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The objective of the present investigation was to develop a quantitative electroencephalographic measure (qEEG) that is sensitive and specific to changes in sustained human performance. A principal components analysis (PCA) was performed on the qEEG obtained from participants during a continuous performance test. Measures of sensitivity (proportion of correctly identified correct responses, or hits) and specificity (proportion of correctly identified incorrect responses, or misses) were calculated to assess the classification accuracy of each newly derived component. PCA solutions produced a right hemisphere component comprised of beta-wave activity measured from four unipolar sites (F8, C6a, C6, and T4) that appeared to be sensitive and specific to changes in human performance. Results provide evidence for the validity of a right hemisphere qEEG measure that is sensitive and specific to changes in sustained human performance. Consistent with the findings of previous research, the present findings implicate the right cerebral hemisphere in the sustained attention process.

Australia has the highest incidence of skin cancer in the world and ultraviolet (UV)-B radiation has been implicated as its major aetiological agent. Despite the link between melanoma and exposure to UV-B radiation in childhood, little work has been carried out to determine the effects of UV-B on neonatal skin. In this study, we investigated the response of adult and neonatal Langerhans cells (LC) to UV-B radiation to determine whether exposure in the neonatal period impairs the development of the skin immune system, thus having implications for the immune response later in life. Neonatal and adult mice were irradiated with a single dose of UV-B radiation and epidermal sheets prepared to determine the number of LC present. In addition, antigen carriage and T-cell proliferation assays were carried out to assess the immune response when the mice reached maturity. Results showed that neonatal LC were more susceptible than adult LC to depletion at 2 kJ/m(2) UV-B exposure; however, there was similar susceptibility at lower doses. When mice that were irradiated as neonates were analysed at maturity, there was an increased ability to respond to cutaneously applied antigen as more antigen was transported to the lymph node and the lymph node dendritic cells had an enhanced ability to stimulate T-cell proliferation. In addition, this response was skewed towards a Th2 type response. Thus, single high-dose UV-B exposure alters the development of neonatal LC, resulting in a short-term reduction in the number of LC but an enhanced immune response when assessed at maturity.

Aims/hypothesis: The aim of this study was to test the construct validity of the Diabetes Quality of Life for Youth (DQOLY) questionnaire in a large representative sample of young people with type 1 diabetes mellitus., Methods: The 52-item DQOLY questionnaire was completed by 2,077 adolescent individuals (aged 10-18 years) with type 1 diabetes. Participants were recruited from 22 paediatric diabetes centres in 18 countries across Europe, Asia and North America. HbA(1c) levels were determined once and analysed centrally., Results: Exploratory factor analysis generated three possible measurement models of a revised questionnaire, two with four factors and one with six factors with all models indicating the presence of one satisfaction scale, but with many of the impact and worry scale items either double loading or not loading on any factors. Subsequent confirmatory analysis indicated that compared with the original DQOLY scales, the six-factor solution was the best-fitting model., Conclusions/interpretation: The DQOLY factor structure does not show construct validity in a large, diverse representative sample of young people with type 1 diabetes. However, a revised (short-form) version of the DQOLY is proposed that has improved construct validity, adequate internal consistency, and more precise and hypothesised association with HbA(1c). It is anticipated that this shorter version will enhance the acceptability and clinical utility of the measure, making it more feasible to introduce as part of routine care.

Background: The national Cardiovascular Health Strategy including specific plans for cardiac rehabilitation was launched in Ireland in 1999. A survey of cardiac rehabilitation services was conducted in 2003 to evaluate progress on service provision., Aim: To establish levels of service provision, service formats and geographic distribution of cardiac rehabilitation services in 2003 and compare them with the status pre-Strategy (1998)., Method: All hospitals in Ireland (n = 39) admitting cardiac patients to a coronary or intensive care unit were surveyed by postal questionnaire., Results: All hospitals provided information and all reported providing Phase I cardiac rehabilitation. Seventy-seven per cent (30 of 39) provided Phase III rehabilitation in 2003 (i.e. outpatient cardiac rehabilitation services) compared with 29% (12 of 41) in 1998. Of those hospitals currently without programmes, 78% (seven of nine) had plans in place for programme establishment. All programmes had trained cardiac rehabilitation coordinators, multidisciplinary teams and multiple components as recommended in the Strategy. In 82% of hospitals, intervention was provided at Phase II (immediate post-discharge period) while 26% of hospitals provided intervention at Phase IV (long-term maintenance period)., Conclusions: There have been substantial achievements towards the Cardiovascular Health Strategy target of providing cardiac rehabilitation services for all relevant hospitals in Ireland over the past five years. Service provision of cardiac rehabilitation can benefit from collective efforts made across centres to encourage the prioritisation of cardiac rehabilitation in national health policy initiatives.

