An Exploratory Study into Objective and Reported Characteristics of Neuropathic Pain in Women with Chronic Pelvic Pain.

Chronic pelvic pain (CPP) affects 5.7-26.6% women worldwide. 55% have no obvious pathology and 40% have associated endometriosis. Neuropathic pain (NeP) is pain arising as a consequence of a lesion/disease affecting the somatosensory system. The prevalence of NeP in women with CPP is not known. The diagnosis of NeP is challenging because there is no gold-standard assessment. Questionnaires have been used in the clinical setting to diagnose NeP in other chronic pain conditions and quantitative sensory testing (QST) has been used in a research setting to identify abnormal sensory function. We aimed to determine if women with chronic pelvic pain (CPP) have a neuropathic pain (NeP) component to their painful symptoms and how this is best assessed. We performed an exploratory prospective cohort study of 72 pre-menopausal women with a diagnosis of CPP. They underwent a clinician completed questionnaire (DN4) and completed the S-LANSS and PainDETECT™ questionnaires. Additionally QST testing was performed by a clinician. They also completed a patient acceptability questionnaire. Clinical features of NeP were identified by both questionnaires and QST. Of the women who were NeP positive, 56%, 35% and 26% were identified by the S-LANSS, DN4 and PainDETECT™ respectively. When NeP was identified by questionnaire, the associated laparoscopy findings were similar irrespective of which questionnaire was used. No subject had entirely unchanged QST parameters. There were distinct loss and gain subgroups, as well as mixed alteration in function, but this was not necessarily clinically significant in all patients. 80% of patients were confident that questionnaires could diagnose NeP, and 90% found them easy to complete. Early identification of NeP in women with CPP with a simple questionnaire could facilitate targeted therapy with neuromodulators, which are cheap, readily available, and have good safety profiles. This approach could prevent unnecessary or fertility-compromising surgery and prolonged treatment with hormones.

Cannabis, tobacco smoking, and lung function: a cross-sectional observational study in a general practice population.

BACKGROUND: Health concerns around cannabis use have focused on the potential relationship with psychosis but the effect of cannabis smoking on respiratory health has received less attention. AIM: To investigate the association between tobacco-only smoking compared with tobacco plus cannabis smoking and adverse outcomes in respiratory health and lung function. DESIGN AND SETTING: The design was cross-sectional with two groups recruited: cigarette smokers with tobacco pack-years; cannabis smokers with cannabis joint-years. Recruitment occurred in a general practice in Scotland with 12 500 patients. METHOD: Exposures measured were tobacco smoking (pack-years) and cannabis smoking (joint-years). Cannabis type (resin, herbal, or both) was recorded by self-report. Respiratory symptoms were recorded using NHANES and MRC questionnaires. Lung function was measured by spirometry (FEV1/FVC ratio). RESULTS: Participants consisted of 500 individuals (242 males). Mean age of tobacco-only smokers was 45 years; median tobacco exposure was 25 pack-years. Mean age of cannabis and tobacco smokers was 37 years; median tobacco exposure was 19 pack-years, rising to 22.5 when tobacco smoked with cannabis. Although tobacco and cannabis use were associated with increased reporting of respiratory symptoms, this was higher among those who also smoked cannabis. Both tobacco and cannabis users had evidence of impaired lung function but, in fully adjusted analyses, each additional joint-year of cannabis use was associated with a 0.3% (95% confidence interval = 0.0 to 0.5) increase in prevalence of chronic obstructive pulmonary disease. CONCLUSION: In adults who predominantly smoked resin cannabis mixed with tobacco, additional adverse effects were observed on respiratory health relating to cannabis use.

Adolescent seasonal allergic rhinitis and the impact of health-care professional training: cluster randomised controlled trial of a complex intervention in primary care.

