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Background: Pneumonia is common in stroke patients and is associated with worse clinical outcomes. Prevalence of stroke-associated pneumonia varies between studies, and reasons for this variation remain unclear. We aimed to describe the variation of observed stroke-associated pneumonia in England and Wales and explore the influence of patient baseline characteristics on this variation. Methods: Patient data were obtained from the Sentinel Stroke National Audit Programme for all confirmed strokes between 1 April 2013 and 31 December 2018. Stroke-associated pneumonia was defined by new antibiotic initiation for pneumonia within the first seven days of admission. The probability of stroke-associated pneumonia occurrence within stroke units was estimated and compared using a multilevel mixed model with and without adjustment for patient-level characteristics at admission. Results: Of the 413,133 patients included, median National Institutes of Health Stroke Scale was 4 (IQR: 2–10) and 42.3% were aged over 80 years. Stroke-associated pneumonia was identified in 8.5% of patients. The median within stroke unit stroke-associated pneumonia prevalence was 8.5% (IQR: 6.1–11.5%) with a maximum of 21.4%. The mean and variance of the predicted stroke-associated pneumonia probability across stroke units decreased from 0.08 (0.68) to 0.05 (0.63) when adjusting for patient admission characteristics. This difference in the variance suggests that clinical characteristics account for 5% of the observed variation in stroke-associated pneumonia between units. Conclusions: Patient-level clinical characteristics contributed minimally to the observed variation of stroke-associated pneumonia between stroke units. Additional explanations for the observed variation in stroke-associated pneumonia need to be explored which could reduce variation in antibiotic use for stroke patients. [ABSTRACT FROM AUTHOR]

Objective: To create a classification system based on stroke-related impairments. Data source: All adults with stroke admitted for at least 72 hours in England, Wales and Northern Ireland from July 2013 to July 2015 extracted from the Sentinel Stroke National Audit Programme Analysis: Impairments were defined using the National Institute of Health Stroke Scale scores at admission. Common combinations of impairments were identified based on geometric coding and expert knowledge. Validity of the classification was assessed using standard descriptive statistics to report and compare patients' characteristics, therapy received and outcomes in each group. Results: Data from 94,905 patients were extracted. The items of the National Institute of Health Stroke Scale (on admission) were initially grouped into four body systems: Cognitive, Motor, Sensory and Consciousness. Seven common combinations of these impairments were identified (in order of stroke severity); Patients with Loss of Consciousness (n = 6034, 6.4%); those with Motor + Cognitive + Sensory impairments (n = 28,226, 29.7%); Motor + Cognitive impairments (n = 16,967, 17.9%); Motor + Sensory impairments (n = 9882, 10.4%); Motor Only impairments (n = 20,471, 21.6%); Any Non-Motor impairments (n = 7498, 7.9%); and No Impairments (n = 5827, 6.1%). There was a gradation of age, premorbid disability, mortality and disability on discharge. People with the most and least severe categories were least likely to receive therapy, and received least therapy (−20 minutes/day of stay) compared to −35 minutes/day of stay for the moderately severe categories. Conclusions: A classification system of seven Stroke Impairment Categories has been presented. [ABSTRACT FROM AUTHOR]

Objective: Determine the psychometric properties of PRECiS (Patient Reported Evaluation of Cognitive State): A new patient-centred, patient reported outcome measure for perceived impact of cognitive problems, developed through qualitative work, systematic review and service user consultation. Design: An observational study exploring acceptability, internal consistency, construct validity, inter-rater reliability and test-retest reliability, with opportunistic qualitative data on sensitivity to change. Setting: Home visits in the community. Participants: Stroke survivors with self-reported cognitive difficulties and informal carers. Measures: The 27 item PRECiS was self-completed with support, and proxy completed by informal carers. We collected descriptive cognitive screening test data, and measures of overall stroke impact, mood and activities of daily living to explore construct validity. Results: Data were collected from 159 (visit 1) and 66 (visit 2) stroke survivors and 86 informal carers. PRECiS showed good acceptability (no missing values or floor/ceiling effects, minimal skewness); high internal consistency (α = 0.94, indicative of potential redundancy); with moderate to strong construct correlations in the directions hypothesised (0.40 to 0.74). An intraclass correlation coefficient of 0.85 indicated good test-retest reliability. Where self-reported change had occurred from visit 1 to 2, PRECiS appeared sensitive. Using carers as proxy respondents is not supported by this analysis (inter-rater ICC = 0.43). Conclusions: PRECiS is a patient-centred, practical and reliable measure assessing perceived impact of cognitive problems from the unique perspective of stroke survivors. [ABSTRACT FROM AUTHOR]

