesterol (LDL-C), and triglyceride levels were measured in umbilical venous blood at birth and in maternal blood collected at 28 wk gestation. Results: Cord adiponectin was significantly inversely associated with cord LDL-C (r = −0.32; P = 0.005) but not HDL-C. In a multiple regression analysis, cord LDL-C remained the most significant association of cord adiponectin (β = −0.13; P < 0.001). We did not find any significant ethnic differences in cord adiponectin or lipids with the exception of triglycerides, which were significantly lower in South Asian newborns (P < 0.05). Conclusion: This is the first report of an inverse relationship between cord adiponectin and LDL-C at birth. In contrast to adult studies, we found no significant association between adiponectin and HDL-C in cord blood. Our results and the strong independent association between adiponectin and HDL-C observed in adult studies suggest a role for adiponectin in lipid metabolism. Ethnic differences in adiponectin may arise after birth.

Paraoxonase1 (PON1) is an anti-inflammatory enzyme located on HDL, which protects against the development of atherosclerosis. C-reactive protein (CRP) is a marker of the inflammatory response in CHD. We hypothesised that low PON1 and high CRP found in CHD may be important markers of CHD and the CRP:PON1 ratio may be an index of the risk of developing atherosclerosis. We have, therefore, compared the levels of PON1 and CRP between control subjects, those with no diabetes and CHD, type 1 diabetes and type 2 diabetes.PON1 activity was different between the populations in the order: controlstype 1 diabetestype 2 diabetesCHD with no diabetes (P0.001). CRP concentration also differed between the populations in the order: controlstype 1 diabetestype 2 diabetesCHD with no diabetes (P0.001). The CRP:PON1 ratio followed the same trend as the CRP concentration (P0.001). Both CRP and the CRP:PON1 ratio were associated with the presence of CHD. In the control population only, PON1 was a determinant of CRP concentration. Amongst the diabetics, people with CHD had higher levels of CRP (P0.001) and in comparing the control group with the CHD group, the CHD group had a higher level of CRP (P0.001).Higher levels of CRP seem to be generally associated with low levels of PON1 activity, providing a mechanistic link between inflammation and the development of atherosclerosis. However, the relationship between PON1, CRP and atherosclerosis, and the usefulness of the PON1:CRP ratio as a risk factor for CHD requires further evaluation.

This study examined the effectiveness of giving medical oncologists immediate feedback about cancer patients' self-reported psychosocial well-being in reducing those patients' levels of anxiety, depression, perceived needs and physical symptoms. Cancer patients attending one cancer centre for their first visit were allocated to intervention (n = 42) or control (n = 38) groups. All patients completed a computerized survey assessing their psychosocial well-being while waiting to see the oncologist. Intervention patients' responses were immediately scored and summary reports were placed in each patient's file for follow-up. A total of 48 participants (25 intervention and 23 control) completed the survey four times. Intervention patients who reported a debilitating physical symptom at visit 2 were significantly less likely to report a debilitating physical symptom at visit 3 compared with control patients (OR = 2.8, P = 0.04). Reductions in levels of anxiety, depression and perceived needs among intervention patients were not significantly different to control patients. Repeated collection and immediate feedback of patient-reported health information to oncologists has potential to improve patients' symptom control, but has little impact upon emotional well-being, including those at high risk. Future research should consider providing the feedback to other health professionals and patients, and monitor the impact on the process of individual patient care.

Background/aim Women with a reduced concentration of sex hormone-binding globulin (SHBG) in the first trimester of pregnancy are at increased risk of developing gestational diabetes. Furthermore, a lower concentration of SHBG in women with gestational diabetes identifies women at increased likelihood of requiring insulin treatment. The aim of this study was to explore the relationship of SHBG concentration in pregnancy to insulin resistance and glucose tolerance. Methods Prospective cohort study of 220 pregnant women who attended The Royal North Shore Hospital in Sydney, Australia between August 2002 and June 2003 for their 75-g glucose tolerance test. All tests were performed in the morning after the women had fasted for at least 10 h. To test for differences between patients with or without gestational diabetes, t-tests and chi-square tests were used. Stepwise linear regression was used to determine the independent predictors of SHBG. Results The mean concentration of SHBG increased linearly with gestational age. Statistically significant predictors of SHBG from the stepwise regression were gestational age (P < 0.001), insulin resistance (P < 0.001) and body mass index (P = 0.003). Glucose tolerance as assessed by either a fasting or 2-h glucose tolerance test did not predict SHBG concentration in this population. In addition, there was no significant difference in the concentration of SHBG between patients categorized as normal glucose tolerance or gestational diabetes (P = 0.77). This remained the case when SHBG was expressed as SHBG/insulin ratio as suggested by Bartha et al. (Sex hormone-binding globulin in gestational diabetes. Acta Obstet Gynecol Scanda 2000; 79: 839-845) (P = 0.10). Conclusion In a cross-sectional study of pregnant women, we find no association between SHBG concentration and glucose tolerance.

