Search

Objectives:The primary objective was to quantify the risk of perinatal mortality in non‐anomalous monochorionic monoamniotic (MCMA) twin pregnancies complicated by birth‐weight (BW) discordance. The secondary objectives were to investigate the effect of inpatientvsoutpatient fetal monitoring on the risk of mortality in weight‐discordant MCMA twin pregnancies, and to explore the predictive accuracy of BW discordance for perinatal mortality. Methods:This analysis included data on 242 MCMA twin pregnancies (484 fetuses) from three major research collaboratives on twin pregnancy (MONOMONO, STORK and NorSTAMP). The primary outcomes were the risks of intrauterine (IUD), neonatal (NND) and perinatal (PND) death, according to weight discordance at birth from ≥ 10% to ≥ 30%. The secondary outcomes were the association of inpatientvsoutpatient fetal monitoring with the risk of mortality in weight‐discordant pregnancies, and the accuracy of BW discordance in predicting mortality. Logistic regression and receiver‐operating‐characteristics‐curve analyses were used to analyze the data. Results:The risk of IUD was significantly increased in MCMA twin pregnancies with BW discordance ≥ 10% (odds ratio (OR), 2.2; 95% CI, 1.1–4.4;P= 0.022) and increased up to an OR of 4.4 (95% CI, 1.3–14.4;P= 0.001) in those with BW discordance ≥ 30%. This association remained significant on multivariate logistic regression analysis for BW‐discordance cut‐offs ≥ 20%. However, weight discordance had low predictive accuracy for mortality, with areas under the receiver‐operating‐characteristics curve of 0.60 (95% CI, 0.46–0.73), 0.52 (95% CI, 0.33–0.72) and 0.57 (95% CI, 0.45–0.68) for IUD, NND and PND, respectively. There was no difference in the risk of overall IUD, single IUD, double IUD, NND or PND between pregnancies managed as an inpatient compared with those managed as an outpatient, for any BW‐discordance cut‐off. Conclusions:MCMA twin pregnancies with BW discordance are at increased risk of fetal death, signaling a need for increased levels of monitoring. Despite this, the predictive accuracy for mortality is low; thus, detection of BW discordance alone should not trigger intervention, such as iatrogenic delivery. The current data do not demonstrate an advantage of inpatient over outpatient management in these cases. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Introduction Some individuals with Crohn’s Disease who take long term three monthly Vitamin B12 injections complain of lack of energy and tiredness prior to their next B12 injection. Some have persuaded their General Practitioners to give the B12 injection more frequently than 3 monthly. Methods We wanted to determine if this was a common experience,and also if seen in other causes of B12 deficiency besides Crohn’s Disease. 453 patients on long term B12 in the community were invited to complete a questionnaire, 148 agreed. Most of these patients were elderly with a history of pernicious anaemia. 445 patients completed the questionnaire online. Most of these patients had Crohn’s disease. 593 questionnaires were analysed. Results In the period prior to Vitamin B12 injection, the majority reported tiredness, lack of energy, poor concentration and mood. Selected control symptoms were only seen in 1/4, figure 1. Of those noticing fatigue, 65% noticed this in the week prior to B12 injection. The community recruited group and the online group showed a similar pattern of complaints, but the incidence was lower in the Community group. Following B12 injection there was an improvement in the majority, in energy, concentration, fatigue and mood. Multivariate analysis to identify factors differing between high and low symptom sufferer, showed only age and treatment interval which predicted greater symptom burden but this only explained a very small proportion of the variation seen (less than 9%) A small proportion reported worsening of symptoms following B12 injection; the most common symptom was feeling cold in 7%. Conclusions In summary, fatigue, lack of energy, poor mood, and difficulty in concentration are seen frequently as individuals approach the 3 monthly B12 injection both in Crohn’s Disease and pernicious anemia. These improve following injection

BackgroundSubclinical thyroid dysfunction — abnormal serum thyrotrophin (thyroid-stimulating hormone; TSH) concentrations with normal free thyroxine (FT4) is common in older people. It remains unclear whether individuals with subclinical serum status experience an increased symptom profile.AimTo compare the prevalence of those symptoms typically associated with overt thyroid dysfunction in older individuals with a subclinical and euthyroid serum profile.Design and settingCross-sectional study, nested within the Birmingham Elderly Thyroid Study (BETS); from 19 UK general practices.MethodAdults living in a community setting (aged ≥65 years), without overt thyroid dysfunction or associated treatment, self-reported the presence or absence of 18 symptoms (while serum result naïve). Serum concentrations of TSH and FT4 were measured to establish thyroid status.ResultsA total of 2870 individuals were screened: 2703 (94%) were categorised as euthyroid (normal), 29 (1%) subclinically hyperthyroid, and 138 (5%) subclinically hypothyroid. Symptoms were common in all groups. No significant differences in the prevalence of individual symptoms were observed between the euthyroid and subclinically hypothyroid groups nor in comparison with the subclinically hyperthyroid group. Multivariate logistic regression analysis failed to reveal an association between individual or multiple symptoms and subclinical status.ConclusionFindings suggest that subclinical thyroid dysfunction does not confer a symptom burden in older individuals and support adherence to guidelines in the non-treatment of subclinical thyroid dysfunction. GPs may use the findings to reassure older people presenting with symptoms that subclinical thyroid dysfunction is an unlikely explanation. The presence of persistently abnormal TSH concentrations may be linked to long-term risks of cardiovascular disease, especially atrial fibrillation, but whether this should prompt treatment and whether such treatment alters vascular outcomes is unknown.

Introduction:\ud To determine the benefits of healing therapy (spiritual healing) as an adjunct to conventional management in irritable bowel syndrome (IBS) and inflammatory bowel disease (IBD).\ud \ud Methods:\ud 200 outpatients with IBS or IBD were randomised to either conventional treatment (control) or conventional plus five sessions of healing therapy (intervention). After 12 weeks controls also had healing therapy. Outcomes used were, the Measure Yourself Medical Outcomes Profile (MYMOP). IBS-QOL, IBDQ, and symptom measures.\ud \ud Results:\ud There was a significant improvement in the MYMOP score at week 6 (p < 0.001) which was maintained to week 12 (p < 0.001) and 24 (p < 0.001). Improvements in MYMOP were significantly greater in the intervention group at both 6 (p < 0.001) and 12 weeks (p < 0.001) with effect sizes of 0.7 (95% CI: 0.4–1.1) and 0.8 (95% CI: 0.4–1.2). Condition-specific data for IBS showed that most QoL dimensions had a significant minimum 10-point score improvement at 6 and 12 weeks. The overall score improvement was 12.9 units at week 6 (p < 0.001), 12.4 units at week 12 (p < 0.001) and 13.8 units at week 24 (p < 0.001). In IBD there was also similar score improvement, but only up to week 12 were there associations of improved social and bowel functions (p < 0.001, respectively). Between group differences were identified for QoL scores in IBS at both week 6 (p < 0.001) and 12 (p < 0.001) but only for week 12 (p < 0.001) in the IBD group.\ud \ud Conclusions:\ud The addition of healing therapy to conventional treatment was associated with improvement in symptoms and QoL in IBS, and to a lesser extent in IBD.