Objectives. Acro-osteolysis (bony resorption of the terminal digital tufts) is a well-recognized, but under-researched, manifestation of SSc. Our aim was to investigate the hypothesis that acro-osteolysis is associated with (i) the severity of digital ischaemia and (ii) the presence of calcinosis.Methods. This was a retrospective study of 101 patients with SSc in whom hand radiographs taken between 2001 and May 2008 were available for review. These radiographs were graded for severity of acro-osteolysis on a 0–4-point scale for each finger (0 = normal bone structure, 4 = severe pencilling of the terminal phalanges). From these scores, patients were subdivided into the following two groups: normal/minimal acro-osteolysis and moderate/severe acro-osteolysis. The presence or absence of calcinosis (mild, moderate or severe) was also documented.Results. Of the 101 patients, 68 were grouped as normal/minimal acro-osteolysis and 33 as moderate/severe acro-osteolysis. Forty-five had severe digital ischaemia: 25 (76%) of the patients with moderate/severe acro-osteolysis compared with 20 (29%) of those with normal/minimal acro-osteolysis (multifactorial analysis: P < 0.001). Patients with moderate/severe acro-osteolysis were more likely to have severe calcinosis (33% vs 13%), but this was not statistically significant after adjustment for potential confounders.Conclusion. Acro-osteolysis was strongly associated with severe digital ischaemia. The potential association with severe calcinosis merits further study. Prospective studies are required to investigate acro-osteolysis as a marker of digital vascular disease progression and of treatment response. [ABSTRACT FROM PUBLISHER]

Vitamin D is necessary for bone health and is potentially protective against a range of malignancies. Opinions are divided on whether the proposed optimal circulating 25-hydroxyvitamin D [25(OH)D] level (≥ 32 ng mL) is an appropriate and feasible target at population level. We examined whether personal sunlight exposure levels can provide vitamin D sufficient (≥ 20 ng mL) and optimal status in the U.K. public. This prospective cohort study measured circulating 25(OH)D monthly for 12 months in 125 white adults aged 20-60 years in Greater Manchester. Dietary vitamin D and personal ultraviolet radiation (UVR) exposure were assessed over 1-2 weeks in each season. The primary analysis determined the post-summer peak 25(OH)D required to maintain sufficiency in wintertime. Dietary vitamin D remained low in all seasons (median 3·27 μg daily, range 2·76-4·15) while personal UVR exposure levels were high in spring and summer, low in autumn and negligible in winter. Mean 25(OH)D levels were highest in September [28·4 ng mL; 28% optimal, zero deficient (<5 ng mL)], and lowest in February (18·3 ng mL; 7% optimal, 5% deficient). A February 25(OH)D level of 20 ng mL was achieved following a mean (95% confidence interval) late summer level of 30·4 (25·6-35·2) and 34·9 (27·9-41·9) ng mL in women and men, respectively, with 62% of variance explained by gender and September levels. Late summer 25(OH)D levels approximating the optimal range are required to retain sufficiency throughout the U.K. winter. Currently the majority of the population fails to reach this post-summer level and becomes vitamin D insufficient during the winter. [ABSTRACT FROM AUTHOR]