Summary Study objective To assess levels of physical activity in the general population and amongst the ‘healthy’, and to identify factors associated with this important health behaviour. Design Population-based cross-sectional study. Setting North-west England. Participants Adults (aged at least 18 years) registered with a general practitioner with a residential address within two local administrative districts (local authorities). Main results Less than one-third of adults performed adequate amounts of physical activity for health protection, and this differed little when analyses were restricted to ‘healthy’ people. Lower levels of physical activity were observed amongst women, older people, ethnic groups, those with obesity and in each increased quintile of social deprivation. Current smokers, but not previous smokers, were less likely to be physically active, as were those not eating at least five portions of fruit and vegetables per day. Lack of physical activity was associated with poor general health and a history of, or current, chronic disease. Conclusions Concerted efforts are required by the Government, society and individuals to overturn our predominantly physically inactive adult population. Interventions may be needed which specifically target certain groups, especially the most socially deprived, and that consider individuals and societal barriers to becoming physically active. Evidence of the effectiveness of individual and population-based interventions remains scant and this needs to be addressed urgently.

Background. Upper-limb (UL) dysfunction is experienced by up to 75% of patients poststroke. The greatest potential for functional improvement is in the first month. Following reperfusion, evidence indicates that neuroplasticity is the mechanism that supports this recovery. Objective. This preliminary study hypothesized increased activation of putative motor areas in those receiving intensive, task-specific UL training in the first month poststroke compared with those receiving standard care. Methods. This was a single-blinded, longitudinal, randomized controlled trial in adult patients with an acute, first-ever ischemic stroke; 23 participants were randomized to standard care (n = 12) or an additional 30 hours of task-specific UL training in the first month poststroke beginning week 1. Patients were assessed at 1 week, 1 month, and 3 months poststroke. The primary outcome was change in brain activation as measured by functional magnetic resonance imaging. Results. When compared with the standard-care group, the intensive-training group had increased brain activation in the anterior cingulate and ipsilesional supplementary motor areas and a greater reduction in the extent of activation ( P = .02) in the contralesional cerebellum. Intensive training was associated with a smaller deviation from mean recovery at 1 month (Pr>F0 = 0.017) and 3 months (Pr>F = 0.006), indicating more consistent and predictable improvement in motor outcomes. Conclusion. Early, more-intensive, UL training was associated with greater changes in activation in putative motor (supplementary motor area and cerebellum) and attention (anterior cingulate) regions, providing support for the role of these regions and functions in early recovery poststroke.

Indiscriminate health screening is increasingly seen as being problematic. In particular, vitamin D testing rates are increasing rapidly despite recommendations against population screening. The purpose of this study was to determine the level of vitamin D testing among family practice/general practitioner (GP) trainees and to establish associations of this testing.Cross-sectional analysis of data from the ReCEnT (Registrars Clinical Encounters in Training) cohort study. The setting was GP practices in four Australian states. Data from 60 consecutive consultations per trainee were recorded each 6-month training term (up to four terms).Vitamin D tests were ordered in 726 (1.0%) of encounters (n = 69 412). Vitamin D test ordering was significantly associated with patients being older, female and non-English speaking. Trainees were more likely to test if they worked in a completely bulk-billing practice (i.e. a practice without any patient payment), if more problems were dealt with, more pathology tests were ordered in the consultation and if a lipid profile was ordered. They were less likely to test if they sought in-consultation advice or information. The most common reasons for testing were 'check-up' and 'health maintenance'.In this first report of associations of vitamin D testing in the GP setting, we found that non-targeted vitamin D testing (testing inconsistent with current guidelines) is widespread in GP trainees' practice. Adoption of more rational testing approaches is needed.