Background: Gender differences in presentation and management of acute coronary syndromes (ACS) are well established internationally. This study investigated differences in a national Irish sample., Design: Cross-sectional survey., Methods: All centres (n=39) admitting cardiac patients to intensive/coronary care provided information on 25 consecutive acute myocardial infarction patients and other ACS patients admitted concurrently (n=1365 episodes). Patient data was analyzed in terms of those with prior ACS/revascularization, and those without., Results: Men with prior established ACS/revascularization were twice as likely to have received revascularization procedures (coronary artery bypass graft or percutaneous coronary intervention) prior to admission when controlling for age, total cholesterol and insurance status [odds ratio (OR) 1.97, 95% confidence interval (CI) 1.18-3.29, P=0.011]. No gender differences were seen in acute-phase reperfusion (OR 0.96, 95% CI 0.76-1.24, P>0.05) or antiplatelet therapy (OR 0.99, 95% CI 0.69-1.41, P>0.05). For patients with prior ACS/revascularization, men were twice as likely to receive statins on discharge after adjustment for age and total cholesterol (OR 1.94, 95% CI 1.02-3.71, P=0.045)., Conclusions: Women were treated differently to men. Fewer women with a positive history of ACS received revascularization prior to current admission and fewer women were prescribed lipid-lowering medications on discharge. Acute phase hospital treatment was not gender determined. These findings have implications for secondary prevention in Ireland.

Background: Shorter time to treatment is associated with lower mortality in acute coronary syndromes (ACS). A previous (1994) survey showed substantial delays for acute myocardial infarction (AMI) in Ireland. The present study compared current practice with 1994 and surveyed acute coronary syndromes as a more complete contemporary evaluation of critical cardiac care than assessing AMI alone., Methods: Following ethics committee approval, all centres (N = 39) admitting acute cardiac patients to intensive/coronary care unit provided information on 1365 episodes. A cross-sectional survey design was employed., Results: Since 1994, median hospital arrival to thrombolysis time was reduced by 41% (76 to 45 minutes). Thrombolysis was delivered more often in the emergency department in 2003 (48% vs 2%). Thrombolysis when delivered in the emergency department was achieved faster than thrombolysis delivered in intensive/coronary care (35 mins v 60 mins; z = 5.62, p < .0001). Suspected AMI patients who did not subsequently receive thrombolysis took longer to present to hospital (5 h vs 2 h 34 mins; z = 7.33, p < .0001) and had longer transfer times to the intensive/coronary care unit following arrival (2 h 17 mins vs 1 h 10 mins; z = 8.92, p < .0001). Fewer confirmed AMI cases received thrombolysis in 2003 (43% vs 58%). There was an increase in confirmed cases of AMI from 1994 (70% to 87%)., Conclusions: Substantial improvements in time to thrombolysis have occurred since 1994, probably relating to treatment provision in emergency departments. Patient delay pre-hospital is still the principal impediment to effective treatment of ACS. A recent change of definition of AMI may have precluded an exact comparison between 1994 and 2003 data.

Objective: To validate the usefulness of written information for patients with venous leg ulcers and test the hypothesis that patients who receive written information retain more knowledge than those who receive verbal information alone., Method: Twenty patients newly diagnosed with venous leg ulcers were recruited into this prospective trial. Patients were randomised either to the control group (given verbal information on their condition) or the intervention group (same verbal information and an information leaflet). The verbal information was in the same format as in the leaflet. Patients' knowledge of the condition was ascertained at an initial interview and at follow-up four to six weeks later., Results: At follow-up both groups showed an overall improvement in knowledge, with no statistical difference between them., Conclusion: The results indicate there is limited value in providing information leaflets to this patient group, who were predominantly older patients with low levels of education. The relatively small sample size may explain the disappointing results. Further research may reveal a benefit of providing these leaflets to carers.

Background: Little is understood about the conceptual relationship of depression and quality of life (QoL). Judgments concerning both, implicitly or explicitly, involve a time perspective. The aim of this study was to test de Leval's theoretical model linking depression and QoL with a time perspective. The model predicts that changes in cognitions about one's past, present and future QoL, will be associated with changes in depressive symptomatology., Methods: Eighteen psychiatric in-patients with a clinically confirmed diagnosis of depression were assessed on commencing treatment and 12 weeks later. QoL was assessed by the Schedule for Evaluation of Individual Quality of Life (SEIQoL), depression by the Beck Depression Inventory (BDI-II) and hopelessness by the Beck Hopelessness Scale (BHS). Time perspective was incorporated by asking QoL questions about the past, present and future., Results: Depression and hopelessness were associated with a poorer present QoL. Depression lowered present QoL but did not alter future QoL, as these remained consistently high whether participants were depressed or recovering. However, depressed individuals had a larger gap between their actual present QoL and future (aspired to) QoL. Changes in QoL were influenced by depression and hopelessness. Contrary to the model, perception of "past" QoL was not affected by depression or hopelessness., Conclusions: de Leval's model was largely confirmed. Thus depression and hopelessness influence a person's present and future QoL. The analysis of a temporal horizon was helpful in understanding the link between depression and QoL.