BackgroundThyroid function tests (TFTs) are among the most requested tests internationally. However, testing practice is inconsistent, and potentially suboptimal and overly costly. The natural history of thyroid function remains poorly understood.AimTo establish the stability of thyroid function over time, and identify predictors of development of overt thyroid dysfunction.Design and settingLongitudinal follow-up in 19 general practices in the UK.MethodA total of 2936 participants from the Birmingham Elderly Thyroid Study (BETS 1) with a baseline TFT result indicating euthyroid or subclinical state were re-tested after approximately 5 years. Change in thyroid-stimulating hormone (TSH), free thyroxine (FT4), and thyroid status between baseline and follow-up was determined. Predictors of progression to overt dysfunction were modelled.ResultsParticipants contributed 12 919 person-years; 17 cases of overt thyroid dysfunction were identified, 13 having been classified at baseline as euthyroid and four as having subclinical thyroid dysfunction. Individuals with subclinical results at baseline were 10- and 16-fold more likely to develop overt hypothyroidism and hyperthyroidism, respectively, compared with euthyroid individuals. TSH and FT4 demonstrated significant stability over time, with 61% of participants having a repeat TSH concentration within 0.5 mIU/L of their original result. Predictors of overt hypothyroidism included new treatment with amiodarone (odds ratio [OR] 92.1), a new diagnosis of atrial fibrillation (OR 7.4), or renal disease (OR 4.8).ConclusionHigh stability of thyroid function demonstrated over the 5-year interval period should discourage repeat testing, especially when a euthyroid result is in the recent clinical record. Reduced repeat TFTs in older individuals is possible without conferring risk, and could result in significant cost savings.

Haploinsufficiency of the transcription factor short stature homeobox (SHOX) manifests as a spectrum of clinical phenotypes, ranging from disproportionate short stature and Madelung deformity to isolated short stature. Here, we describe five infants with molecularly confirmed diagnoses of SHOX haploinsufficiency who presented in utero with short long bones during routine antenatal scanning from as early as 19 weeks gestation. Other foetal growth parameters were normal. The molecular basis of SHOX haploinsufficiency was distinct in each case. In four cases, SHOX haploinsufficiency was inherited from a previously undiagnosed parent. In our de novo case, SHOX haploinsufficiency reflected the formation of a derivative sex chromosome during paternal meiosis. Final adult height in the SHOX-deficient parents ranged from -1.9 to -1.2 SDS. All affected parents had disproportionately short limbs and two affected mothers had bilateral Madelung deformity. To our knowledge, SHOX haploinsufficiency has not previously been reported to present in utero. Our experience illustrates that SHOX deficiency should form part of the differential diagnosis of foetal short long bones and suggests a low threshold for genetic testing. This should be particularly targeted at, but not limited to, families with a history of features suggestive of SHOX deficiency. Data on the postnatal growth of our index cases is presented which demonstrates that antenatal presentation of SHOX haploinsufficiency is not indicative of severe postnatal growth restriction. Early identification of SHOX deficiency will enable accurate genetic counselling reflecting a good postnatal outcome and facilitate optimal initiation of growth hormone therapy.

Introduction : Transmission in serodiscordant couples (SDCs) accounts for approximately half of all new HIV infections, both in Kenya and the wider sub-Saharan region [1]. With evidence to suggest inconsistent condom use within this population [2], the World Health Organization has recommended two new methods of HIV prevention for SDCs: Treatment as Prevention (TasP) and Pre-Exposure Prophylaxis (PrEP). However, there has been little research about the attitudes of SDCs towards these strategies [3,4]; knowledge that is paramount for successfully predicting the acceptability and efficacy of each method, as well as for informing decisions regarding HIV policy changes in Kenya. Methods : An exploratory, qualitative study was conducted in the Muhoroni constituency of Nyando district, Kenya from January to March 2013. Purposive sampling was predominately used to recruit 21 HIV-positive and 17 HIV-negative individuals in a serodiscordant relationship from four hospitals and health centres. During face-to-face semi-structured interviews, topic guides were used to elicit information about participants’ attitudes and preferences towards TasP and PrEP. Collected data underwent framework analysis, allowing the development of overarching categories, sub-themes and inductive interpretation. Results : The majority of participants, irrespective of gender and HIV status, found TasP more acceptable than PrEP. A key factor influencing this decision was HIV-negative participants’ limited motivation to take and adhere to antiretrovirals (ARVs), primarily due to a predominantly external health locus of control, a lack of cultural acceptance of prophylactic medication and concerns about side effects. In addition to this, the likely health improvements TasP offers HIV-positive partners, as well as the attitude that the sick individual should be the first to receive HIV medication, also contributed to this conclusion. Issues of risk compensation were raised, with some HIV-negative partners indicating a desire to stop using condoms if ARV-based prevention methods were available. Conclusions : Findings from the study indicate that TasP may represent a more viable approach to HIV prevention in Kenya than PrEP. Couples’ preferences, however, may differ depending on local attitudes towards prophylaxis and health locus of control. (Published: 2 November 2014) Citation : Abstracts of the HIV Drug Therapy Glasgow Congress 2014 Fowler N et al. Journal of the International AIDS Society 2014, 17(Suppl 3): 19563 http://www.jiasociety.org/index.php/jias/article/view/19563 | http://dx.doi.org/10.7448/IAS.17.4.19563

Objective Single intrauterine death (sIUD) in twin pregnancy is associated with a significant risk of cotwin demise and preterm birth (PTB), especially in monochorionic (MC) twins. However, it is yet to be established whether the gestational age at loss may influence the pregnancy outcome. The aim of this study was to explore the risk of PTB according to the gestational age at diagnosis of sIUD. Methods This was a cohort study of all twin pregnancies booked for antenatal care in a large regional network of nine hospitals over a 10-year period. Ultrasound data were matched to hospital delivery records and to a mandatory national register for stillbirth and neonatal loss provided by the Centre for Maternal and Child Enquires. Cases with double fetal loss at the time of the scan and cases of sIUD occurring at or after 34weeks of gestation were not included in the analysis. The relative risk (RR) of PTB at Results The analysis included 3013 twin gestations (2469 dichorionic (DC) and 544 MC). Median gestational age at birth was lower in the pregnancies complicated by sIUD compared with those thatwere not (32.0weeks: interquartile range (IQR), 29.0–34.3weeks vs 36.7weeks: IQR, 35.0–37.6; P Conclusions Twin pregnancies complicated by sIUD, regardless of the chorionicity, have a significantly higher risk of PTB at

Objective To generate reference charts for expected fetal growth in dichorionic diamniotic (DCDA) and monochorionic diamniotic (MCDA) twin pregnancies and to compare these with those from singleton pregnancies. Methods This was a retrospective study of biometric measurements from serial ultrasound examinations of twin pregnancies in the second and third trimesters, from 14 weeks' gestation to term, collected by nine hospitals over a 10-year period. The measurements obtained in each fetus at each examination included head circumference (HC), biparietal diameter (BPD), abdominal circumference (AC) and femur length (FL). Multilevel mixed effects statistical models were used to evaluate growth in each biometric variable in relation to gestational age, taking account of the serial examinations and the association between the two fetuses in each pregnancy, with separate models constructed for DCDA and MCDA pregnancies. Results The final dataset for analysis included a total of 9866 second- and third-trimester ultrasound examinations in 1802 DCDA and 323 MCDA twin pregnancies, with a median of five (range, 1–14) scans per pregnancy. For each variable, the mean value for DCDA twins was close to the reported value in singletons at 20–30 weeks and showed a decrease relative to singletons beyond 30 weeks. The differences were greater for AC and HC, for which the mean in twins was approximately equivalent to the 30th percentile in singletons at 18 weeks, the 35th percentile at 25 weeks and the 30th percentile at 35 weeks. Fetuses in MCDA twin pregnancies displayed lower mean measurements than did those in DCDA pregnancies throughout the gestational age range considered. Conclusions Ultrasound biometry shows a small but statistically significant reduction in fetal growth in twin pregnancies relative to that in singletons, particularly in the third trimester, with a more marked difference for MCDA than for DCDA pregnancies. Copyright © 2014 ISUOG. Published by John Wiley & Sons Ltd.