Background Early life exposure to inorganic arsenic may be related to adverse health effects in later life. However, there are few data on postnatal arsenic exposure via human milk. In this study, we aimed to determine arsenic levels in human milk and the correlation between arsenic in human milk and arsenic in mothers and infants urine. Methods Between March 2011 and March 2012, this prospective study identified a total of 120 new mother-baby pairs from Kashiani (subdistrict), Bangladesh. Of these, 30 mothers were randomly selected for human milk samples at 1, 6 and 9 months post-natally; the same mother baby pairs were selected for urine sampling at 1 and 6 months. Twelve urine samples from these 30 mother baby pairs were randomly selected for arsenic speciation. Results Arsenic concentration in human milk was low and non-normally distributed. The median arsenic concentration in human milk at all three time points remained at 0.5 μg/L. In the mixed model estimates, arsenic concentration in human milk was non-significantly reduced by -0.035 μg/L (95% CI: -0.09 to 0.02) between 1 and 6 months and between 6 and 9 months. With the progression of time, arsenic concentration in infant’s urine increased non-significantly by 0.13 μg/L (95% CI: -1.27 to 1.53). Arsenic in human milk at 1 and 6 months was not correlated with arsenic in the infant’s urine at the same time points (r = -0.13 at 1 month and r = -0.09 at 6 month). Arsenite (AsIII), arsenate (AsV), monomethyl arsonic acid (MMA), dimethyl arsinic acid (DMA) and arsenobetaine (AsB) were the constituents of total urinary arsenic; DMA was the predominant arsenic metabolite in infant urine. Conclusions We observed a low arsenic concentration in human milk. The concentration was lower than the World Health Organization’s maximum permissible limit (WHO Permissible Limit 15 μg/kg-bw/week). Our findings support the safety of breastfeeding even in arsenic contaminated areas.

BACKGROUND: Transient ischaemic attacks (TIA) and minor strokes (TIAMS) have the same pathophysiological mechanism as stroke and carry a high risk of recurrent ischaemic events. Diagnosis of TIAMS can be challenging and often occurs in general practice. Absolute cardiovascular risk (ACVR) is recommended as the basis for vascular risk management. Consideration of cardiovascular risk in TIAMS diagnosis has been recommended but its utility is not established. OBJECTIVES: Firstly, to document the ACVR of patients with incident TIAMS and with TIAMS-mimics. Secondly, to evaluate the utility of ACVR calculation in informing the initial diagnosis of TIAMS. METHODS: The International comparison of Systems of care and patient outcomes in minor Stroke and TIA (InSiST) study is an inception cohort study of patients of 17 Australian general practices presenting as possible TIAMS. An expert panel determines whether participants have had TIAMS or TIAMS-mimics. ACVR was calculated at baseline for each participating patient. In this cross-sectional baseline analysis, ACVR of TIAMS and TIAMS-mimics were compared univariately and, also, when adjusted for age and sex. The diagnostic utility of ACVR was evaluated via receiver operating characteristic (ROC) curves. RESULTS: Of 179 participants, 87 were adjudicated as TIAMS. The presence of motor and speech symptoms and body mass index were associated with a diagnosis of TIAMS. ACVR was associated with TIAMS diagnosis on univariate analysis, but not when age- and sex-adjusted. ACVR did not significantly improve area under ROC curves beyond that of age and sex. CONCLUSION: In patients presenting with transient or minor neurological symptoms, calculation of ACVR did not improve diagnostic accuracy for TIAMS beyond that of age and sex.