Background. Estimates suggest that over half of general practices in England currently employ a health care assistant (HCA) but there is little evidence of their impact, effectiveness and acceptability to patients and primary care team members. [ABSTRACT FROM PUBLISHER]

Background: The ABCD2 score predicts stroke risk within a few days of transient ischaemic attack (TIA). It is not clear whether the predictive value of the ABCD2 score can be generalised to UK TIA services, where delayed presentation of TIA and minor stroke are common. We investigated prognosis, and the use of the ABCD2 score, in patients attending TIA services in the North West of England with a diagnosis of TIA or minor stroke. Methods: 711 patients with TIA or minor stroke were prospectively recruited from five centres (median duration from index event to recruitment 15 days). The primary outcome was the composite of incident TIA, stroke, acute coronary syndrome or cardiovascular death at the 3 month follow-up. Prognostic factors were analysed using Cox proportional hazards regression. Results: The primary outcome occurred in 126 (18%) patients. Overall, there were 30 incident strokes. At least one incident TIA occurred in 100 patients (14%), but only four had a subsequent stroke. In multifactorial analyses, the ABCD2 score was unrelated to the risk of the primary outcome, but predicted the risk of incident stroke: score 4-5: hazard ratio (HR) 3.4 (95% CI 1.0 to 12); score 6-7: HR 4.8 (1.3 to 18). Of the components of the ABCD2 score, unilateral motor weakness predicted both the primary outcome (HR 1.8 (1.2 to 2.8)) and stroke risk (HR 4.2 (1.3 to 14)). Conclusions: In patients attending typical NHS TIA services, the risk of incident stroke was relatively low, probably reflecting delays to assessment. Current provision of TIA services, where delayed presentation to "rapid access" TIA clinics is common, does not appear to provide an appropriate setting for urgent evaluation, risk stratification or timely secondary prevention for those who may be at highest risk. [ABSTRACT FROM AUTHOR]

Background Changing Childbirth became policy for the maternity services in England in 1994 and remains policy. One-to-One midwifery was implemented to achieve the targets set. It was the first time such a service had been implemented in the Health Service. An evaluation was undertaken to compare its performance with conventional maternity care. [ABSTRACT FROM PUBLISHER]

Background: One-to-one midwifery was a demonstration project introduced into a London-based maternity service in 1993 to put into practice the new government policy for maternity services in England. Evaluation was integral to the development of the project. Methods: The evaluation of women's responses was conducted between August 1994 and August 1995 based on a longitudinal, self-completion questionnaire, interviews, and focus groups. Women in the study group (n = 728) received the new service and women in the control group (n = 675) received conventional care. The study design integrated quantitative and qualitative methods and went beyond a simple estimation of satisfaction with care. Results: Satisfaction with antenatal and birth care was generally high, but study group women showed more positive responses overall. Both groups showed a preference for continuity of caregiver, but expectations were higher in the study group (72% of the study group and 42% of the control group preferred to see one caregiver). Both groups had less satisfied responses to hospital postnatal care (50% study and 54% control group were very satisfied). Study group women showed greater preparedness for birth than control group women (18% vs 12% “very well prepared”) and for the time after the baby's birth (26% vs 15% “very prepared”). Conclusions: The study demonstrated that women were more satisfied with the one-to-one model of care. Taken together with the results of clinical and economic audit and professional responses, the evaluation suggests that this model should be developed and evaluated further to gain a greater understanding of women's needs of the maternity service. (BIRTH 25:2 June 1998). [ABSTRACT FROM AUTHOR]