The changing demographic profile of the world's population towards old age and evidence of people living for longer with less time spent in ill health highlight the importance of addressing quality-of-life (QOL) assessment issues for older people. The assessment of health-related QOL (HR-QOL) has received considerable attention in the last 2-3 decades, with a wide variety of assessment instruments available. These instruments can be either generic or disease specific, health profiles or preference based. The literature was reviewed systematically to identify studies measuring HR-QOL in older patient groups. A total of 37 studies were identified, 11 of which were randomised, controlled trials/evaluations, 14 were prospective studies that did not involve a randomised, controlled intervention, and 12 were cross-sectional studies. Studies were summarised in terms of the study aim, patient population characteristics, the instrument used to measure HR-QOL, and HR-QOL findings. A majority of studies used a generic HR-QOL instrument, the single most commonly used being the 36-Item Short-Form Health Survey. In many cases, a second disease-specific measure was used in combination with the generic measure. In a majority of studies involving interventions, significant improvements in HR-QOL were noted. In prospective studies, a negative impact of health conditions (e.g. myocardial infarction and chronic heart failure) was also identified using HR-QOL assessments. None of the studies in this review used HR-QOL measurement instruments that were old-age specific. Using instruments that are not specific to a particular age group enables comparisons to be made with other age groups, i.e. younger or middle-aged groups. However, the questionnaire items of HR-QOL instruments tend to be phrased predominantly in relation to physical function and thus may inadvertently discriminate against older persons, whose physical function is likely to be not as good as that of younger people. Particular issues in the assessment of HR-QOL in older patient populations include the persistent finding of a poor relationship between QOL and disability/disease severity, the dynamic nature of QOL, and the importance of valid proxy ratings for those unable to make decisions or communicate for themselves. It is important, therefore, that assessment of HR-QOL incorporates issues of importance to individual older people by broadening the scope of the measurement instruments, thus representing more validly the HR-QOL status of older patient groups. Future research in HR-QOL must incorporate the perspective of the individual in order to enable valid conclusions to be derived based on content that is relevant to the individual being assessed, thus informing management decisions, policy and practice more meaningfully.

Inferior vena caval obstruction (IVCO) is an occasional cause of lower limb oedema in palliative care patients with metastatic malignancy. We present five cases who underwent IVC stenting for symptomatic relief. Four of the five cases had significant reduction in their oedema but three of these four patients died within two weeks of the procedure. The procedure itself is described and the appropriateness of this intervention in patients with end-stage disease is discussed.

Background: The National Health Strategy envisages a health system incorporating patient views; and providing accessible, consultant-led dialysis services with patient choice of dialysis modality, in all regions., Aims: To describe patients' experiences of renal services against National Health Strategy objectives., Methods: Telephone interviews with 192 dialysis patients from three hospitals in the Eastern region., Results: One-quarter of participants (16% of haemodialysis [HD] and 46% of peritoneal dialysis patients) lived outside the Eastern region, and travelled there because dialysis was not available locally. Two-thirds (65%) had a choice of dialysis modality. High satisfaction with interpersonal care was observed (83-98% satisfaction). Dissatisfaction with physical environment included parking (39-56%), waiting areas (62-69%), HD unit space (74%). Regarding support services, dietary services were satisfactory (92-95%), with lower satisfaction ratings for social and financial support services (62%)., Conclusions: Structural and management issues must be addressed to advance a quality agenda for renal care in Ireland.

Background: Ethical approval of research projects is, appropriately, an essential prerequisite in health settings., Aims: This paper outlines difficulties encountered with procedures for gaining ethical approval for two multicentre surveys in Ireland., Methods: The experiences of two national surveys were documented., Results: Delays in processing ethics applications led to substantial delays in both surveys. Research ethics committees (RECs) assessed applications in an idiosyncratic manner., Conclusion: In Ireland, there is currently no accepted mechanism for single location ethical approval for multicentre studies. Instead, they require separate approval from all participating centres. The challenges of this system of application to multiple committees are outlined in this paper, and possible solutions presented.