BACKGROUND: Seasonal allergic rhinitis is typically poorly managed, particularly in adolescents, in whom it is responsible for considerable morbidity. Our previous work has demonstrated that if poorly controlled this can impair educational performance. AIM: The primary aim of this trial was to assess the impact of a primary care-based professional training intervention on clinical outcomes in adolescents with seasonal allergic rhinitis. METHODS: Cluster trial in which UK general practice staff were randomised to a short, intensive workshop on the evidence-based management of seasonal allergic rhinitis. The primary outcome measure was the change in the validated Rhinoconjunctivitis Quality of Life Questionnaire with Standardized Activities (RQLQ(S)) score between baseline and 6 weeks post intervention (minimal clinically important difference=0.5). Secondary outcome measures of interest included health-care professionals' knowledge and confidence in managing seasonal allergic rhinitis, number of seasonal allergic rhinitis-related consultations, relevant treatments prescribed and symptom scores. RESULTS: Thirty-eight general practices were randomised (20 in the intervention arm) and 246 patients (50.2% males, mean age 15 years) were included in the primary outcome analysis. Health-care professionals' knowledge and confidence of the clinical management of seasonal allergic rhinitis improved. This did not, however, result in clinically or statistically significant improvements in RQLQ(S): -0.15, (95% confidence interval, -0.5 to +0.2). There were no differences in consultation frequency, treatments issued for seasonal allergic rhinitis or symptom scores. CONCLUSIONS: Although associated with increases in professionals' self-assessed confidence and understanding of seasonal allergic rhinitis management, this intensive training workshop did not translate into improvements in adolescents' disease-specific quality of life or a reduction in rhinitis symptoms.

Investigating the association between obesity and asthma in 6- to 8-year-old Saudi children: a matched case-control study.

BACKGROUND: Previous studies have demonstrated an association between obesity and asthma, but there remains considerable uncertainty about whether this reflects an underlying causal relationship. AIMS: To investigate the association between obesity and asthma in pre-pubertal children and to investigate the roles of airway obstruction and atopy as possible causal mechanisms. METHODS: We conducted an age- and sex-matched case-control study of 1,264 6- to 8-year-old schoolchildren with and without asthma recruited from 37 randomly selected schools in Madinah, Saudi Arabia. The body mass index (BMI), waist circumference and skin fold thickness of the 632 children with asthma were compared with those of the 632 control children without asthma. Associations between obesity and asthma, adjusted for other potential risk factors, were assessed separately in boys and girls using conditional logistic regression analysis. The possible mediating roles of atopy and airway obstruction were studied by investigating the impact of incorporating data on sensitisation to common aeroallergens and measurements of lung function. RESULTS: BMI was associated with asthma in boys (odds ratio (OR)=1.14, 95% confidence interval (CI), 1.08-1.20; adjusted OR=1.11, 95% CI, 1.03-1.19) and girls (OR=1.37, 95% CI, 1.26-1.50; adjusted OR=1.38, 95% CI, 1.23-1.56). Adjusting for forced expiratory volume in 1 s had a negligible impact on these associations, but these were attenuated following adjustment for allergic sensitisation, particularly in girls (girls: OR=1.25; 95% CI, 0.96-1.60; boys: OR=1.09, 95% CI, 0.99-1.19). CONCLUSIONS: BMI is associated with asthma in pre-pubertal Saudi boys and girls; this effect does not appear to be mediated through respiratory obstruction, but in girls this may at least partially be mediated through increased risk of allergic sensitisation.

Prevalence of allergic disorders among primary school-aged children in Madinah, Saudi Arabia: two-stage cross-sectional survey.

BACKGROUND: There are limited data on the epidemiology of allergic disorders in Saudi Arabia. Such data are needed for, amongst other things, helping to plan service provision at a time when there is considerable investment taking place in national healthcare development. We sought to estimate the prevalence of atopic eczema, allergic rhinitis and asthma in primary school children in Madinah, Saudi Arabia. METHODS AND FINDINGS: We conducted a two-stage cross-sectional survey of schoolchildren in Madinah. Children were recruited from 38 randomly selected schools. Questionnaires were sent to the parents of all 6,139 6-8 year old children in these schools. These parental-completed questionnaires incorporated questions from the International Study of Asthma and Allergies in Childhood (ISAAC), which had previously been validated for use in Arab populations. We undertook descriptive analyses, using the Generalized Estimating Equation (GEE) to calculate 95% confidence intervals. The overall response rate was 85.9% (n = 5,188), 84.6% for girls and 86.2% for boys, respectively. Overall, parents reported symptoms suggestive of a history of eczema in 10.3% (95%CI 9.4, 11.4), rhinitis in 24.2% (95%CI 22.3, 26.2) and asthma in 23.6% (95%CI 21.3, 26.0) of children. Overall, 41.7% (95%CI 39.1, 44.4) of children had symptoms suggestive of at least one allergic disorder, with a substantial minority manifesting symptoms indicative of co-morbid allergic disease. Comparison of these symptom-based prevalence estimates with reports of clinician-diagnosed disease suggested that the majority of children with eczema and asthma had been diagnosed, but only a minority (17.4%) of children had been diagnosed with rhinitis. International comparisons indicated that children in Madinah have amongst the highest prevalence of allergic problems in the world. CONCLUSIONS: Symptoms indicative of allergic disease are very common in primary school-aged children in Madinah, Saudi Arabia, with figures comparable to the highest risk regions in the world.