Background: Severe strokes and stroke-associated pneumonia (SAP) have long been associated with poorer patient health outcomes, for example, in-hospital mortality. However, it is unclear what role SAP plays in the risk of in-hospital mortality associated with a severe stroke at admission., Methods: Using the Sentinel Stroke National Audit Program data on stroke admissions (2013-2018) in England and Wales, we modeled the "total" effect for severe stroke on risk of in-hospital mortality. Through four-way decomposition methodology, we broke down the "total" observed risk into four components. The direct "severity on outcome only" effect, the pure indirect effect of severity mediated via SAP only, the interaction between severity and SAP when mediation is not present, and when mediation via SAP is present., Results: Of 339,139 stroke patients included, 9.4% had SAP and 15.6% died in hospital. Of SAP patients, 45% died versus 12% of non-SAP patients. The risk ratio for in-hospital mortality associated with severe versus mild/moderate stroke (i.e. total effect) was 4.72 (95% confidence interval: 4.60-4.85). Of this, 43%-increased risk was due to additive SAP interaction, this increased to 50% for "very severe" stroke. The remaining excess relative risk was due to the direct severity on outcome effect only, that is, there was no evidence here for a mediation effect via SAP., Conclusion: SAP was associated with a higher mortality in severe stroke patients. Prioritizing SAP prevention in severe stroke patients may improve in-hospital survival. Our results suggest that in severe stroke patients avoiding SAP might result in an up to 43% reduction in mortality., Competing Interests: Declaration of conflicting interestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: M.G., M.A.L.C., A.V., and C.J.S. have no conflicts related to this work. This study is additional follow-up work based on M.A.L.C.’s PhD thesis investigating stroke-associated pneumonia using the SSNAP data. M.A.L.C.’s work at Glaxosmithkline Biologicals is in no way related or in conflict to the work presented here.

Introduction: It is not known whether modern stroke unit care reduces the impact of stroke complications, such as stroke-associated pneumonia (SAP), on clinical outcomes. We investigated the relationship between SAP and clinical outcomes, adjusting for the confounding effects of stroke care processes and their timing., Methods: The Sentinel Stroke National Audit Programme provided patient data for all confirmed strokes between April 2013 and December 2018. SAP was defined as new antibiotic initiation for suspected pneumonia within the first 7 days from stroke admission. We compared outcomes after SAP versus non-SAP in appropriate multilevel mixed models. Each model was adjusted for patient and clinical characteristics, as well as markers of stroke care and their timing within the first 72 h. The appropriate effect estimates and corresponding 95% confidence intervals (CIs) were reported., Results: Of 201,778 patients, SAP was present in 14.2%. After adjustment for timing of acute stroke care processes and clinical characteristics, adverse outcomes remained for SAP versus non-SAP patients. In these adjusted analyses, patients with SAP maintained an increased risk of longer length of in-hospital stay (IRR of 1.27; 95% CI: 1.25, 1.30), increased odds of worse functional outcome at discharge (OR of 2.9; 95% CI: 2.9, 3.0), and increased risk of in-hospital mortality (HR of 1.78; 95% CI: 1.74, 1.82)., Conclusion: We show for the first time that SAP remains associated with worse clinical outcomes, even after adjusting for processes of acute stroke care and their timing. These findings highlight the importance of continued research efforts aimed at preventing SAP., (© 2022 The Author(s). Published by S. Karger AG, Basel.)