Background: In 1996, the CONSORT (CONsolidated Standards Of Reporting Trials) statement for the reporting of clinical trials was produced, based on empirical evidence regarding bias., Aims: This study assessed the quality of reporting of randomized controlled trials (RCTs) in the palliative care literature., Methods: Three specialist journals were hand searched for RCTs. A checklist was devised based on CONSORT recommendations. Two investigators independently assessed all the trials against this checklist. The trials were grouped into time cohorts of five years and quality comparisons made. Trials looking at pain were compared with those trials looking at other aspects of palliative care., Results: Ninety-three RCTs were identified. The number of trials has increased over time: nine in the first cohort, 37 in the second and 47 in the last cohort. The number of patients in the individual trials has also increased over time. Generally, the reporting quality was poor, particularly the areas of allocation concealment, randomization technique and intention to treat analysis, where there is empirical evidence, that it leads to trial bias. Although there were more pain papers than non-pain papers, the quality of reporting was only better for blinding and intention to treat analysis., Conclusion: The quality of reporting of RCTs in the palliative care literature is generally poor. However, there has been an increase in the number and the size of RCTs being carried out. This shows recognition of the importance of an evidence base in palliative care. However, in order to guide clinical decision making, future trials need to improve the quality of their reporting by adhering to the CONSORT statement.

There is now clear scientific evidence linking regular aerobic physical activity to a significant cardiovascular risk reduction, and a sedentary lifestyle is currently considered one of the five major risk factors for cardiovascular disease. In the European Union, available data seem to indicate that less than 50% of the citizens are involved in regular aerobic leisure-time and/or occupational physical activity, and that the observed increasing prevalence of obesity is associated with a sedentary lifestyle. It seems reasonable therefore to provide institutions, health services, and individuals with information able to implement effective strategies for the adoption of a physically active lifestyle and for helping people to effectively incorporate physical activity into their daily life both in the primary and the secondary prevention settings. This paper summarizes the available scientific evidence dealing with the relationship between physical activity and cardiovascular health in primary and secondary prevention, and focuses on the preventive effects of aerobic physical activity, whose health benefits have been extensively documented.

The purpose of this statement is to provide specific recommendations in regard to evaluation and intervention in each of the core components of cardiac rehabilitation (CR) to assist CR staff in the design and development of their programmes; the statement should also assist health care providers, insurers, policy makers and consumers in the recognition of the comprehensive nature of such programmes. Those charged with responsibility for secondary prevention of cardiovascular disease, whether at European, at national or at individual centre level, need to consider where and how structured programmes of CR can be delivered to the large constituency of patients now considered eligible for CR.

Few reports about methods of evaluating quality of life (QoL) among the thousands published since medical interest in the subject slowly began nearly 40 years ago are based upon theory. This paper, prepared in response to a request to furnish an exception (Meadows KA. Introduction to an Advanced Seminar: Assessing Health-Related Quality of Life. What can the Cognitive Sciences Contribute? Hull University, October 9, 2000) describes the origins of the Schedule for the Evaluation of Individual Quality of Life (SEIQoL). This derives its cognitive aspects from theoretical studies of perception by Egon Brunswik, their extension to Social Judgment Theory (SJT) by Kenneth Hammond and the application of these ideas to QoL by the present authors and their colleagues.

Objective: It is unclear whether the demands of good metabolic control or the consequences of poor control have a greater influence on quality of life (QOL) for adolescents with diabetes. This study aimed to assess these relations in a large international cohort of adolescents with diabetes and their families., Research Design and Methods: The study involved 2,101 adolescents, aged 10-18 years, from 21 centers in 17 countries in Europe, Japan, and North America. Clinical and demographic data were collected from March through August 1998. HbA(1c) was analyzed centrally (normal range 4.4-6.3%; mean 5.4%). Adolescent QOL was assessed by a previously developed Diabetes Quality of Life (DQOL) questionnaire for adolescents, measuring the impact of diabetes, worries about diabetes, satisfaction with life, and health perception. Parents and health professionals assessed family burden using newly constructed questionnaires., Results: Mean HbA(1c) was 8.7% (range 4.8-17.4). Lower HbA(1c) was associated with lower impact (P < 0.0001), fewer worries (P < 0.05), greater satisfaction (P < 0.0001), and better health perception (P < 0.0001) for adolescents. Girls showed increased worries (P < 0.01), less satisfaction, and poorer health perception (P < 0.01) earlier than boys. Parent and health professional perceptions of burden decreased with age of adolescent (P < 0.0001). Patients from ethnic minorities had poorer scores for impact (P < 0.0001), worries (P < 0.05), and health perception (P < 0.01). There was no correlation between adolescent and parent or between adolescent and professional scores., Conclusions: In a multiple regression model, lower HbA(1c) was significantly associated with better adolescent-rated QOL on all four subscales and with lower perceived family burden as assessed by parents and health professionals.

This article reports the views of 155 relatives of patients who died during a 12-month period with varying degrees of palliative care service (hospital-based, home care and no palliative care). Although overall care was rated as excellent or good by the majority of interviewees, the Critical Incident Technique (Flanagan, 1954) was used to gather examples of good and poor care from relatives' perspectives. These incidents are recounted here under a framework describing the process of care from access to services through to care at the time of death and aftercare for relatives. The range of incidents reported suggest that relatives consider all aspects of care - technical and interpersonal - as important towards the end of life, but particular importance is placed on the attitudinal and dignity-preserving aspects of care. The movement to integrate principles of palliative care into all clinical practice is reinforced by the findings from this study.