Background Physical inactivity is fourth in the list of risk factors for global mortality. General practitioners are well placed to offer physical activity counseling but insufficient time is a barrier. Although referral to an exercise specialist is an alternative, in Australia, these allied health professionals are only publicly funded to provide face-to-face counseling to patients who have an existing chronic illness. Accordingly, this trial aims to determine the efficacy of GP referral of insufficiently active patients (regardless of their chronic disease status) for physical activity counseling (either face-to-face or predominately via telephone) by exercise specialists, based on patients’ objectively assessed physical activity levels, compared with usual care. If the trial is efficacious, the equivalence and cost-effectiveness of face-to-face counseling versus telephone counseling will be assessed. Methods This three arm pragmatic randomized trial will involve the recruitment of 261 patients from primary care clinics in metropolitan and regional areas of New South Wales, Australia. Insufficiently active (less than 7000 steps/day) consenting adult patients will be randomly assigned to: 1) five face-to-face counseling sessions, 2) one face-to-face counseling session followed by four telephone calls, or 3) a generic mailed physical activity brochure (usual care). The interventions will operationalize social cognitive theory via a behavior change counseling framework. Participants will complete a survey and seven days of pedometry at baseline, and at three and 12 months post-randomization. The primary analyses will be based on intention-to-treat principles and will compare: (i) mean change in average daily step counts between baseline and 12 months for the combined intervention group (Group 1: face-to-face, and Group 2: telephone) and usual care (Group 3); (ii) step counts at 3 months post-randomization. Secondary outcomes include: self-reported physical activity, sedentary behavior, quality of life, and depression. Discussion If referral of primary care patients to exercise specialists increases physical activity, this process offers the prospect of systematically and sustainably reaching a large proportion of insufficiently active adults. If shown to be efficacious this trial provides evidence to expand public funding beyond those with a chronic disease and for delivery via telephone as well as face-to-face consultations. Trial registration Australian New Zealand Clinical Trials Registry ACTRN12611000884909.

The dysregulation of the IGF system has been implicated in the pathogenesis of obesity, diabetes, and diabetes complications such as nephropathy, but little is known about the genomics of the IGF system in health and disease. We genotyped 13 single nucleotide polymorphisms (SNPs) in IGFBP1 gene in 732 representative type 2 diabetic patients from the Salford Diabetes Register. Of the 13 SNPs, 8 were polymorphic and 7 of those had minor allele frequencies >0.1, one of which was in the gene promoter and one of which was nonsynonymous in exon 4. The minor alleles of these SNPs and two others were associated with a reduced prevalence of diabetic nephropathy. Haplotype analysis revealed that 97% of the genetic variation for IGFBP1 in the population sample could be accounted for using two of the “reno-protective” SNPs, with other SNPs adding little extra information. One of these two SNPs was the nonsynonymous mutation in exon 4, lying close to the integrin-binding RGD motif, which is thought to affect tissue delivery of IGF-I by IGF-binding protein 1 (IGFBP-1), possibly suggesting a “reno-protective” effect via altered IGFBP-1 binding. In conclusion, we have described the first genomic markers to be associated with diabetic microvascular complications within the human IGFBP1 gene.

Background. Diabetes mellitus and chronic kidney disease (CKD) are common and exhibit synergistic associations with premature mortality. Current diabetes guidelines in the UK recommend annual urinary albumin and serum creatinine determinations to screen for diabetic kidney disease. The aim of this study was to estimate the burden of CKD in patients with diabetes and examine the ability of serum creatinine and albuminuria to detect clinically meaningful CKD compared with estimated glomerular filtration rate (eGFR). Methods. All adults known to have diabetes in primary and secondary care in Salford, UK, alive with independent renal function on 1 January 2004 were included in this observational study (n ¼ 7596). Demographic and laboratory parameters were obtained from the Electronic Patient Record. eGFR was determined using the 4-variable modification of diet in renal disease (MDRD) formula. Clinically meaningful CKD was defined as an eGFR

Objective. To investigate the paraoxonase-2 (PON2)-C/S310 polymorphism and its relationship to the presence of diabetic complications and glycaemic control. Design. Case–control study. Setting. One study centre at University hospital. Materials and methods. The subjects were people with type 2 diabetes (n = 252), type 1 diabetes (n = 152) and healthy controls (n = 282). The PON2-C/S310 polymorphism was measured by restriction fragment length polymorphism analysis. Lipids and lipoproteins were measured by standard clinical chemistry methods. Diabetes and diabetic complications were defined by World Health Organization criteria. Results. There was an over-representation of the C/C310 genotype in those with diabetes and microvascular complications (type 2 diabetes P = 0.043, type 1 diabetes P = 0.052, both populations combined P = 0.014). The PON2-C/S310 polymorphism was also associated with glycaemic control. C310/C310 homozygotes had the highest HbA1c concentration (P = 0.020 type 2 diabetes, P = 0.065 type 1 diabetes, P = 0.035 both populations combined). There was no association between the PON2-310 polymorphism and lipid and lipoprotein concentrations. Conclusions. PON2 could be directly involved in protecting critical enzymes or organelles against oxidative damage; PON2 may thus predispose to the development of microvascular complications.