Objectives: Accurate and timely diagnosis of pneumonia complicating stroke remains challenging and the diagnostic accuracy of chest X-ray (CXR) in the setting of stroke-associated pneumonia (SAP) is uncertain. The overall objective of this study was to evaluate the use of pulmonary computed tomography (CT) in diagnosis of suspected SAP., Materials and Methods: Patients with acute ischemic stroke (IS) or intracerebral hemorrhage (ICH) were recruited within 24h of clinically suspected SAP and underwent non-contrast pulmonary CT within 48h of antibiotic initiation. CXR and pulmonary CT were reported by two radiologists. Pulmonary CT was used as the reference standard for final diagnosis of SAP. Sensitivity, specificity, positive and negative predictive values (PPV and NPV), and diagnostic odds ratio (OR) for CXR were calculated., Results: 40 patients (36 IS, 4 ICH) with a median age of 78y (range 44y-90y) and a median National Institute of Health Stroke Scale score of 13 (range 3-31) were included. All patients had at least one CXR and 35/40 patients (88%) underwent pulmonary CT. Changes consistent with pneumonia were present in 15/40 CXRs (38%) and 12/35 pulmonary CTs (34%). 9/35 pulmonary CTs (26%) were reported normal. CXR had a sensitivity of 58.3%, specificity of 73.9%, PPV of 53.8 %, NPV of 77.2 %, diagnostic OR of 3.7 (95% CI 0.7 - 22) and an accuracy of 68.5% (95% CI 50.7% -83.1%)., Discussion: CXR has limited diagnostic accuracy in SAP. The majority of patients started on antibiotics had no evidence of pneumonia on pulmonary CT with potential implications for antibiotic stewardship., Conclusions: Pulmonary CT could be applied as a reference standard for evaluation of clinical and biomarker diagnostic SAP algorithms in multi-center studies., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background and Aims: Concerns have arisen regarding patient access and delivery of acute stroke care during the COVID-19 pandemic. We investigated key population level events on activity of the three hyperacute stroke units (HASUs) within Greater Manchester and East Cheshire (GM & EC), whilst adjusting for environmental factors., Methods: Weekly stroke admission & discharge counts in the three HASUs were collected locally from Emergency Department (ED) data and Sentinel Stroke National Audit Programme core dataset prior to, and during the emergence of the COVID-19 pandemic (Jan 2020 to May 2020). Whilst adjusting for local traffic-related air pollution and ambient measurement, an interrupted time-series analysis using a segmented generalised linear model investigated key population level events on the rate of stroke team ED assessments, admissions for stroke, referrals for transient ischaemic attack (TIA), and stroke discharges., Results: The median total number of ED stroke assessments, admissions, TIA referrals, and discharges across the three HASU sites prior to the first UK COVID-19 death were 150, 114, 69, and 76 per week. The stable weekly trend in ED assessments and stroke admissions decreased by approximately 16% (and 21% for TIAs) between first UK hospital COVID-19 death (5 th March) and the implementation of the Act-FAST campaign (6 th April) where a modest 4% and 5% increase per week was observed. TIA referrals increased post Government intervention (23 rd March), without fully returning to the numbers observed in January and February. Trends in discharges from stroke units appeared unaffected within the study period reported here., Conclusion: Despite adjustment for environmental factors stroke activity was temporarily modified by the COVID-19 pandemic. Underlying motivations within the population are still not clear. This raises concerns that patients may have avoided urgent health care risking poorer short and long-term health outcomes., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: To identify the main drivers of inpatient stroke care resource use, estimate the influence of stroke teams on the length of stay (LoS) of its patients and analyse the variation in relative performance across teams., Design: For each of four types of stroke care teams, a two-level count data model describing the variation in LoS and identifying the team influence on LoS purged of patient and treatment characteristics was estimated. Each team effect was interpreted as a measure of stroke care relative performance and its variation was analysed., Setting: This study used data from 145 396 admissions in 256 inpatient stroke care teams between June 2013 and July 2015 included in the national stroke register of England, Wales and Northern Ireland-Sentinel Stroke National Audit Programme., Results: The main driver of LoS, and thus resource use, was the need for stroke therapy even after stroke severity was taken into account. Conditional on needing the therapy in question, an increase in the average amount of therapy received per inpatient day was associated with shorter LoS. Important variations in stroke care performance were found within each team category., Conclusions: Resource use was strongly associated with stroke severity, the need for therapy and the amount of therapy received. The variations in stroke care performance were not explained by measurable patient or team characteristics. Further operational and financial analyses are needed to unmask the causes of this unexplained variation., Competing Interests: Competing interests: AB was until 2016 a member of the Intercollegiate Stroke Working Party that produces SSNAP from which the SSNAPIEST data were drawn and her University salary is part-funded by a personal award from Stroke Association. All other authors declare that they have no competing interests., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY. Published by BMJ.)