Avoiding inappropriate invitations to cancer screening programmes: the role of primary care.

OBJECTIVES: To examine current procedures for cancer screening invitation list (SIL) checking in primary care, and to make recommendations for the future use of these procedures. SETTING: Cancer screening departments/units and associated general practices across England. METHODS: 1) An analysis of the outputs of screening programme SIL checking, and accompanying practice questionnaire, for cancers of the cervix (9 screening centres, 36 general practices), breast (6 centres, 76 practices) and bowel (pilot hub, 7 practices)--supplemented by an audit of calls to screening centres to identify inappropriate invitations; 2) a national postal questionnaire survey sent to all 80 breast screening departments across England and 320 associated general practices; 3) telephone interviews with 13 NHS screening staff to obtain detailed perspectives about SIL checking procedures. RESULTS: SIL checking in primary care is undertaken by a variety of clinical and non-clinical staff. It plays a useful role in cervical screening with tangible evidence of refinements to the SIL and support from both primary care and screening centre staff. Conversely, its role in breast and bowel screening is not supported by the results of this study. Overall, there is no significant evidence of adverse effects from inappropriate invitations. CONCLUSIONS: SIL checking in primary care for cervical cancer should continue, but its use in breast and bowel cancer screening is not supported by our results. New ways of undertaking the SIL checking process to make it more accurate and less burdensome should be examined.

Protocol for the adolescent hayfever trial: cluster randomised controlled trial of an educational intervention for healthcare professionals for the management of school-age children with hayfever.

BACKGROUND: Seasonal allergic rhinitis (hayfever) is common and can contribute to a considerable reduction in the quality of life of adolescents. This study aims to examine the effectiveness of standardised allergy training for healthcare professionals in improving disease-specific quality of life in adolescents with hayfever. METHODS/DESIGN: Adolescents with a history of hayfever registered in general practices in Scotland and England were invited to participate in a cluster randomised controlled trial. The unit of randomisation is general practices.The educational intervention for healthcare professionals consists of a short standardised educational course, which focuses on the management of allergic rhinitis. Patients in the intervention arm of this cluster randomised controlled trial will have a clinic appointment with their healthcare professional who has attended the training course. Patients in the control arm will have a clinic appointment with their healthcare professional and will receive usual care. The primary outcome measure is the change in the Rhinoconjunctivitis Quality of Life Questionnaire with Standardised Activities (RQLQ(S)) score between baseline and six weeks post-intervention in the patient intervention and control groups. Secondary outcome measures relate to healthcare professionals' understanding and confidence in managing allergic rhinitis, changes in clinical practice, numbers of consultations for hayfever and adolescent exam performance.A minimum of 11 practices in each arm of the trial (10 patients per cluster) will provide at least 80% power to demonstrate a minimal clinically important difference of 0.5 in RQLQ(S) score at a significance level of 5% based on an Intraclass Correlation Coefficient (ICC) of 0.02. DISCUSSION: At the time of submission, 24 general practices have been recruited (12 in each arm of the trial) and the interventions have been delivered. Follow-up data collection is complete. 230 children consented to take part in the trial; however complete primary outcome data are only available for 160. Further recruitment of general practices and patients will therefore take place in the summer of 2010. TRIAL REGISTRATION: Current Controlled Trials ISRCTN95538067.

A randomised control trial of the effectiveness of personalised letters sent subsequent to school dental inspections in increasing registration in unregistered children.