In Kenya, one of the most significant public health concerns is the spread of HIV. Additionally, 13,000 girls drop out of school every year due to pregnancy. Although the Kenyan Ministry of Education and other independent organisations have tried to implement various means of developing puberty and sexual health education for young people, the situation is not improving. Aims: To explore the opinions of teachers and parents in rural Kenya about delivering puberty and sex education and to identify their perceptions of barriers to young people accessing this education. Study Design: Qualitative study. Place and Duration of Study: Rural Nyanza Province, Western Kenya between January and March 2013. Methodology: semi-structured interviews with 19 teachers and 30 parents following a topic guide to explore their opinions about what young people need to learn about sex education and perceived barriers to accessing that education. The interviews were Original Research Article British Journal of Medicine & Medical Research, 4(4): 1014-1033, 2014 1015 transcribed and subjected to Framework analysis. Results: Analysis revealed a lack of continuity in teacher training for sex education and discrepancies in what is being taught in schools. It also highlighted internal contradictions in teachers’ and parents’ views about some aspects of sex education, particularly the emphasis on abstinence and negative attitudes towards contraception. Conclusion: Strategies for improvement may include a full evaluation of the formal sex education curriculum and retraining where necessary to ensure consistency in the sexual health messages that are delivered to young people. Additionally, parents and wider rural communities may need to be better supported in their ways of discussing puberty and sexual health with their children.

Evidence is emerging that rates of adverse events in patients taking warfarin may vary with ethnicity. This study investigated the rates of bleeds and thromboembolic events, the international normalised ratio (INR) status and the relationship between INR and bleeding events in Malaysia. Patients attending INR clinic at the Heart Centre, Sarawak General Hospital were enrolled on an ad hoc basis from May 2010 and followed up for 1 year. At each routine visit, INR was recorded and screening for bleeding or thromboembolism occurred. Variables relating to INR control were used as predictors of bleeds in logistic regression models. 125 patients contributed to 140 person-years of follow-up. The rates of major bleed, thromboembolic event and minor bleed per 100 person-years of follow-up were 1.4, 0.75 and 34.3. The median time at target range calculated using the Rosendaal method was 61.6 % (IQR 44.6–74.1 %). Of the out-of-range readings, 30.0 % were below range and 15.4 % were above. INR variability, (standard deviation of individuals’ mean INR), was the best predictor of bleeding events, with an odds ratio of 3.21 (95 % CI 1.10–9.38). Low rates of both major bleeds and thromboembolic events were recorded, in addition to a substantial number of INR readings under the recommended target range. This may suggest that the recommended INR ranges may not represent the optimal warfarin intensity for this population and that a lower intensity of therapy, as observed in this cohort, could be beneficial in preventing adverse events.

Background: Sunbed use in childhood increases risk of melanoma. The under-18s sunbed ban was introduced in England, April 2011. Impact on use has not been investigated since. This cross-sectional study estimates the prevalence of under-18s’ use in Sandwell after the commercial ban and identifies factors associated with use/intention. Methods: Adolescents aged 15 to 17 years in schools were surveyed using self-completed anonymous questionnaires. Data collected include demographics, sunbed use, tanning attitudes, knowledge of risks and ban awareness. All Sandwell schools were approached; adolescents available on the survey days were included. Results: Five out of 22 schools participated, 407 adolescents responded (95.1%). Twenty participants (5.3%; 95% confidence interval [CI] = 3.4-8.0) had used sunbeds, of who 16 reported use in commercial settings. After exclusion of one school cohort with atypical use (possibly associated with beauty vocational course and European migrants), the prevalence of use was 1.7% (95% CI = 0.7-3.9, n = 5). Less than half of all were aware of the ban (48.2%; 95% CI = 43.2-53.3). Users/potential users were less aware of associated risks. Being female, having family/friends who use sunbeds increased use/intention 2- to 4-fold. Conclusion: Strategies targeting parents, stricter enforcement, and greater publicity of the ban are needed. Further research exploring the possible association between certain vocational courses, migrants, and sunbed use is required.

Context: Population-based screening has been advocated for subclinical thyroid dysfunction in the elderly because the disorder is perceived to be common, and health benefits may be accrued by detection and treatment. Objective: The objective of the study was to determine the prevalence of subclinical thyroid dysfunction and unidentified overt thyroid dysfunction in an elderly population. Design, Setting, and Participants: A cross-sectional survey of a community sample of participants aged 65 yr and older registered with 20 family practices in the United Kingdom. Exclusions: Exclusions included current therapy for thyroid disease, thyroid surgery, or treatment within 12 months. Outcome Measure: Tests of thyroid function (TSH concentration and free T 4 concentration in all, with measurement of free T3 in those with low TSH) were conducted. Explanatory Variables: These included all current medical diagnoses and drug therapies, age, gender, and socioeconomic deprivation (Index of Multiple Deprivation, 2004) Analysis: Standardized prevalence rates were analyzed. Logistic regression modeling was used to determine factors associated with the presence of subclinical thyroid dysfunction Results: A total of 5960 attended for screening. Using biochemical definitions, 94.2% [95% confidence interval (CI) 93.8-94.6%] were euthyroid. Unidentified overt hyper- and hypothyroidism were uncommon (0.3, 0.4%, respectively). Subclinical hyperthyroidism and hypothyroidism were identified with similar frequency (2.1%, 95% CI 1.8-2.3%; 2.9%, 95% CI 2.6-3.1%, respectively). Subclinical thyroid dysfunction was more common in females (P < 0.001) and with increasing age (P < 0.001). After allowing for comorbidities, concurrent drug therapies, age, and gender, an association between subclinical hyperthyroidism and a composite measure of socioeconomic deprivation remained. Conclusions: Undiagnosed overt thyroid dysfunction is uncommon. The prevalence of subclinical thyroid dysfunction is 5%. We have, for the first time, identified an independent association between the prevalence of subclinical thyroid dysfunction and deprivation that cannot be explained solely by the greater burden of chronic disease and/or consequent drug therapies in the deprived population. Copyright © 2006 by The Endocrine Society.

Objectives To examine the effectiveness and cost-effectiveness of two interventions based in primary care aimed at increasing uptake of breast screening. Setting 24 General practices with low uptake in the second round of screening (below 60%) in north west London and the West Midlands, UK. Participants were all women registered with these practices and eligible for screening in the third round. Methods Pragmatic factorial cluster randomised controlled trial, with practices randomised to a systematic intervention (general practitioner letter), an opportunistic intervention (flag in women's notes prompting discussion by health professionals), neither intervention, or both. Outcome measures were attendance for screening 6 months after the practices had been screened and cost-effectiveness of the interventions. Results 6133 Women were included: 1721 control; 1818 letter; 1232 flag; 1362 both interventions. Attendance data were obtained for 5732 (93%) women. The two interventions independently increased breast screening uptake in a logistic regression model adjusted for clustering, with the flag (odds ratio (OR) 1.43, 95% confidence interval (95% CI) 1.14 to 1.79; p=0.0019) marginally more effective than the letter (OR 1.31, 95% CI 1.05 to 1.64; p=0.015). Health service costs per additional attendance were £26 (letter) and £41 (flag). Conclusions Although both interventions increased attendance for breast screening, the letter was the more cost-effective. Any decision to implement both interventions rather than just the letter will depend on whether the additional (£41) costs are judged worthwhile in terms of the gains in breast screening uptake.