While actinic keratoses (AKs) have a known association with cutaneous squamous cell carcinoma (SCC), the relation of actinic field change to SCC has not been quantified. This study investigated the presence of field change and AKs in renal transplant recipients (RTRs) and estimated SCC risk. In May 2010 to October 2011, a dermatologist examined 452 white RTRs (mean age 53 years) at two hospitals in Manchester, UK, counting AKs and recording field change presence by body site and SCCs arising during the study period. Of the participants 130 (29%) had AKs at examination. In 60 (13%) RTR patients with AKs but no field change, 4 (7%) developed SCCs, compared with 15 (21%) of the 70 (15%) with AKs and field change. SCCs developed directly within field change areas in 11/15 (73%) RTRs. This study confirms that RTRs with widespread confluent actinic skin damage are at very high risk of SCC and should be monitored closely.

Background: Orolingual angio-oedema is a recognised complication of tissue plasminogen activator (tPA) for ischaemic stroke. We investigated its incidence, clinical characteristics and relationship with other factors in patients receiving tPA at a UK centre., Methods: 530 consecutive patients (median age 70 years) receiving tPA treatment for confirmed ischaemic stroke were included. Cases were defined as those developing angio-oedema within 24 h of initiation of tPA. Angio-oedema was retrospectively classified as mild, moderate or severe using predefined criteria. The primary analysis was the association between prior ACE inhibitor (ACE-I) treatment and angio-oedema., Results: Orolingual angio-oedema was observed in 42 patients (7.9%; 95% CI 5.5% to 10.6%), ranging from 5 to 189 min after initiation of tPA (median 65 min). 12% of the angio-oedema cases were severe (1% of all patients treated with tPA), requiring urgent advanced airway management. 172 patients (33%) were taking ACE-I. In multifactorial analyses, only prior ACE-I treatment remained a significant independent predictor of angio-oedema (odds ratio (OR) 2.3; 95% CI 1.1 to 4.7)., Conclusions: Angio-oedema occurs more frequently than previously reported and is associated with preceding ACE-I treatment. Angio-oedema may be delayed and progress to life-threatening airway compromise, which has implications for the assessment and delivery of thrombolysis., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Background and Hypothesis: Inflammation is implicated in the pathogenesis and outcome of ischaemic injury. Poststroke inflammation is associated with outcome but it remains unclear whether such inflammation precedes or results from ischaemic injury. We hypothesised that inflammatory markers are associated with an increased risk of recurrent vascular events soon after transient ischaemic attack and minor stroke., Methods: This was a multicentre, prospective, nested case-control study. Plasma concentrations of C-reactive protein, interleukin-6, interleukin-1-receptor antagonist and fibrinogen, leucocyte counts, erythrocyte sedimentation rate and inflammatory gene allele frequencies were analysed in 711 patients with recent transient ischaemic attack or minor stroke. Cases were defined by the incidence of one or more recurrent vascular events during the three-month follow-up. Association of inflammatory markers with case-status was determined using conditional logistic regression., Results: Plasma concentrations of C-reactive protein, interleukin-1-receptor antagonist and interleukin-6 were not associated with case-status. In secondary analyses, only erythrocyte sedimentation rate was significantly associated with case-status (odds ratio 1·39, 95% confidence interval 1·03-1·85; P=0·03), but this effect did not persist after adjustment for smoking and past history of transient ischaemic attack or stroke. Single nucleotide polymorphisms in four inflammatory genes (interleukin-6, fibrinogen, P-selectin and vascular cell adhesion molecule-1) were nominally associated with case-status., Conclusions: Circulating inflammatory markers were not associated with recurrent vascular events. Nominally significant associations between genetic markers and case-status will require replication. These data provide little evidence for an inflammatory state predisposing to stroke and other vascular events in a susceptible population., (© 2011 The Authors. International Journal of Stroke © 2011 World Stroke Organization.)