Background: The first national survey of cardiac rehabilitation services was conducted., Aims: To establish levels of service provision, service formats, and geographic distribution of cardiac rehabilitation services in 1998., Methods: Public hospitals in the Republic (n=41) and Northern Ireland (n=12) which provide services to cardiac patients were surveyed. RESULTSl Response rate was 81%. Twelve centres (29%) in the Republic and nine (75%) in Northern Ireland provided cardiac rehabilitation. There was wide geographic variability in service provision. Most centres were unable to identify the proportion of eligible patient participation. Most programmes were established for less than five years. All programmes had multidisciplinary teams, multicomponent courses and co-ordinators. Additionally, 44% of hospitals without programmes had plans regarding programme establishment., Conclusions: The findings highlight the underdeveloped but rapidly expanding nature of cardiac rehabilitation services in Ireland. They provide a baseline from which to address rehabilitation needs and to judge the success of the National Cardiovascular Health Strategy in addressing these needs.

Dislocation of total knee arthroplasty is a rare but serious complication. The experience with the Insall-Burstein II modified knee prosthesis, which was designed to address the issue of dislocation, has been favorable. We present a series of 3 dislocations in 1,500 total knee arthroplasties done with this prosthesis, accounting for about 0.2% of cases.

Tissue plasminogen activator (tPA) promotes fibrinolysis, and impaired fibrinolysis is associated with atherosclerosis and thrombosis. Plasminogen activator inhibitor-1 (PAI-1) inhibits t-PA expression. The effects of acute laboratory stressors on tPA and tPA/PAI-1 complexes were assessed in a sample of 11 cardiac patients. Participants were randomly assigned to either a stress or relaxation condition at time 1, and the alternative condition at time 2. Blood samples were taken before (pre) and after (post) each session and participants completed a battery of psychological questionnaires. Two-way repeated-measures analysis of variance revealed a statistically significant decrease in tPA (P = 0.01) and tPA-PAI-1 complexes (P = 0.04) during the mental stress condition. Anger-in had a strong relationship to decreases in tPA/PAI-1 levels in the stress condition (r = 0.68, P < 0.05). Relaxation had no significant effect on tPA and tPA/PAI-1 levels. These data suggest that decreased fibrinolysis mediates the relationship between mental stress and atherosclerosis.

A variety of measures are currently used to assess psychosocial outcome (quality of life) in cardiac rehabilitation programmes. However, there is no consensus on the most appropriate instruments to use. Instruments that are not sufficiently responsive to change in cardiac populations are unsuitable as audit tools as they underrepresent the benefits of programme attendance. To identify the most responsive instruments in cardiac rehabilitation populations a systematic overview of studies for the 10-year period 1986-1995 was conducted. The following databases were searched: Medline, Psychlit, Cinahl and Sociofile and 32 relevant studies were identified. The effect size statistic (a comparison of the magnitude of change to the variability in baseline scores) was used to determine those instruments most responsive to change. The following instruments were identified as being responsive in more than one study: Beck Depression Inventory, Global Mood Scale, Health Complaints Checklist, Heart Patients Psychological Questionnaire and Speilberger State Anxiety Inventory. There is little consensus on psychosocial evaluation instrument use in the cardiac rehabilitation literature. A number of measures show significant potential for routine outcome assessment. Formal assessment of these instruments is recommended to inform final recommendations about instrument selection for audit and evaluation purposes in cardiac rehabilitation.

Background: Recombinant human growth hormone (rhGH) has been shown to have powerful anabolic effects and to reduce or even prevent nitrogen catabolism in stressed patients. The effects of rhGH on functional parameters are less clearly defined. The aim of this study was to assess the effects of perioperative rhGH on nutritional markers, skeletal muscle function, and psychological well-being in patients undergoing infrarenal, abdominal aortic aneurysm repair., Methods: Thirty-three patients undergoing elective infrarenal abdominal aortic aneurysm repair were randomized to one of three groups: (1) control (n = 12): placebo for 6 days before and after surgery; (2) preop + postop (n = 10): rhGH (Genotropin; Pharmacia Ltd, Uppsala, Sweden) 0.3 IU/kg/d for 6 days before and after surgery; and (3) postop (n = 11): placebo for 6 days before and rhGH 0.3 IU/kg/d for 6 days after surgery. Patients were assessed on days -7 and -1 before surgery and days 7, 14, and 60 after surgery., Results: Administration of rhGH resulted in increased insulin-like growth factor 1 levels, the increase being significantly more marked in the group given rhGH preoperatively. Preoperative and postoperative rhGH reduced the postoperative decrease in both serum transferrin and grip strength at day 7 by 30% and 70%, respectively. Postoperative respiratory function and arterial oxygenation also were improved, with significant differences in arterial oxygenation between rhGH-treated and untreated groups. No difference in mood was seen between groups after surgery, nor was there any difference between subjective assessment of fatigue scores between groups., Conclusions: This pilot study indicates that rhGH administered preoperatively has beneficial effects on skeletal muscle and respiratory function and may be more useful than postoperative rhGH administration alone.