BACKGROUND: Recent studies have cast doubt on the effectiveness and efficiency of school based dental screening programmes in improving dental attendance or improving dental health. In 2002 the National Dental Inspection Programme was introduced in Scotland which categorises children by their dental health and informs parents of the findings via a personalised letter home and encourages dental registration. In addition, epidemiological data for local and national planning purposes is collected. This replaced an earlier school screening system in Lothian where a generic letter urging registration was sent to children who were identified as not being registered with a dentist. The objective of this study is to compare dental registrations rates among unregistered children in these two school inspection systems with a system where letters were sent home but no dental inspection was carried out. METHODS: The study was designed as a single blinded, cluster randomised, controlled trial involving 12,765 12-13-year-old children attending all 65 state Secondary schools in Lothian and Fife during the academic year 2003/4.After stratifying for school size and range of social deprivation, schools were randomly allocated to one of four groups:1. 'Traditional' inspection, letter to unregistered children only,2. Letter sent home to unregistered children only, no inspection,3. National Dental Inspection Programme, letter to all children,4. Control group in which the children were neither inspected nor sent a letter.Dental Registration status was compared at baseline and 3 months post inspection. RESULTS: The registration levels in both the 'Traditional' screening and the NDIP inspection groups rose 3 months post inspection (14% and 15.8% respectively) but were not significantly different from one another or the control group which rose by 15.8% (p > 0.05). The group who were sent a letter home but were not inspected also has a rise in registration levels of 18.1% which was not significantly different from either of the groups who were inspected or the control group (p > 0.05). The only significant predictors of registration were previous registration (p < 0.05) and within those who previously registered, the length of time since last registration (P < 0.001). CONCLUSION: Neither of the two dental inspection methods nor a letter home to unregistered children resulted in a significant rise in registration rates in 12-13-year-olds compared to a control group of children who received no intervention.

What factors affect medication-storage practice among patients on methadone maintenance treatment?

OBJECTIVES: Medication storage in patients' homes is an important safety issue. Safe storage of methadone oral solution is of particular concern. Previous studies have suggested that only about half of patients store methadone appropriately. The aims of this study were to describe medication-storage practice in a sample of patients receiving methadone maintenance treatment (MMT), and to identify factors associated with safe storage. METHODS: The setting was a primary health care centre in Edinburgh, Scotland. One hundred and four consecutive patients on MMT completed a self-administered questionnaire covering medication-storage practice, together with clinical and demographic variables. Storage of medication was classified as 'acceptable' if medication was out of sight and out of reach of children, and 'optimal' if it was also kept in a secure container. KEY FINDINGS: Percentages (95% confidence intervals) for acceptable and optimal storage were as follows: methadone 80% (71-86%) and 33% (24-42%); other prescribed medication 69% (59-78%) and 27% (19-37%); purchased medication 64% (50-76%) and 28% (17-42%). Safe storage of methadone was more common in patients taking higher doses of methadone (P = 0.004 for acceptable storage, and P = 0.012 for optimal storage), and in those with children in the house (P = 0.007 and 0.061). Safe storage of prescribed and purchased medication was strongly associated with safe storage of methadone (P < 0.01 in both cases). CONCLUSIONS: Medication-storage practice was better than in previous surveys of patients on MMT. This may reflect the high profile given to safety issues for children of drug-using parents in Scotland, as well as local initiatives. Some aspects of prescribing and dispensing practice could be improved further.

What factors affect medication-storage practice among patients on methadone maintenance treatment?

OBJECTIVES: Medication storage in patients' homes is an important safety issue. Safe storage of methadone oral solution is of particular concern. Previous studies have suggested that only about half of patients store methadone appropriately. The aims of this study were to describe medication-storage practice in a sample of patients receiving methadone maintenance treatment (MMT), and to identify factors associated with safe storage. METHODS: The setting was a primary health care centre in Edinburgh, Scotland. One hundred and four consecutive patients on MMT completed a self-administered questionnaire covering medication-storage practice, together with clinical and demographic variables. Storage of medication was classified as 'acceptable' if medication was out of sight and out of reach of children, and 'optimal' if it was also kept in a secure container. KEY FINDINGS: Percentages (95% confidence intervals) for acceptable and optimal storage were as follows: methadone 80% (71-86%) and 33% (24-42%); other prescribed medication 69% (59-78%) and 27% (19-37%); purchased medication 64% (50-76%) and 28% (17-42%). Safe storage of methadone was more common in patients taking higher doses of methadone (P = 0.004 for acceptable storage, and P = 0.012 for optimal storage), and in those with children in the house (P = 0.007 and 0.061). Safe storage of prescribed and purchased medication was strongly associated with safe storage of methadone (P < 0.01 in both cases). CONCLUSIONS: Medication-storage practice was better than in previous surveys of patients on MMT. This may reflect the high profile given to safety issues for children of drug-using parents in Scotland, as well as local initiatives. Some aspects of prescribing and dispensing practice could be improved further.