Background: The Oxfordshire Community Stroke Project (OCSP) and Trial of ORG 10172 in Acute Stroke Treatment (TOAST) classifications are widely used for the assessment of major ischaemic stroke. We explored their intra- and inter-observer reliability in the classification of outpatient minor stroke., Methods: Four physicians of differing seniority and training backgrounds classified minor stroke using clinical data from 90 patients., Results: For both the OCSP and TOAST classifications, the intra-observer reliability varied from moderate to excellent (kappa = 0.48-0.83). The inter-observer reliability was good (kappa = 0.64) for the OCSP and moderate (kappa = 0.42) for the TOAST. Thus, neither classification was consistently reliable., Conclusions: Our results may reflect the limited validity of these classifications in a typical minor stroke outpatient population and variable observer expertise.

Purpose: To study the incidence of acute postoperative presumed infectious endophthalmitis (PIE) in a UK district general hospital over a 10-year period. Consideration of such departmental healthcare-associated infection frequency rates as part of reflective and comparative quality practice in the light of local concerns., Methods: Hospital-based retrospective case series: 12 831 cataract extraction operations from 01/01/1995 to 31/12/2004 were studied. All cases of PIE within 6 weeks of cataract surgery were ascertained and investigated in a standardised format. PIE incidence rate per 1000 cataract surgical procedures was contrasted with the existing literature., Results: Seven isolated PIE cases occurred following phacoemulsification. None followed extra-capsular extractions. The PIE rate was 0.55 [95% CI; 0.22 to 1.12] cases per 1000 cataract extractions, or one PIE case within 6 weeks of surgery in every 1833 [95% CI; 893 to 4545] cataract operations undertaken. Five cases were culture positive. Details of PIE cases are presented., Conclusion: PIE incidence rates in our department are slightly lower than reported case series in similar settings. Whether this is due to a variety of preventive measures deployed locally and/or methods of case ascertainment in published studies is problematic and is discussed. Departmental benchmarking data is important in relation to rare, but critical, patient safety incidents. Collection and monitoring of endophthalmitis outcomes is of merit and may inform patient choice. Surgical site infection surveillance systems of relevance are discussed. Implications for making healthcare safer, including reflective practice are, discussed in relation to cataract care.

Objectives: To explore dietary risk factors, in particular fat intake, for breast cancer, using an approach to reduce recall bias of subjects and so provide a more reliable estimate of dietary intake than previous similar studies., Design: A case-control study of women aged 50-65 years attending the breast assessment clinics of the breast screening programme in Southampton and Portsmouth, southern England. Data were analysed for all women requiring further clinical procedures; all women recalled to have an early rescreen; and a random sample of women found to be normal and referred for a routine rescreening appointment (standard recall)., Measurements: An interview obtained information on various lifestyle characteristics including smoking and alcohol intake, weight, waist, and hip measurements were also taken at the clinic. Women were given a detailed questionnaire on food intake to complete at home and return by post., Results: 1577 women were included in the study: 220 with breast cancer (cases); 179 with benign breast disease; 353 early rescreen and 825 given a standard recall appointment. There were few differences in nutritional intake between the four groups. Logistic regression analyses were carried out comparing the dietary intake of cases with that of each control group adjusting for important demographic and reproductive factors. Results for the case and standard recall comparison are presented. The only non-calorific nutrient to reach significance was iron, which was negatively associated with risk (p = 0.03). For fat intake, the odds decreased with increasing polyunsaturated fat (p = 0.15), showed no trend with monounsaturated fat (p = 0.37) and increased (p = 0.10) with increasing saturated fat. No pattern was clear for the other calorie providing nutrients., Conclusions: In line with recent cohort studies, this study has shown no evidence to support the hypothesis that dietary fat is an important contributor to breast cancer rates. Biases should have been reduced by studying subjects from the screening programme who were at an early stage of disease.