Background As the number of female GPs increases, the need to understand delivery of maternity care to this group becomes increasingly important. Previous literature suggests doctors face additional barriers in utilizing health care compared to other patients, but little is known about GPs' maternal health care experiences and whether their occupation facilitates or compromises care. Objective To explore female GPs' personal experiences of maternal health care and how occupation affects care received. Methods Female GPs with children aged 6 months to 5 years were recruited from South Birmingham Primary Care Trust with subsequent snowballing. Data were obtained using semi-structured interviews and constant comparison analysis was applied to develop themes and categories. Results Fourteen GPs participated and no new themes emerged after interview 10 suggesting data saturation was achieved. Overall, GPs felt they received better care due to their occupation and where established relationships between the GP and the health care professional existed, communication and care satisfaction was enhanced. However, assumptions about knowledge led to reduced information provision and some problems in care provision, especially during labour and early motherhood when women were most vulnerable and unable to rely on work skills to address information deficits. Conclusion This research supports the growing body of evidence that there are unique problems facing doctor-patients and clinicians treating them. However, contrary to expectations derived from anecdotal evidence, GPs indicated that care was enhanced due to their occupation. This study raises awareness of areas for consideration when female GPs approach pregnancy and health care professionals deliver maternal health care.

CONTEXT Previous research has shown that general practitioners (GPs) hold negative attitudes towards patients with schizophrenia, which do not simply reflect the nature or chronic aspects of the illness. This study aimed to describe the attitudes and predicted behaviour of medical students towards patients with mental illness in a primary care setting and to investigate whether these were affected by the students' level of training. METHODS A sample of 1239 students from the University of Birmingham Medical School were each given one of four case vignettes, all of which were identical except that the patient involved was described as having a previous diagnosis of, respectively, schizophrenia, depression, diabetes or no illness. Students rated their level of agreement with 12 attitudinal statements relating to the vignette. RESULTS A total of 1081 (88%) students responded to the questionnaire. Students were generally less favourable in their responses to patients with either schizophrenia or depression. They would not be as happy to have them on their list, believed they would consume more time and considered they would be less likely to comply with advice and treatment. They expressed more concern about the risk of violence, the potential welfare of children and the possibility of illegal drug and excessive alcohol use. General clinical and psychiatric training had little effect on these reactions. CONCLUSIONS Patients with mental illness provoke less favourable responses in medical students, which are not altered by furthering education. Undergraduate primary care-based mental health education should be re-evaluated to ensure that students develop an empathetic and positive approach to mental health patients and their treatment.

Chronic kidney disease (CKD) is one of the major complication from non-communicable diseases (NCD), such as diabetes or hypertension. We aimed to determine if routine measurement of neutrophil gelatinase-associated lipocalin (NGAL) in NCD patients could provide additional benefit for diagnosing kidney disease.Fasting serum NGAL, urea, creatinine, uric acid and albumin were measured in 298 NCD patients. Estimated glomerular filtration rate (e-GFR) was calculated using the CKD-EPI equation. Multiple linear regression modeling was used for analysis.CKD patients have the highest levels of NGAL than the other NCD patients (p 0.001). Although NGAL was significantly related to e-GFR, creatinine, urea and albumin in CKD-patients (p 0.001) and not in the other NCD patients (p 0.05), only serum creatinine predicted NGAL levels in CKD-patients (p 0.001).NGAL level is best associated with serum creatinine only in patients with CKD and NGAL measurement may not be cost effective as a routine kidney function test in NCD patients in under-resourced economies.

Identifying patients at risk and ensuring they are on appropriate therapy is the mainstay of preventive medicine and an integral role of the GP. The process of audit can highlight areas of suboptimal management, and in recent years electronic audit packages have become increasingly popular. PRIMIS (Primary Care Information Services), a group from the University of Nottingham, currently have 21 different audit tools available, ranging from asthma care to flu jab uptake, to oral contraception.1 This is the organisation that created the GRASP-AF audit tool in collaboration with the West Yorkshire Cardiovascular Network. This software interrogates primary care databases with a predefined set of search criteria and therefore relies on the accuracy of data recording and coding performed at the practice. We investigated the management of atrial fibrillation (AF) in January 2014 with anticoagulation for effective stroke prevention in four general practices in the West Midlands. AF, being the most common sustained cardiac arrhythmia, should be one of the areas in which patient management is at …

Irritable bowel syndrome (IBS) is the most common functional gastrointestinal disorder; however, it remains poorly understood. Inflammatory bowel disease (IBD) is a chronic, organic bowel disease characterized by young age of onset, debilitating symptoms, and invasive and toxic treatment options. This study aimed to determine the impact of IBS and IBD on health-related quality of life (HRQoL) and the ways by which these conditions affect HRQoL, with the purpose of informing nurse specialists in gastroenterology who are best placed to support HRQoL improvements. Quality of life, symptom, and demographic data were collected from patients with IBS and IBD and tabulated and examined. Analysis of data demonstrated that HRQoL is significantly lower in IBS than in IBD. However, the ways by which these two conditions affect HRQoL differs, with greater impairments in social and emotional aspects of life in individuals with IBS. Bowel symptoms were the same or worse in IBD.

Summary Aim To systematically review the literature evaluating hypnotherapy in the management of irritable bowel syndrome (IBS). Methods Electronic databases were searched (Cochrane Library, Medline, CINAHL, AMED, Embase, PsycINFO, CISCOM, TRIP and the Social Science Citation index), bibliographic references scanned and main authors contacted. No restrictions were placed on language or publication year. Eligible studies involved adults with IBS using single-component hypnotherapy. All studies, except single case or expert opinion, were sought and all patient-related outcomes eligible. Results Out of 299 unique references identified, 20 studies (18 trials of which four were randomized, two controlled and 12 uncontrolled) and two case series were eligible. These tended to demonstrate hypnotherapy as being effective in the management of IBS. Numbers of patients included were small. Only one trial scored more than four out of eight on internal validity. Conclusion The published evidence suggests that hypnotherapy is effective in the management of IBS. Over half of the trials (10 of 18) indicated a significant benefit. A randomized placebo-controlled trial of high internal validity is necessary to establish the effectiveness of hypnotherapy in the management of IBS. Until such a trial is undertaken, this form of treatment should be restricted to specialist centres caring for the more severe forms of the disorder.

The frequency distribution of serum thyroid stimulating hormone (TSH) shows a skewed pattern that may change with age. The set point of the hypothalamic-pituitary-thyroid axis for an individual is thought to be genetically determined and has been described as a log-linear relationship of serum TSH to free thyroxine (T4); however, the validity of this hypothesis has yet to be established in older people. The aim of the study was to describe the relationship between serum TSH and free T4 in older people and define factors influencing this relationship. We conducted a cross-sectional, observational study of thyroid function in a community population of older subjects over 65 years of age. The relationship between serum TSH and free T4 was not linear as previously described, but is best described as a fourth-order polynomial. Both gender and smoking status affected the relationship. This suggests that more complex modelling is required when investigating the hypothalamic-pituitary-thyroid axis.

The frequency distribution of serum thyroid stimulating hormone (TSH) shows a skewed pattern that may change with age. The set point of the hypothalamic-pituitary-thyroid axis for an individual is thought to be genetically determined and has been described as a log-linear relationship of serum TSH to free thyroxine (T4); however, the validity of this hypothesis has yet to be established in older people. The aim of the study was to describe the relationship between serum TSH and free T4 in older people and define factors influencing this relationship. We conducted a cross-sectional, observational study of thyroid function in a community population of older subjects over 65 years of age. The relationship between serum TSH and free T4 was not linear as previously described, but is best described as a fourth-order polynomial. Both gender and smoking status affected the relationship. This suggests that more complex modelling is required when investigating the hypothalamic-pituitary- thyroid axis.