BACKGROUND: Diabetes and its complications are more prevalent among South Asians than people of European origin and there is some evidence that patients of South Asian origin with diabetes receive poorer quality care. METHODS: Longitudinal study of patients with diabetes in Blackburn, UK. Processes of care indicators [measurement of blood pressure (BP), cholesterol and glycosolated haemoglobin (HbA1c)] and values of these intermediate outcomes were extracted for all patients registered on a diabetes information system for the period 1995-2001. Differences in processes of care indicators and intermediate outcomes between ethnic groups were estimated after adjusting for the potential confounding factors of sex, age and socioeconomic status (SES). Generalized estimating equations were used to model trends and to test for differences in trends over time. RESULTS: Process of care was similar in South Asian and European patients. Mean BP and cholesterol concentration fell during the study period. South Asians had a higher level of HbA1c throughout the study period. South Asians had lower levels of BP and cholesterol in 1995 but the differences diminished or were abolished over time. SES did not explain differences between ethnic groups. Analyses stratified by baseline levels of intermediate outcomes (above or within target) demonstrated improvements among above target patients were greater among European patients. CONCLUSIONS: Processes of care indicators are similar in diabetic patients of South Asian and European origin, irrespective of SES. However, there are worrying differences in improvements over time in the intermediate outcomes, and glycaemic control remained poorer among patients of South Asian origin patients throughout.

Purpose of review Blood lipoprotein profiles in early life are known to be related to and predictive of those in adulthood, but little is known about their determinants. Genetic and environmental influences affect cord blood lipoproteins, but how this occurs and the relative contribution of these influences to the overall profile in healthy newborns remains uncertain. Recent findings This review discusses findings from a range of earlier and more recent studies, and summarizes the key influences on cord blood lipoproteins. In particular, we review the potential contribution of maternal blood total cholesterol levels during pregnancy and the increased maternal transmission in newborns of mothers with diabetes. Summary In cord blood, cholesterol levels are lower than in adults and the relative proportion present in HDL as opposed to LDL is much higher. The currently available evidence suggests that several factors influence the composition of cord blood lipoproteins. Although inheritance of major monogenic disorders can affect cord lipids in general, the genetic contribution appears to be minimal, although effects of the proprotein convertase subtilisin/kexine type 9 gene (PCSK9) need fuller exploration in this regard in certain ethnic groups. Evidence is summarized that maternal lipoprotein levels, particularly those due to diet or induced by pregnancy, influence cord lipid levels. Placental insufficiency and other conditions affecting fetal growth and the mode of delivery may also influence cord lipoprotein concentrations. How maternal glucose tolerance during pregnancy affects cord blood lipoproteins remains unclear. In view of increasing evidence that cardiovascular risk may have prenatal antecedents, this would seem to be an important area for further investigation.

Summary objective Medroxyprogesterone (MP) was used as the progestogen in randomized clinical trials of postmenopausal hormone replacement on cardiovascular risk. To attempt to understand the lack of benefit in these trials, we have examined the effects of MP and two other progestogens, the less androgenic desogestrel (DG) and the more androgenic norethisterone (NE), on cardiovascular risk factors against a background of oestrogen therapy. design and measurements Thirty-four women were treated with conjugated equine oestrogens (CEE) 0·625 mg daily alone for 12 weeks, followed in random order by each of the three progestogens (DG 75 µg, MP 10 mg and NE 1 mg daily) given sequentially for three 12-week cycles while maintaining the same CEE treatment. We measured serum lipoproteins, paraoxonase activity, C-reactive protein (CRP), fibrinogen, fasting glucose and insulin levels at baseline, at the end of the oestrogen-only phase and at the end of each of the combined oestrogen and progestogen phases. results The addition of progestogens to CEE maintained the oestrogen-induced reduction in apolipoprotein B (apo B) and lipoprotein (a) [Lp(a)], and further lowered total cholesterol (P