Psychological management of older people undergoing cardiac rehabilitation should be delivered, in the main, as it is to younger people with the heterogeneity of patient characteristics taken as standard. General considerations in delivering a service to older people include societal definitions of ageing, the profile of older cardiac patient groups, ageism as practised by both health professionals and patients, psychological issues of particular relevance to ageing and evidence from scientific studies with older individuals. These topics are considered in this review. The challenge is to develop a system which includes and is responsive to this growing subgroup of patients who can benefit from cardiac rehabilitation.

Objective: To find out whether patients undergoing repair of ruptured abdominal aortic aneurysms (AAA) had more emotional problems and limitations of lifestyle than those listed for elective resection., Design: Retrospective study, Setting: Teaching hospital, Eire. SUBJETS: 28 patients, 14 in each group, matched for age, sex, duration of stay in the intensive care unit (ICU), hospital stay postoperatively, and length of time since operation., Interventions: Application of structured questionnaire., Main Outcome Measures: Emotional problems, mobility, activities of daily living, ability to sleep, degree of psychological stress, presence of symptoms, and Rosser index to measure quality of life (QoL)., Results: There were no significant differences between the groups in any measure., Conclusions: Patients have few emotional difficulties or disturbances of QoL after emergency or elective repair of AAA. Survivors after repair of ruptured AAA can expect as good a quality of life as those operated on electively. These results support an aggressive approach to the treatment of ruptured AAA.

An increasing array of health status instruments provides challenges to the researcher in selecting the most appropriate measure in health outcomes studies. The responsiveness of a measure is its ability to identify small but important changes over time or following interventions. For health outcomes studies, responsiveness is an important psychometric requirement to guide instrument selection and it can be evaluated using the effect size statistic. The calculation and meaning of effect sizes are described here. Effect size considerations can also contribute to other topics of importance to health researchers. Issues of power and statistical and clinical significance are discussed.

The Schedule for the Evaluation of Individual Quality of Life allows individuals to nominate the domains they consider most important to their quality of life and to use their own value system when describing the functional status and relative importance of those domains. The weights for domain importance are derived through a procedure called judgement analysis. As judgement analysis is impractical for individuals with cognitive impairment and in many clinical situations, a shorter, direct weighting procedure has been developed. To test the new procedure, 40 healthy individuals completed both direct and judgement analysis weightings, at t1 and 7-10 days later (t2). After a further 7-10 days (t3), they were asked to identify the weight profiles they had previously produced using each method. The weights produced by the two methods differed on average by 7.8 points at t1 and 7.2 points at t2. The direct weights changed on average by 4.5 points from t1 to t2, while the judgement analysis weights changed by 8.4 points. At t2, 55% of individuals were able to identify the direct weights they had previously produced. The new procedure demonstrates stability and validity but is not interchangeable with judgement analysis. The most appropriate ways of using and interpreting both procedures are discussed.

A number of risk factors for malnutrition in the elderly have been identified, but their relative importance has yet to be established. General practitioners and public health nurses were interviewed to elicit the relative weights placed on 6 major risk factors when assessing nutritional risk in the elderly (living alone, recent bereavement, denture problems, mobility problems, psychiatric morbidity and multiple medication use). Participants rated risk for 35 hypothetical cases, described by their status on the 6 risk factors. Multiple regression models of these judgments revealed a consistently high weight for psychiatric morbidity compared to the other factors. Little group variation in diagnostic policies was observed between general practitioners and public health nurses or by case gender. These policies may reflect the perception that psychiatric problems pervade many areas of life functioning related to nutritional intake and are therefore more likely to cause malnutrition than other, more specific risk factors.