Among school leavers applying to study medicine in the United Kingdom a majority offer General Certificate of Education, Advanced Level (A-level) examinations as part of the assessment of academic ability. At the time of application, up to 9 months before completing A-level studies, schools are requested to predict the final grades likely to be achieved by the applicant. A total of 5054 A-level predictions from 1661 applicants to a single medical school were compared with the results achieved. Predicted and achieved grades were both high with 93% of predicted grades being A or B. Over half the predictions were correct, with 41% of predictions above achieved grades and only 7% below achieved grade. Independent and selective schools predicted higher grades than comprehensive schools and sixth form colleges, and their pupils were more likely to achieve the entrance requirements. A-level predictions for medical school applicants are a strong predictor of achievement and should continue to be regarded as a useful part of the selection process.

Study Objectives: The aim was to quantify the influence of demographic and reproductive factors on breast cancer. The subjects' path through the screening clinic, the inherent differences between the control groups, and the possible biases when using screening programmes were also considered., Design: A case-control study using both personal contact and postal questionnaires to gather demographic and reproductive information., Setting: Women attending two breast screening recall clinics in Portsmouth and Southampton over the period 1990-92., Participants: Altogether 1813 subjects between the ages of 50 and 65 years. The subjects' disease status was ascertained using a mammography and classified into four categories: 253 breast cancer (cases); 207 benign breast disease (BD); 410 requiring early rescreen (ER); and 943 for standard recall (SR). The BD, ER, and SR groups were used as separate controls., Main Results: Of the factors considered here, the only two that showed a consistently significant effect on the risk of breast cancer were age and body mass index (BMI). Odds ratios were calculated for five yearly age groups and four groups of BMI using the youngest and lightest group as the baseline, respectively. There seemed to be an increase in the risk of breast cancer for increasing age for each comparison made (for cases v SR:OR (95% CI) = 1.60 (1.10, 2.34), 2.54 (1.76, 3.68)). All subjects above the lowest quartile of BMI experienced increased risk, although a trend was not clear (for cases v SR: OR (95% CI) = 1.66 (1.03, 2.66), 1.37 (0.86, 2.20), 1.98 (1.24, 3.15))., Conclusions: Various other potential risk factors were found to be inconsistently significant depending on choice of control group. This may help in understanding the differences between the three control groups used.

Objective: To test the effect of extra non-directive information about prenatal testing, given individually or in a class., Setting: Antenatal clinics in a district general hospital and a university hospital., Design: Randomised controlled trial; participants allocated to control group or offer of extra information individually or in class., Subjects: 1691 women booking antenatal care before 15 weeks' gestation., Interventions: All participants received the usual information about prenatal tests from hospital staff. Individual participants were offered a separate session with a research midwife in which prenatal screening was described in detail. Class participants were offered the same extra information in an early prenatal class., Main Outcome Measures: Attendance at extra information sessions; uptake rates of prenatal tests; levels of anxiety, understanding, and satisfaction with decisions., Results: Attendance at classes was lower than at individual sessions (adjusted odds ratio 0.45; 95% confidence interval 0.35 to 0.58). Ultrasonography was almost universally accepted (99%) and was not affected by either intervention. Uptake of cystic fibrosis testing, high in controls (79%), was lowered in the individual group (0.44; 0.20 to 0.97) and classes (0.39; 0.18 to 0.86). Uptake of screening for Down's syndrome, already low (34%) in controls, was not further depressed by extra information in classes (0.99; 0.70 to 1.39) and was slightly higher in the individual group (1.45; 1.04 to 2.02). Women offered extra information had improved understanding and were more satisfied with information received; satisfaction with decisions about prenatal testing was unchanged. The offer of individual information reduced anxiety later in pregnancy., Conclusions: Ultrasonography is valued for non-medical reasons and chosen even by fully informed people who eschew prenatal diagnosis. The offer of extra information has no overall adverse effects on anxiety and reduces uptake of blood tests when background uptake rate is high (but not when it is already low). High uptake of prenatal blood tests suggests compliant behaviour and need for more information.