Background: Cohort studies have shown that smoking has a substantial influence on coronary heart disease mortality in young people. Population based data on non-fatal events have been sparse, however. Objective: To study the impact of smoking on the risk of non-fatal acute myocardial infarction (MI) in young middle age people. Methods: From 1985 to 1994 all non-fatal MI events in the age group 35–64 were registered in men and women in the WHO MONICA (multinational monitoring of trends and determinants in cardiovascular disease) project populations (18 762 events in men and 4047 in women from 32 populations from 21 countries). In the same populations and age groups 65 741 men and 66 717 women participated in the surveys of risk factors (overall response rate 72%). The relative risk of non-fatal MI for current smokers was compared with non-smokers, by sex and five year age group. Results: The prevalence of smoking in people aged 35–39 years who experienced non-fatal MI events was 81% in men and 77% in women. It declined with increasing age to 45% in men aged 60–64 years and 36% in women, respectively. In the 35–39 years age group the relative risk of non-fatal MI for smokers was 4.9 (95% confidence interval (CI) 3.9 to 6.1) in men and 5.3 (95% CI 3.2 to 8.7) in women, and the population attributable fractions were 65% and 55%, respectively. Conclusions: During the study period more than half of the non-fatal MIs occurring in young middle age people can be attributed to smoking.

Aims - To compare the relative frequency of eight indicators of problem drug use and potentially adverse social circumstances in drug using parents and non-parents and to explore whether a profile based on these characteristics differs according to whether or not dependent children live with their drug-using parent. Design – The study utilises a 5-year national UK treatment monitoring system dataset. Sample – 61,425 users with, and 105,473 without dependent children accessing drug treatment services in England and Wales between January 1996 and December 2000. Measurements – Information about parenthood and children’s residence was routinely collected. Drug use and social circumstance indicators were daily heroin use, daily alcohol use, regular stimulant use, sharing of injecting equipment, living with another user, living alone, unstable accommodation, and criminal justice referral. Findings – There were clear differences between drug using parents according to where children live. Parents with children at home and non-parents showed fewer of the indicators than parents with children in care or elsewhere. Sixty-five percent of parents with none of the indicators lived with their children, compared to only 28% of those with three indicators and 9% of those with six or more indicators. Parents with children in care or living elsewhere showed the highest prevalence for each individual indicator. Conclusions – Drug using parents demonstrate a range of potentially unfavourable drug use behaviours and social circumstances but those whose children live with them use drugs less frequently and live in more favourable conditions than those whose children live elsewhere. Protective factors may operate in family situations while severe drug use and adverse social circumstances may result in a breakdown of family structures.

Objectives: To estimate the total health gain from improving the quality of care among patients with cardiovascular disease in line with the quality indicator targets in the new contract for general practitioners (GPs) in the UK. Design: Statistical modelling, applying population impact measures to estimate cardiovascular health gains from achieving treatment targets in the GP contract, taking into account current levels of treatment and control. Main outcome measures: Number of events prevented in the population over 5 years applied to a notional general practice population of 10 000. Results: The greatest health gain in those aged 45–84 years would come from reaching cholesterol reduction targets. This could prevent 15 events in people with coronary heart disease, seven events in those with a history of stroke, and seven events in those with diabetes. Achieving blood pressure control targets in hypertensive patients without the above conditions could prevent 15 cardiovascular events, with further benefits from reducing blood pressure in patients with high blood pressure and coronary heart disease, stroke, or diabetes. Achieving other targets would have smaller impacts because high levels of care are already being achieved or because of the low prevalence of conditions or associated event risk. Conclusion: It is possible to quantify the health gain to a practice population of achieving quality targets such as those set in the new GP contract. The amount of health gain is sensitive to current quality of care, prevalence of conditions, and risk factors, and to the size of change anticipated. Nevertheless, it appears that significant health gains could result from achieving the proposed quality targets.

BACKGROUND: Understanding pre-test probability and baseline risks helps to interpret the results of diagnostic tests and the benefits of treatment, but how good is the understanding of these concepts? OBJECTIVES: Our aim was to assess the ability of GPs and consultant physicians to make accurate estimates and understand the application of pre-test probability and baseline risk for two common clinical conditions. METHODS: A two-stage questionnaire survey based on case scenarios of patients with angina and congestive heart failure was carried out of 202 physicians, randomly selected from the members of the Royal College of Physicians in the NW of England, 205 GPs randomly chosen from the practice list of the NW Health Authorities and 128 MRCGP examiners attending an examiners meeting. A total of 115, 106 and 81 members of these groups, respectively, responded to the first stage, and 44, 46 and 64 to the second. The main outcome measures were the stated likelihood of true ischaemic heart disease (IHD) being present and the predicted 1-year mortality; the impact of changing prevalence and baseline risk on these results; and interpretation of different methods of risk presentation. RESULTS: Estimates of pre-test probability of IHD being present ranged from 5 to 100% and of baseline risk of 1-year mortality from 0 to 86%. More GP examiners and consultant physicians understood the impact of increasing age on the test result than did the random sample of GPs. A majority of each group correctly said that increasing age would reduce the number needed to treat (NNT). Presentation of benefit as relative risk reduction was a greater stimulus to starting treatment than the NNT or measures of population impact. CONCLUSION: Clinicians should collect data to allow a better knowledge of the likelihood of disease and of baseline risk in their patient populations. Methods to increase the understanding of the influence of pre-test probability on diagnostic test results and of how to quantify and demonstrate the impact of the benefit of interventions should be explored.