Do quality incentives change prescribing patterns in primary care? An observational study in Scotland.

BACKGROUND: The 2004 General Medical Services (GMS) contract introduced financial incentives for the management of chronic illnesses in 10 clinical areas. The effect of the scheme on prescribing is unknown. OBJECTIVES: To quantify the impact of the latest GMS contract, which incorporates additional payments for quality outcomes, on prescribing patterns in GP practices. METHODS: This retrospective observational study of prescribing compared the defined daily doses (DDDs) for drugs mentioned or implied within the Quality and Outcomes Framework (QOF) of the latest GMS contract (QOF drugs) to the DDDs for all other drugs listed within the first 10 chapters on the British National Formulary (non-QOF drugs) for four financial years; two before and two after the introduction of the latest GMS contract. These measures were calculated for 92 GP practices of 100 in the Lothian region of Scotland, and the rate of change of prescribing was calculated from regression slopes within the log-scale interrupted time series analyses. RESULTS: The prescribing of QOF drugs increased significantly faster than the non-QOF drugs both before and after the introduction of the latest GMS contract but the rate of increase for the QOF drugs slowed significantly after April 2005 unlike prescribing of non-QOF drugs. CONCLUSIONS: The prescribing of relevant drugs increased before the introduction of the 2004 GMS contract; the increase continued in the first 2 years of the new contract but at a significantly lower level.

Severe receptive language disorder in childhood--familial aspects and long-term outcomes: results from a Scottish study.

BACKGROUND AND AIMS: Little is known about the familial characteristics of children with severe receptive specific language impairment (SLI). Affected children are more likely to have long-term problems than those with expressive SLI but to date they have only been described as small cohorts within SLI populations. We therefore aimed to describe the clinical and familial characteristics of severe receptive SLI as defined by a rigorous phenotype and to establish whether non-word repetition showed a relationship with language impairment in these families. METHODS: Cross-sectional study of children who met ICD-10 (F80.2) criteria for receptive SLI at school entry, their siblings and genetic parents with standardised measures of language and non-verbal IQ, phonological auditory memory and speech sound inventory. RESULTS: At a mean of 6 years after school entry with a severe receptive SLI, the 58 participants had a normal mean and standard deviation non-verbal IQ, but only 3% (two) had attained language measures in the normal range. One third still had severe receptive language impairment. One third of siblings not known to be affected had language levels outside the normal range. Phonological auditory memory was impaired in most family members. CONCLUSION: Severe receptive SLI is nearly always associated with an equally severe reduction in expressive language skills. Language impairment in siblings may go undetected and yet they are at high risk. Family members had weak phonological auditory memory skills, suggesting that this could be a marker for language acquisition difficulties. Receptive SLI rarely resolves and trials of therapy are urgently needed.

A diurnal variation in testicular hormone production is maintained following gonadotrophin suppression in normal men.