Background The use and value of different complementary therapies requires investigation. In particular, qualitative research is required to understand the perceptions and experiences of patients who undergo healing therapy as one type of complementary therapy. The aim of this research is to consider patients perceptions and experiences following a course of healing therapy. Methods Twenty two patients took part in this study. This included 13 patients with irritable bowel disease (3 male, 10 female, 47.6 ± 15.0 years), 6 patients with ulcerative colitis (3 male, 3 female, 48.5 ± 25.6 years) and 3 female patients with Crohn’s Disease (45.0 ± 5.2 years). Each patient undertook a single semi-structured interview following a course of healing therapy. The data was analysed using a thematic analysis. Results Three broad themes were identified from patient interviews (1) The understanding and expectation of healing (2) Experiences and reflection on healing (3) Impact and outcome of healing. The details of each theme are explored within the text, often revealing a unique experience of healing therapy. Conclusion Patients were open towards the benefits that could be attained by healing, although most patients were not sure what healing would entail. Some patients expected to be relaxed by the sessions. However, the most consistent reports were that patients experienced a relaxing sensation that was generated within the session and lasted for a time period after the sessions. In addition to this the healing appeared to be associated with patients feeling more tolerant of their symptoms. Patients valued the therapist and their input into the healing process. It should be noted however, that this report cannot consider the efficacy of the treatment. Further details and experiences are considered within the article, including one negative experience. Electronic supplementary material The online version of this article (doi:10.1186/s12906-015-0611-x) contains supplementary material, which is available to authorized users.

Background. Given the high prevalence of chronic conditions and multimorbidity in the elderly, there is a need to determine which chronic conditions have the greatest impact on health-related quality of life (HRQL) and identify where additional intervention may be required. Objective. To explore the impact of a range of common chronic conditions on HRQL in a community-based population aged 65 years or more in the UK. Methods. Secondary analysis of data derived from a large (n = 5849) cross-sectional study. HRQL was assessed using the EuroQoL EQ-5D. Multivariable models were used to estimate the relative effect of 15 individual common chronic conditions and combinations of these conditions on HRQL. Results. Mean age of participants was 74.6 years, 49.2% were male. The mean EQ-5D index score was 0.78 (standard deviation 0.2), range −0.43 to 1.00. Overall, 53% (n = 3078) of the cohort reported problems with pain, 39% (n = 2273) with mobility and 9% (n = 529) with self-care. Multivariate modelling demonstrated that impaired HRQL was significantly associated with 13 of the 15 common chronic conditions studied. Clinically meaningful reductions in EQ-5D index scores were observed for osteoarthritis (−0.081, P = 0.0006), neurological disease (−0.172, P < 0.0001) and depression (−0.269, P < 0.001). Conclusions. This study quantifies the relative impact of 13 common chronic conditions on HRQL in a UK-based community-dwelling ageing population. Findings indicate that osteoarthritis, depression and neurological disease have a strong clinically important negative effect on HRQL. These findings may help clinical decision making and priority setting for management of individuals with multimorbidity.

Background Irritable Bowel Syndrome (IBS) is a common condition characterised by pain, distension and altered bowel habit. Evidence suggests functional foods containing probiotics improve gastrointestinal transit, however, data are limited by short follow-up periods and evaluation in selected populations. Methods A multi-centre, randomized, double blind, controlled trial to evaluate the effect of a probiotic vs non-probiotic dairy product on symptoms in IBS with a constipation element (IBS – Constipation or IBS – Mixed profile). Set in 13 general practices within central England. Individuals meeting the ROME III criteria for IBS, aged 18–65 completed a pre-study diary. Eligible individuals were randomized to consume dairy ‘yoghurt’ products which either did or did not contain active probiotics twice daily and to complete a daily diary. Primary outcome was subjective global assessment of symptom relief at week 4. Other outcomes comprised, IBS symptom scores, pain, bloating and flatulence levels, stool frequency, stool consistency, ease of bowel movement and quality of life. Results 179 were randomized (91 active, 88 placebo). 76 (43 active, 33 placebo) completed the study. No significant between group differences existed at 4 weeks (57% active vs 53% placebo, reported adequate relief (p = 0.71)). By week 8, 46% active vs 68% placebo reported adequate relief (p = 0.03). This was sustained at week 12. Conclusions Significant improvements were reported for most outcomes in all trial participants but improvement did not differ by group. This trial does not provide evidence for effectiveness of a probiotic in IBS, in variance with a body of published literature and review conclusions. Differential drop out may however cloud interpretation of data. UK Trial registration ISRCTN78863629

Introduction To determine benefits of healing therapy as an adjunct to conventional management in irritable bowel syndrome (IBS) and inflammatory bowel disease (IBD). Methods : 200 outpatients with IBS or IBD were randomised to either conventional treatment or conventional plus 5 sessions of healing therapy. After 12 weeks Controls also had healing therapy. Outcomes used were, the Measure Yourself Medical Outcomes Profile (MYMOP). IBS-QOL and IBDQ and symptom measures. Results There was a significant improvement in the MYMOP score at week 6 (p Conclusion The addition of healing therapy in IBS was associated with improvements in symptoms and QoL in IBS, and to a lesser extent in IBD. Disclosure of Interest None Declared

BACKGROUND: Subclinical hypothyroidism (SCHo) is a common biochemical diagnosis in older age. Evidence of impact is inconclusive and guidelines are inconsistent. With increasing numbers of thyroid function tests (TFTs) performed, GPs frequently have to make management decisions regarding this diagnosis. However, little is known about how SCHo is currently being managed in primary care. AIM: To explore management of SCHo in primary care and GP reported rationale for treatment of SCHo in older individuals. DESIGN: Descriptive study using retrospective case note review and GP survey. SETTING: Nineteen General Practices, Central England, UK. METHODS: Follow-up of a large cohort with subsequent detailed review of individuals for whom therapy had been initiated following diagnosis of SCHo. Data on practice policies, and rationale behind treatment were collected via GP questionnaire. RESULTS: Forty-two individuals were treated following identification of SCHo. Factors regarded as supporting instigation of therapy recorded by practitioners included symptoms, a positive antithyroid antibody test and history of radioiodine therapy. In all, 55% were registered at 3/19 practices suggesting significant between practice variation. Reasons for testing included chronic disease check-up (n = 14), presenting 'thyroid symptoms' (n = 5) and presenting other symptoms (n = 9). Reasons for therapy initiation were only recorded in 26 cases and included presence of symptoms, persistently high or increasing serum thyroid stimulating hormone concentration and patient request. Only 2/15 GPs reported having practice guidelines on management. CONCLUSION: Results suggest that GPs are uncertain how to interpret symptoms and TFT results in older individuals. There is considerable variation in management of SCHo between GPs with some GPs treating patients outside of all guideline recommendations.