It is generally accepted that supplemental Ca and/or vitamin D is effective in reducing the incidence of bone fractures; this is supported by numerous randomised controlled trials and meta-analyses. However, a question that has received much less attention is whether dietary Ca, i.e. Ca in physiological doses in normal food intake, also affects bone fracture risk. The present study aims to review the effect of dietary Ca on bone fractures at the hip, spine and radius in women >35 years old, and to compare these results with previous meta-analyses. MEDLINE (1966–1999) and reference lists in papers were searched for observational dietary Ca studies. Data were extracted in duplicate and separately. Heterogeneity and publication bias were tested. Observational studies failed to show any association between dietary Ca intake and risk of hip fracture (risk ratio 1·01, 95% CI 0·96, 1·07 for each increment of 300mg dietary Ca intake/d). There is a suggestion that either extremely low Ca intake may increase fracture risk, or that East Asian women may respond differently to increasing Ca intake.

Communicating population risk to policy makers and the public is important, but traditional epidemiological measures of risk are difficult to understand. PIN-ER- t , a measure of the population impact of risk factors, is simpler to understand and hence may be useful Communicating levels of health related risks to decision makers and the public is increasingly important. Clinical and public health professionals are becoming familiar with best practice in communicating risk to individual patients or members of the public.1 However, communicating risk to those who determine health policy has been less well studied. Although we do not have direct evidence of inappropriate health policy decisions being made, a questionnaire survey found health service managers seem to be inappropriately influenced by presentations of risk and benefit in relative rather than absolute terms.2 For understanding disease causation and to describe the impact of risk factors for disease, the traditional epidemiological measures are absolute and relative risk. However, these do not give a clear indication of the impact of a risk factor at population level, since they do not take into account the prevalence of the risk factor in a population. Epidemiological measures that do take this into account, such as population attributable risk (PAR), are difficult to conceptualise and remember and may be incomprehensible to non-epidemiologists. (In addition, different terms are used for PAR,3 including population attributable fraction (PAF)4 and population attributable risk proportion (PARP),5 which can be confusing for expert and non-expert audiences alike.6) For a healthcare organisation to allocate resources effectively and develop services according to its health priorities, there may be value in producing and communicating numbers that show the impact of risk factors for disease in the local population in ways that can be easily calculated and understood. We have therefore …

Aims: The aim of the present study was to determine: (i) the prevalence of the investigation and treatment of osteoporosis in patients admitted to hospital with a minimal-trauma fracture, (ii) the prevalence of osteo­porosis using bone mineral density assessment by dual X-ray absorptiometry (DEXA) in such patients and (iii) a clinical pathway for the management of osteo­porosis in such patients. Methods: A cross-sectional study was undertaken involving all patients admitted with a fracture to Westmead Hospital, Sydney, Australia, between January 1999 and June 2000 (n = 327). Of these, 264 were excluded because of: (i) the fracture following significant trauma (n = 83), (ii) unavailability of medical records for review (n = 38), (iii) nursing home status (n = 37), (iv) previous malignancy (n = 18), (v) deceased (n = 11), (vi) recent osteoporosis screening and/or treatment (n = 18), (vii) refusal to participate (n = 37), (viii) uncontactable (n = 16) and (ix) inadequate English (n = 6). The remaining 63 patients underwent DEXA assessment and the following laboratory investigations: (i) liver function tests, (ii) urea, (iii) electrolytes, (iv) calcium, (v) phosphate, (vi) full blood count, (v) 25-hydroxyvitamin D level and (vi) thyroid-function tests. In men, levels of serum free testosterone, luteinizing hormone, follicle-stimulating hormone and prolactin were also obtained. Results: Of the 63 study participants, 87% of the 47 women were either osteoporotic (T

Objectives To document knowledge, behavior and experiences of adults regarding potential signs and symptoms of bowel cancer. Methods Telephone interviews with 1332 randomly selected adults, using similar questions to a survey conducted in 1988. Results Twenty three percent (n=306) of respondents reported that they had experienced blood in bowel motions and about one third of these reported that they did not seek medical advice at all. Conclusions As there has been no change in help seeking for potential symptoms of bowel cancer from similar studies conducted 15 years ago, there are concerns for encouraging behaviors that will result in the early detection of colorectal cancer.