This exposure assessment pilot study tested the hypothesis that elevated blood levels of the dioxin congener 2,3,7,8-TCDD ("TCDD"), due to Agent Orange exposure, in American Vietnam veterans could be demonstrated two to three decades after Vietnam service. A second objective was to determine if dioxins, including TCDD, are present in the semen of adult males. In the early 1990s, blood samples from 50 Vietnam veterans and three pooled semen samples from 17 of them were analyzed by high-resolution gas chromatography-mass spectroscopy for dioxins, dibenzofurans, and the dioxin-like PCBs. Fifty volunteers from the Michigan Vietnam veteran bonus list, which documented Vietnam service, were invited to participate based on their self-reported exposure to Agent Orange in Vietnam. Screening of military and medical records was performed by an epidemiologist and a physician to assure that Agent Orange exposure was possible based on job description, location of service in Vietnam, and military Agent Orange spray records. Elevated 2,3,7,8-TCDD levels, over 20 ppt on a lipid basis, could still be detected in six of the 50 veterans in this nonrandomly selected group. The dioxin and dibenzofuran congeners commonly found in the U.S. population, including TCDD, were also detected in the three pooled semen samples. Quantification and comparison on a lipid basis were not possible due to low lipid concentrations where levels were below the detection limit. Therefore, semen samples were measured and reported on a wet-weight basis. Elevated blood TCDD levels, probably related to Agent Orange exposure, can be detected between two and three decades after potential exposure in some American veterans. Original levels were estimated to be 35-1,500-fold greater that that of the general population (4 ppt, lipid) at the time of exposure. In addition, the detection of dioxins in semen suggests a possible mechanism for male-mediated adverse reproductive outcomes following Agent Orange or other dioxin exposure.

The case for evaluation in cardiac rehabilitation is outlined with particular emphasis on the role of quality of life measurement in the assessment of services. A range of studies evaluating quality of life in cardiac rehabilitation settings are described, and recommendations are made to help identify appropriate measures for use in routine clinical cardiac rehabilitation settings in the future.

The validity of self-reported data on the presence of guns in the home obtained in a telephone survey was assessed in samples of households where a hunting license had been purchased or a handgun registered. The survey was conducted among a random sample of Ingham County, MI, residents who had purchased a hunting license between April 1990 and March 1991 and among those registering a handgun during 1990. A third study sample was selected from the county's general adult population using a random digit dialing method. The interviews were conducted between November 1991 and January 1992. The proportion of respondents who reported that at least one gun was kept in their household was 87.3 percent among handgun registration households and 89.7 percent among hunting license households. In the survey of the general population of the county, approximately one-third of the respondents reported keeping a gun in the household, 67 percent of them for hunting and 23 percent for safety. Despite some limitations, the data indicate that a question on gun presence in a household can be used in a in a telephone survey.

This study examines the proportion of deaths from major diseases among Michigan Vietnam veterans. The distribution of deaths among Michigan Vietnam veterans was compared to deaths among veterans serving elsewhere for 1974-1989 to generate a proportionate mortality ratio (PMR). PMRs were estimated overall and for Black versus non-Black veterans. Overall, Vietnam veterans had significantly elevated PMRs for infectious and parasitic diseases and endocrine disease and lower PMRs for all malignant neoplasms combined. Vietnam veterans overall and non-Black specifically had elevated PMRs for non-Hodgkin's lymphoma. Black Vietnam veterans had elevated PMRs for cancer of the digestive organs, peritoneum, and pancreas. The elevated PMR for non-Hodgkin's lymphoma is consistent with results of individuals exposed to phenoxy herbicides. Results suggest that future studies should examine risks among racial groups separately.

Unrealistic optimism may contribute to risky health practices and to a delay in seeking treatment for medical conditions, as most individuals perceive themselves to be at little risk for various disorders. It is thus an important concept to present to medical students as part of their behavioural sciences training. Social psychological concepts such as unrealistic optimism may appear, on initial presentation to students, to be a misjudgement based on faulty understanding of risk estimates by the general population. This project aimed to teach the principle of unrealistic optimism by having students document their own beliefs about health risks. Students rated their own risk, relative to other classmates, of experiencing a range of 17 health problems. Questionnaires were completed by two classes of medical students (n = 257). Class results showed varying levels of unrealistic optimism for all 17 conditions. Males and females differed significantly on three of the 17 conditions. Student data were obtained rapidly in a large didactic setting and served to illustrate the concept of unrealistic optimism which was subsequently taught in class. Such exercises may be a useful teaching aid to students providing them with feedback on their own cognitive processes and illustrating that they display cognitive distortions similar to those of patients.

Irish data from the ISIS-2 multi-centre study of thrombolytic therapy has indicated longer delays to treatment for acute myocardial infarction (AMI) than in other countries (7.9 vs 6.9 hours, p < 0.001). Further examination of this database (n = 831 patients) found no influence of age and sex of patient on delay times. Distance from hospital was not associated with delay while previous experience of MI was marginally associated with decreased delay (previous MI: 7.1 vs no previous MI: 8 hours, p = 0.06). These relatively lengthy Irish delays require further investigation to inform management strategies aimed at reducing delay.