AimTo explore how irritable bowel syndrome (IBS) impacts on patients’ lives in order to explain the reported reduction in quality of life (QOL).BackgroundIBS affects 10–20% of the population and over half of the people with the condition consult in primary care, with many consultations ending unsatisfactorily. IBS is known to have a detrimental effect on the QOL, though the mechanisms through which this is affected are poorly understood. A greater understanding of the patient experience of IBS would facilitate better healthcare provision.MethodsEighteen semi-structured, in-depth interviews were undertaken in the West Midlands, United Kingdom from August 2006 to March 2008. Interviews were carried out until data saturation was achieved. All interviewees had previously taken part in one of the two recent primary care-based IBS studies and were long-term sufferers of IBS. Participants were purposively sampled to capture a range of experiences and included both genders, a range of ages, symptom severity scores and IBS sub-types.FindingsIn contrast to the previously reported ‘worried well’ label, participants reported integration of the disease into their lives to the extent that it became a part of their identity. Even so, IBS did at times prevent their participation in everyday activities. Strategies used by participants to manage symptoms were an integral part of daily living and events which threatened routine coping strategies caused stress and exacerbated symptoms. Both adaptive and maladaptive coping strategies were identified. These were in part patient created, but for many incorporated advice or medication provided by their doctor. The findings not only confirm the extensive impact of IBS on daily living but also expose the additional impacts of IBS on emotional well-being and self-identity. The reduced QOL reported in previous studies may be an underestimate of the impact of IBS on patients’ lives as patients integrate coping mechanisms completely into daily living.

BACKGROUND:: World Health Organization (WHO) immunological and clinical criteria for monitoring first-line antiretroviral treatment (ART) offer low accuracy for predicting viral failure. Targeting viral load assays to those at high risk has been recommended and a system to do this has been developed in Cambodia. Systems for use in Sub-Saharan African populations were evaluated. METHODS:: A new Ugandan based scoring system for targeting viral load assays was developed from data from the first 4 years of a Ugandan cohort (N = 559) receiving first-line ART. The accuracy of this, the Cambodian system and the WHO criteria to predict viral failure, through targeting viral load assays, were compared in a separate population of 496 Ugandans. RESULTS:: The new Ugandan scoring system included CD4 count, mean cell volume, adherence, and HIV associated clinical events as predictors of viral failure. In the validation population, the Ugandan system undertook viral load assays in 61 (12.3%) cases offering 20.5% sensitivity and 100% positive predictive value (PPV) to predict viral failure. The Cambodian system undertook viral load assays in 33 (6.7%) cases producing 23.1% sensitivity and 90.0% PPV. WHO criteria recommended viral load assays in 72 (14.5%) cases offering 30.8% sensitivity and 100% PPV. CONCLUSIONS:: Locally developed algorithms based on clinical and immunological criteria may offer little additional accuracy over WHO criteria for targeting viral load assays. Where possible, confirming viral load before switching therapy is recommended. Scoring systems are more flexible than WHO criteria in allowing ART providers to choose the proportion of the population that undergo targeted viral load testing.

CONTEXT: Subclinical hypothyroidism (SCH) and cognitive dysfunction are both common in the elderly and have been linked. It is important to determine whether T4 replacement therapy in SCH confers cognitive benefit. OBJECTIVE: Our objective was to determine whether administration of T4 replacement to achieve biochemical euthyroidism in subjects with SCH improves cognitive function. DESIGN AND SETTING: We conducted a double-blind placebo-controlled randomized controlled trial in the context of United Kingdom primary care. PATIENTS: Ninety-four subjects aged 65 yr and over (57 females, 37 males) with SCH were recruited from a population of 147 identified by screening. INTERVENTION: T4 or placebo was given at an initial dosage of one tablet of either placebo or 25 microg T4 per day for 12 months. Thyroid function tests were performed at 8-weekly intervals with dosage adjusted in one-tablet increments to achieve TSH within the reference range for subjects in treatment arm. Fifty-two subjects received T4 (31 females, 21 males; mean age 73.5 yr, range 65-94 yr); 42 subjects received placebo (26 females, 16 males; mean age 74.2 yr, 66-84 yr). MAIN OUTCOME MEASURES: Mini-Mental State Examination, Middlesex Elderly Assessment of Mental State (covering orientation, learning, memory, numeracy, perception, attention, and language skills), and Trail-Making A and B were administered. RESULTS: Eighty-two percent and 84% in the T4 group achieved euthyroidism at 6- and 12-month intervals, respectively. Cognitive function scores at baseline and 6 and 12 months were as follows: Mini-Mental State Examination T4 group, 28.26, 28.9, and 28.28, and placebo group, 28.17, 27.82, and 28.25 [not significant (NS)]; Middlesex Elderly Assessment of Mental State T4 group, 11.72, 11.67, and 11.78, and placebo group, 11.21, 11.47, and 11.44 (NS); Trail-Making A T4 group, 45.72, 47.65, and 44.52, and placebo group, 50.29, 49.00, and 46.97 (NS); and Trail-Making B T4 group, 110.57, 106.61, and 96.67, and placebo group, 131.46, 119.13, and 108.38 (NS). Linear mixed-model analysis demonstrated no significant changes in any of the measures of cognitive function over time and no between-group difference in cognitive scores at 6 and 12 months. CONCLUSIONS: This RCT provides no evidence for treating elderly subjects with SCH with T4 replacement therapy to improve cognitive function.

B Shivananda Nayak1, Vishi Y Beharry1, Shivani Armoogam1, Melinda Nancoo1, Kevin Ramadhin1, Kiron Ramesar1, Ciara Ramnarine1, Anandi Singh1, Anisha Singh1, Kingsley Uche Nwachi1, Surujpaul Teelucksing2, Ramesh Mathura3, Lesley Roberts41Department of Preclinical Sciences, Biochemistry Unit, 2Department of Clinical Science, The University of the West Indies, EWMSC, Trinidad and Tobago; 3Department of Diagnostic Laboratory Services, NCRHA, EWMSC, Trinidad and Tobago; 4Department of Medicine, Nephrology Unit, NCRHA, EWMSC, Trinidad and TobagoAim: The rheological properties of erythrocytes are impaired in diabetes mellitus, especially because of changes in their membrane lipid composition.The aim of this study was to determine and examine the relationship between red blood cell (RBC) membrane and serum lipid composition in type II diabetes subjects with and without nephropathy.Methods: Trinidadian subjects aged 18–65 years were recruited for the study regardless of gender and ethnicity. Fasting blood samples were collected from 60 subjects of whom 20 were healthy individuals, 20 had type II diabetes without complications, and 20 were type II diabetics with nephropathy. Weight, height, waist/hip ratio, and blood pressure were recorded. All the blood samples were analysed to determine the serum lipid concentration, membrane lipid composition and plasma glucose concentration.Results: The body mass index and the systolic blood pressure of the diabetics (28.17 ± 4.98 kg/m2, 153.21 ± 22.10 mmHg) and those with nephropathy (25.87 ± 4.68, 158.60 ± 22.49 mmHg) were higher when compared with controls (24.67 ± 5.18, 119.15 ± 13.03 mmHg). The diabetic (175.89 ± 102.73 μg/mgprotein) and diabetic nephropathy (358.80 ± 262.66) subjects showed significantly higher levels of RBC membrane cholesterol compared with controls (132.27 ± 66.47). The membrane phospholipids, protein and Na+/K+ATPase concentrations were altered in diabetics and diabetic nephropathy patients when compared with controls. The trends of increased serum cholesterol and decreased high-density lipoprotein in diabetics and diabetic nephropathy patients were noted as compared with controls but they are not significant as expected. The low-density lipoprotein cholesterol was significantly higher in diabetics when compared with diabetic nephropathy and control subjects.Conclusions: Our data suggest that there is a relationship between RBC membrane and serum lipid composition in subjects with type II diabetes with and without nephropathy. This relationship shows that diet and lifestyle plays a significant role in the alterations of the lipids both in serum and RBC membrane. The membrane and serum lipid composition may be used as possible indicators for type II diabetic patients with and without nephropathy to control their diet in the beginning stages to prevent them from further complications.Keywords: RBC membrane, phospholipids, protein, diabetes, diabetic nephropathy