Background— The hypothesis that paraoxonase (PON1) has a role in preventing atherosclerosis is based on experimental, transgenic, and case-control studies but has not previously been tested prospectively. Methods and Results— The Caerphilly Prospective Study is a cohort study of men aged 49 to 65 years observed for coronary heart disease (CHD) events (fatal and nonfatal myocardial infarction) over a mean period of 15 years. Serum PON1 activity toward paraoxon was measured in 1353 participants. PON1 activity was 20% lower in the 163 men who had a coronary event ( P =0.039). Men in the highest quintile of PON1 activity had a decreased risk compared with those in the lowest quintile (OR 0.57 [95% CI, 0.33 to 0.96]). The inverse relationship between quintiles of serum PON1 activity and CHD risk was graded, the median change in OR across each quintile being 0.87 (0.77 to 0.98). After adjustment for all other CHD risk factors, including HDL cholesterol, this median value became 0.90 (0.78 to 1.02). PON1 was most predictive of a new CHD event in patients at highest risk by virtue of preexisting CHD (adjusted median OR for each quintile, 0.74 [0.59 to 0.93]; n=313) or the presence of other risk factors. For the highest tertile of CHD risk (n=390) calculated by the Framingham equation, adjusted median OR for each quintile was 0.84 (0.66 to 1.05); n=390. Conclusions— Low serum PON1 activity toward paraoxon is an independent risk factor for coronary events in men at high risk because of preexisting disease or other CHD risk factors.

Our aim was to investigate trends in provision and outcomes of care by socio-economic status among patients with diabetes in Salford, United Kingdom. Salford is a deprived urban area in North West England. Data for people with diabetes who were younger than 20 years of age (4034 patients in the year 1993 and 5671 by the year 2000) were extracted from the Diabetes Information System. Age-standardised means, proportions and attainment of targets were calculated for: processes of care indicators, intermediate outcomes and prescribing of preventive drug treatments in 1993 to 1994 and in 2000 to 2001 by quintiles of Townsend deprivation score. We did comparisons of means and proportions using age-adjusted linear regression and of trends using generalised estimating equations. Rate ratios for first microvascular and first macrovascular complication were estimated from proportional hazards models. Marked improvements occurred in all indicators. For patients managed in primary care, blood pressure and cholesterol measurement increased from 53% to 64% (p

The objective of this study was to survey hypertensive patients' response to, requirement for and training in self-blood pressure monitoring (SBPM). A total of 222 hypertensives were invited to complete a questionnaire even when not participating in the project. Questions supplied information on demographics, monitoring frequency, convenience of attending the surgery, monitor ownership and preference for and ease of self-monitoring. Comments supplied qualitative data. Training group questionnaires supplied similar data as well as SBPM data before and after training. Of 133 respondents, a higher educated, younger, wider age range wanted to participate (76; 57.2%) and tended to self-monitor. However, only an increase in further education (FE) was associated with an increased probability of participation and inclination to self-monitor in the multivariate analyses. A positive relationship exists between age and frequency in both groups. About a sixth of respondents own monitors and ownership is correlated to FE. Although most patients found it convenient to visit the surgery, the percentage finding it convenient was lower in patients attending training sessions than in the original survey, possibly indicating that independence is important for SBPM. Younger, higher-educated patients tended to self-monitor although FE was again the significant factor. Training increased preference for the idea of SBPM, prospective monitor ownership (64.8% of non-owners) and self-monitoring intention (76.1%). Patients found recording card listed cardiovascular disease (CVD) risks valuable and 69.6% (32) wanted to establish a support group. Comments and interviews indicated haphazard knowledge, routines and uncertainty about SBPM. A standardised procedure including patient assessment, SBPM protocol and lifestyle education is needed for SBPM to be successful.