Quality of life research with the elderly has usually focused on the impact of decline in function, and used a pre-determined model of quality of life in old age. The Schedule for the Evaluation of Individual Quality of Life (SEIQoL) allows individuals to nominate, weigh and assess those domains of greatest relevance to their quality of life. The SEIQoL was administered to 56 healthy elderly community residents at baseline and 12 months later. Quality of life levels were significantly higher at baseline (t = -2.04; p = 0.04) than that of a previously studied sample of healthy adults below 65 years of age, and did not change significantly over the study period. The domains nominated by both samples as relevant to their quality of life differed notably. Health status was not correlated with the perceived importance of health at baseline, and showed only a low correlation (r = 0.27) at 12 months. The weight placed on health did not increase over the study period despite a significant decline in health status. The value of allowing the individual to define personal quality of life values in a research context is explored.

Return to work (RTW) and other treatment outcomes of coronary artery bypass graft (CABG) and percutaneous transluminal coronary angioplasty (PTCA) patients were compared. Consecutive patients at one centre (n = 112 CABG and 119 PTCA patients) were interviewed 6-18 months following treatment (groups were similar in sex and social class). Pre-treatment employment levels were similar (41 and 38% for CABG and PTCA groups, respectively). PTCA patients were more likely to smoke, have angina, have less advanced cardiovascular disease and have been advised to stop working for medical reasons pre-treatment. Post-treatment levels of employment increased significantly. RTW rates were similar for CABG and PTCA groups (59 and 68% respectively). Both groups had reduced smoking to similar levels. The PTCA group continued to have higher levels of angina. For those without angina, PTCA patients were significantly more likely to return to work (73 vs 55%, P < 0.01). Both CABG and PTCA resulted in increased employment post-treatment.

The importance of communication skills training in undergraduate medical education is now widely accepted. However little is known about student attitudes towards their own communication skills and whether their attitudes changes as a result of participating in communication skills courses. The aim of the present study was to identify these attitudes prior to commencing such a course and to further evaluate changes in these attitudes on completion of the course. Results demonstrated an improvement in perceived confidence regarding a number of specific communication skills. The study provides further evidence of the value of such courses in undergraduate medical training.

Thirty-one patients with avascular necrosis of the hip were treated by 34 total hip arthroplasties (THAs). All patients were observed prospectively with a minimum two-year follow-up evaluation (average, 46 months; range, 24-84 months). Twenty had cemented arthroplasties using contemporary cementing techniques. This included insertion of a medullary plug, cleansing of the canal with a medullary brush, pulsatile lavage irrigation, and insertion of the cement with a cement gun. In 14 hips, a cementless prosthesis was used. Patients were rated using a modified Harris hip score. Sequential postoperative roentgenograms were analyzed in each patient. The overall Harris hip score ratings were 88 in the cemented and 84 in the noncemented groups. Mechanical failure with loosening of the femoral component occurred in one patient who developed deep sepsis. Significant thigh pain occurred in four patients in the noncemented group. Previous studies in the literature have generally reported unfavorable results in patients with avascular necrosis of the hip treated with THA. Using cementless and cemented fixation with contemporary cementing techniques, improved results can be expected. A high incidence of thigh pain (29%) in the cementless group remains a problem.

Quality of life (QoL) assessment is becoming increasingly important for measuring the impact of illnesses, diseases, and their treatment and for deciding priorities when allocating resources. We developed a novel method to measure QoL from the perspective of the individual patient. The schedule for the evaluation of individual quality of life (SEIQoL) was devised from the technique known as judgment analysis to measure patients' level of functioning in five self-nominated facets of life and the relative weight or importance attached to these areas. We applied this method, together with traditional measures of health status, in a prospective intervention study of 20 patients undergoing unilateral total hip-replacement surgery with six-month follow-up by comparison with matched, non-patient controls. Health status was significantly improved by hip replacement on the McMaster health index questionnaire (p less than 0.001) and the arthritis impact measurement scales (p less than 0.001). Individually measured QoL was significantly increased after surgery when measured by SEIQoL (p less than 0.02). The individual nature of QoL was reflected in the variety of life areas nominated as important by individual patients, the differences in relative weights attached to these areas, and the complex nature of the changes that occurred postoperatively. Our data not only highlight such individuality but also show that SEIQoL provides a means by which this can be assessed scientifically.

The level of bone resection for osteosarcoma depends on the pre-operative evaluation of the extent of intramedullary tumour. We compared the accuracy of magnetic resonance imaging (MRI), computerised tomography (CT), and isotope bone scanning with the actual extent of the tumour in the resected specimens from 34 patients with primary osteosarcoma of a long bone. The extent of medullary tumour was defined accurately in 23 of 24 MRI scans (96%) and 24 of 32 CT scans (75%). A flexion contracture of a joint close to the tumour was an important cause for inaccurate measurements from both MRI and CT scans. Isotope bone scanning was inaccurate: its role is now confined to detecting skeletal metastases and skip lesions.