Background Irritable Bowel Syndrome (IBS) is a chronic/common condition that causes a significant effect on the individual (reduced quality of life), society (time lost off work) and health services. Comparison of studies evaluating the management of IBS has been hindered by the lack of a widely adopted validated symptom score. The aim of this study was to develop and validate a disease specific score to measure the symptoms of patients with IBS. Methods A self-administered 14-item symptom questionnaire (based on Rome II criteria) was mailed to 533 persons included in a prevalence study of IBS. The reliability of each underlying dimension identified was measured by Cronbach's α. Validity was assessed by comparing symptom scores with concurrent IBS specific quality of life (QoL) scores. Reproducibility was measured by the test-retest method and responsiveness measured by effect size. Results 379 (71%) questionnaires were returned. The underlying dimensions identified were pain, diarrhoea and constipation. Cronbach's α was 0.74 for pain, 0.90 for diarrhoea and 0.79 for constipation. Pain and diarrhoea dimensions had good external validity (r = -0.3 to -0.6), constipation dimension had moderate external validity (r = -0.2 to -0.3). All dimensions were reproducible (ICCs 0.75 to 0.81). Effect sizes of 0.27 to 0.53 were calculated for those with a reported improvement in symptoms. Conclusion The Birmingham IBS Symptom Questionnaire has been developed and tested. It has been shown to be suitable for self-completion and acceptable to patients. The questionnaire has 3 internal dimensions which have good reliability, external validity and are responsive to a change in health status.

While it seems intuitively appealing to promote participation in regular exercise in the management of irritable bowel syndrome, limited randomised controlled trial evidence exists to support this recommendation. We examined the feasibility and effects of an exercise intervention upon quality of life and irritable bowel symptoms using a randomised controlled trial methodology. Patients with a clinically confirmed diagnosis of irritable bowel syndrome according to Rome II criteria were randomised to either an exercise consultation intervention or usual care for 12 weeks. Outcomes included irritable bowel specific quality of life, symptoms (total symptoms, constipation, diarrhoea and pain) and exercise participation. The recruitment rate of eligible patients identified from hospital records was 18.3% (56/305). Analyses revealed no differences in quality life scores between groups at 12-week follow-up. The exercise group reported significantly improved symptoms of constipation (mean difference=10.9, 95 % CI= -20.1, -1.6) compared to usual care at follow-up. The intervention group participated in significantly more exercise than usual care at follow-up (mean difference=21.6, 95% CI=9.4, 33.8). Recruitment of eligible patients into this study was possible but rates were low. Findings highlight the possibility that exercise may be an effective intervention for symptom management in patients with irritable bowel syndrome; this may be particularly the case for constipation predominant patients.

BACKGROUND: Previous studies have suggested that minor changes in thyroid function are associated with risk of atrial fibrillation (AF). Our objective was to determine the relationship between thyroid function and presence of atrial fibrillation (AF) in older subjects. METHODS: A population-based study of 5860 subjects 65 years and older, which excluded those being treated for thyroid dysfunction and those with previous hyperthyroidism. Main outcome measures included tests of thyroid function (serum free thyroxine [T(4)] and thyrotropin [TSH]) and the presence of AF on resting electrocardiogram. RESULTS: Fourteen subjects (0.2%) had previously undiagnosed overt hyperthyroidism and 126 (2.2%), subclinical hyperthyroidism; 5519 (94.4%) were euthyroid; and 167 (2.9%) had subclinical hypothyroidism and 23 (0.4%), overt hypothyroidism. The prevalence of AF in the whole cohort was 6.6% in men and 3.1% in women (odds ratio, 2.23; P

Background: Widespread use of automated sensitive assays for thyroid hormones and thyroid-stimulating hormone (TSH) has increased identification of mild thyroid dysfunction, especially in elderly patients. The clinical significance of this dysfunction, however, remains uncertain, and associations with cognitive impairment, depression, and anxiety are unconfirmed. Objective: To determine the association between mild thyroid dysfunction and cognition, depression, and anxiety in elderly persons. Design: Cross-sectional study. Associations were explored through mixed-model analyses. Setting: Primary care practices in central England. Patients: 5865 patients 65 years of age or older with no known thyroid disease who were recruited from primary care registers. Measurements: Serum TSH and free thyroxine (T4) were measured. Depression and anxiety were assessed by using the Hospital Anxiety and Depression Scale (HADS), and cognitive functioning was established by using the Middlesex Elderly Assessment of Mental State and the Folstein Mini-Mental State Examination. Comorbid conditions, medication use, and sociodemographic profiles were recorded. Results: 295 patients met the criteria for subclinical thyroid dysfunction (127 were hyperthyroid, and 168 were hypothyroid). After confounding variables were controlled for, statistically significant associations were seen between anxiety (HADS score) and TSH level (P = 0.013) and between cognition and both TSH and free T4 levels. The magnitude of these associations lacked clinical relevance: A 50-mIU/L increase in the TSH level was associated with a 1-point reduction in the HADS anxiety score, and a 1-point increase in the Mini-Mental State Examination score was associated with an increase of 50 mIU/L in the TSH level or 25 pmol/L in the free T4 level. Limitations: Because of the low participation rate, low prevalence of subclinical thyroid dysfunction, and other unidentified recruitment biases, participants may not be representative of the elderly population. Conclusions: After the confounding effects of comorbid conditions and use of medication were controlled for, subclinical thyroid dysfunction was not associated with depression, anxiety, or cognition. © 2006 American College of Physicians.

Aims: To assess the cost-effectiveness of two primary care interventions, a letter and a flag, aimed at improving attendance for breast screening among (i) all women invited for breast screening and (ii) non-attenders. Methods: A probabilistic decision analytic model was developed using Markov chain Monte Carlo simulation implemented in WinBUGS. The model was populated using economic and effectiveness data collected alongside two randomised controlled trials. Results: For all women invited, the incremental cost-effectiveness ratio (ICER) for the letter compared with no intervention is £27 per additional attendance, and the ICER for the combined letter and flag intervention compared to the letter alone is £171. The corresponding ICERs for non-attenders are £41 and £90. The flag intervention is an inefficient option in both settings. A large proportion of the costs fall on the practices (25-67%), depending on the intervention and target population. The total costs incurred do not, however, seem prohibitive. Expected value of perfect information suggests that there is greater va lue in carrying out further research on the intervention implemented among all women invited for breast screening rather than on non-attenders. Conclusions: The flag intervention alone does not appear to be an efficient option. The choice between the letter and both interventions combined is subjective, depending on the willingness to pay for an additional screening attendance. Copyright © 2005 John Wiley & Sons, Ltd.

Background Postal questionnaires are an economical and simple method of data collection for research purposes but are subject to non-response bias. Several studies have explored the effect of monetary and non-monetary incentives on response. Recent meta-analyses conclude that financial incentives are an effective way of increasing response rates. However, large surveys rarely have the resources to reward individual participants. Three previous papers report on the effectiveness of lottery incentives with contradictory results. This study aimed to determine the effect of including a lottery-style incentive on response rates to a postal health survey. Methods Randomised controlled trial. Setting: North and West Birmingham. 8,645 patients aged 18 or over randomly selected from registers of eight general practices (family physician practices). Intervention: Inclusion of a flyer and letter with a health questionnaire informing patients that returned questionnaires would be entered into a lottery-style draw for £100 of gift vouchers. Control: Health questionnaire accompanied only by standard letter of explanation. Main outcome measures: Response rate and completion rate to questionnaire. Results 5,209 individuals responded with identical rates in both groups (62.1%). Practice, patient age, sex and Townsend score (a postcode based deprivation measure) were identified as predictive of response, with higher response related to older age, being female and living in an area with a lower Townsend score (less deprived). Conclusion This RCT, using a large community based sample, found that the offer of entry into a lottery style draw for £100 of High Street vouchers has no effect on response rates to a postal health questionnaire.

Objectives To examine the effectiveness and cost-effectiveness of two primary care based interventions aimed at increasing breast screening uptake for women who had recently failed to attend. Setting 13 General practices with low uptake in the second round of breast screening (below 60%) in north west London and the West Midlands, United Kingdom. Participants were women in these practices who were recent non-attenders for breast screening in the third round. Methods Pragmatic factorial randomised controlled trial, with people randomised to a systematic intervention (general practitioner letter), an opportunistic intervention (flag in women's notes prompting discussion by health professionals), neither intervention, or both. Outcome measures were attendance for screening 6 months after randomisation and cost-effectiveness of the interventions. Results 1158 Women were individually randomised as follows: 289 control; 291 letter; 290 flag; 288 both interventions. Attendance was ascertained for 1148 (99%) of the 1158 women. Logistic regression adjusting for the other intervention and practice produced an odds ratio (OR) for attendance of 1.51 (95% confidence interval (95% CI 1.02 to 2.26; p=0.04) for the letter, and 1.39 (95% CI 0.93 to 2.07; p=0.10) for the flag. Health service costs/additional attendance were £35 (letter) and £65 (flag). Conclusions Among recent non-attenders, the letter was effective in increasing breast screening attendance. The flag was of equivocal effectiveness and was considerably less cost-effective than the letter.

BACKGROUND: Dyspepsia can be managed by initial endoscopy and treatment based on endoscopic findings, or by empirical prescribing. We aimed to determine the cost effectiveness of initial endoscopy compared with usual management in patients with dyspepsia over age 50 years presenting to their primary care physician. METHODS: 422 patients were recruited and randomly assigned to initial endoscopy or usual management. Primary outcomes were effect of treatment on dyspepsia symptoms and cost effectiveness. Secondary outcomes were quality of life and patient satisfaction. Total costs were calculated from individual patient's use of resources with unit costs applied from national data. Statistical analysis of uncertainty on incremental cost-effectiveness ratio (ICER) was done along with a sensitivity analysis on unit costs with cost-effectiveness acceptability curves. FINDINGS: In the 12 months following recruitment, 213 (84%) patients had an endoscopy compared with 75 (41%) controls. Initial endoscopy resulted in a significant improvement in symptom score (p=0.03), and quality of life pain dimension (p=0.03), and a 48% reduction in the use of proton pump inhibitors (p=0.005). The ICER was Pound Sterling1728 (UK Pound Sterling) per patient symptom-free at 12 months. The ICER was very sensitive to the cost of endoscopy, and could be reduced to Pound Sterling165 if the unit cost of this procedure fell from Pound Sterling246 to Pound Sterling100. INTERPRETATION: Initial endoscopy in dyspeptic patients over age 50 might be a cost-effective intervention.

Background Sunbed use in childhood increases risk of melanoma. In April, 2011, a ban on use of sunbeds by children younger than 18 years was introduced in England. Effect on use has not been investigated since. This study estimated the prevalence of sunbed use by children younger than 18 years in Sandwell after the commercial ban and identified factors associated with use or intention to use. Methods We undertook a cross-sectional survey of schoolchildren aged 15–17 years using anonymous questionnaires self-completed in class. Data obtained included demographics, sunbed use, tanning attitudes, knowledge of risks, and ban awareness. All state secondary schools in Sandwell, West Midlands, UK, were approached; children available on the survey days were included. Attitudes and knowledge were measured by the percentage of participants who indicated "agree" or "disagree" for related statements, and comparisons between users or potential users and non-users were made with the χ 2 test. All variables collected were entered in the multiple logistic regression model to identify factors associated with sunbed use or intention to use. Findings Five of 22 schools participated, all school types were represented; 407 children responded (95%). Sex was equally distributed (194 [51%] of 381 were girls). Most were aged 15 years (234 [60%] of 388) and the proportion of white ethnic origin (256 [67%] of 381) was lower than the Sandwell population (223 200 [77%] of 291 000). 20 participants (5·3%, 95% CI 3·4–8·0) had used sunbeds after the ban, of whom 16 reported use in commercial settings. 78 (20·6%, 16·8–24·9) expressed intention to use in the future. After exclusion of one school cohort with atypical use (possibly associated with beauty vocational training course and European migrants), the prevalence of sunbed use was 1·7% (95% CI 0·7–3·9, n=5). Less than half of all children surveyed were aware of the ban (177 of 367 children, 48·2%, 43·2–53·3). Users or potential users were less aware of risks associated with sunbed use than were non-users. Only 63 (67%) of 93 users or potential users were aware that using sunbeds can cause skin cancer (versus 224 [83%] of 269 non-users, χ 2 =10·632, p=0·005). Factors independently associated with sunbed use or intention to use included being female (odds ratio 2·57, 1·12–5·91) or having family members (3·53, 1·52–8·19) or friends (4·54, 1·94–10·63) who use sunbeds. Interpretation In view of the single area studied and the low participation rate from schools, the study has restricted generalisability. A small number of children younger than 18 years in Sandwell still have access to sunbeds despite the ban. Greater publicity, stricter enforcement of the ban by local authorities, and raising awareness of skin cancer risk associated with sunbed use are strategies that could be considered. Further research exploring the possible association between specific vocational courses, migrants (whom conventional public health communication campaigns might not be reaching), and sunbed use is needed. Funding University of Birmingham and the Wolfson Foundation.

Serum sialic acid and C reactive protein are the markers for inflammation. The main objective of this study was to determine the sialic acid level in Caribbean type 2 diabetic patients with and without microvascular complications and its relationship with metabolic and anthropometric variables. The Caribbean subjects aged 15–60 years with type 2 diabetes were recruited for the study. Fasting venous blood samples were collected from 162 subjects of which 44 were healthy individuals, 44 were of type 2 diabetes, 44 were of type 2 diabetes with nephropathy and 30 were of diabetes with retinopathy. Simultaneously urine samples were also collected from each of the subjects. All the blood samples were processed for lipid profile, glucose, HbA1C, C-reactive protein and sialic acid. The urine samples were analysed for sialic acid and microalbumin. Serum sialic acid concentrations were significantly higher among diabetic subjects (66.0 ± 11.7 mg %) as compared to controls (55.2 ± 8.3 mg %). There was a significantly increasing trend of serum sialic acid with severity of nephropathy (71.6 ± 23.6 mg %) and degree of urinary albumin excretion (794.3 ± 805.9). The diabetic retinopathy patients also demonstrated significantly higher values of serum sialic acid (77.9 ± 29.0) and urine microalbumin (351.1 ± 559.9). Elevated serum sialic acid microalbumin concentrations were associated with cardiovascular risk factors such as hypertension, increased waist to hip ratios. (P < 0.05). Sialic acid had no correlation with CRP or any component of the lipid profile. The increased serum sialic acid and microalbumin were strongly related to the presence of microvascular complications like diabetic nephropathy and diabetic retinopathy and cardiovascular risk factors like hypertension and waist to hip ratios in Caribbean type-2 diabetic patients. The serum sialic acid may be used as an inflammatory marker and possible indicator of microvascular complications in type-2 diabetic patients.