OBJECTIVE: A diurnal variation in serum testosterone in adult men is well recognized, but whether this occurs during exogenous testosterone administration and the degree to which it is endogenous to the testis is unclear. DESIGN: A clinical research centre investigation of testicular function in normal men. PATIENTS: Twenty normal men were recruited, 10 of whom were investigated during administration of testosterone with etonogestrel to suppress gonadotrophin secretion. MEASUREMENTS: Hourly blood samples were taken over 24 h for measurement of testosterone, inhibin B, LH, FSH and cortisol. Urinary excretion of testosterone and the testicular steroid epitestosterone was also measured. RESULTS: In the controls, a diurnal variation in serum testosterone and LH but not FSH was detected. The treated group had similar testosterone concentrations but showed no diurnal variation. Periodicity was also detected in inhibin B concentrations in 5 of the controls and in 9 of the treated group, who also showed synchrony not seen in the controls. Both groups showed diurnal variation in cortisol. Urinary testosterone excretion did not show a diurnal variation in either group, but this was apparent for epitestosterone with a morning peak in both groups despite the markedly lower excretion in the treated men. CONCLUSIONS: The diurnal variation of testosterone in normal men is due to a change in secretion rather than in clearance and is largely LH driven. An endogenous rhythm in both testicular steroidogenesis (epitestosterone) and Sertoli cell function (inhibin B) is also present.

Impact on hypertension control of a patient-held guideline: a randomised controlled trial.

BACKGROUND: Hypertension is generally poorly controlled in primary care. One possible intervention for improving control is the harnessing of patient expertise through education and encouragement to challenge their care. AIM: To determine whether encouraging patients to manage their hypertension in an 'expert' manner, by providing them with information in a clear clinical guideline, coupled with an explicit exhortation to become involved in and to challenge their own care if appropriate, would improve their care. DESIGN OF STUDY: Single blind randomised controlled trial of detailed guideline versus standard information. SETTING: Single urban general practice over 1 year. METHOD: Patient-held guideline with written explicit exhortation to challenge care when appropriate. Two hundred and ninety-four of 536 eligible patients on the practice hypertension register were recruited, all of whom were randomised into one of two groups. Two hundred and thirty-six patients completed the study. PRIMARY OUTCOME: average systolic blood pressure. SECONDARY OUTCOMES: proportion of patients with blood pressure < 150 mmHg systolic and < 90 mmHg diastolic, average cholesterol, proportion of patients prescribed statins and aspirin according to guideline, hospital anxiety and depression score. No clinically, or statistically significant differences were found between intervention and control with respect to all parameters or in anxiety and depression levels. Statin and aspirin use improved throughout the course of the study in both groups. Statin use showed a trend (P = 0.02) in favour of control. CONCLUSION: In this study there was no clinically significant perceived benefit to patients as a result of providing them with a hypertension guideline. Patient guidelines are currently planned for many chronic illnesses. It is important to determine the utility of such interventions before scarce resources are applied to them.

Predicting colorectal cancer risk in patients with rectal bleeding.

BACKGROUND: Rectal bleeding is an important symptom of colorectal cancer but has low predictive value in primary care. AIM: To determine which characteristics of rectal bleeding, along with other factors, are predictive of colorectal cancer. DESIGN OF STUDY: Observation study of patients with rectal bleeding referred to an open-access diagnostic clinic. SETTING: Primary care, southern England. METHOD: Symptom data were collected, using a self-completed questionnaire. Logistic regression techniques were used to determine predictors of colorectal cancer. RESULTS: There were 604 patients in the study and 22 (3.6%, 95% confidence interval [CI] = 2.0% to 5.2%) were diagnosed with colorectal cancer. Significant predictors of colorectal cancer were found to be age (<50 years: odds ratio [OR] = 1; 50-69 years: OR = 5.1, 95% CI = 1.4 to 18.6; > or = 70 years: OR = 8.2, 95% CI = 2.1 to 31.8) and blood mixed with the stool (Likelihood ratio [LR] 1.5; adjusted OR = 3.8; 95% CI = 1.4 to 10.5). Presence of haemorrhoids associated with bright red bleeding not mixed with stool reduced the likelihood of cancer (OR = 0.4, 95% CI = 0.1 to 1.2) but did not eliminate it--a cancer was present in 2% of patients with these symptoms. CONCLUSION: Patient-reported type of rectal bleeding as an isolated symptom has insufficient diagnostic value to be useful in general practice. By studying referred patients, we may even have overestimated its value. At best, it could be useful as a component of a composite symptom score to guide referral decisions.

Hepatitis B vaccination and injecting drug users.

This study seeks to test the feasibility of vaccinating injecting drug users for hepatitis B in primary care and to identify predictors of poor immune response. Two hundred and seventy-five injecting drug users were identified from the case notes of a large general practice in an area of high multiple deprivation in northwest Edinburgh and, where appropriate, offered hepatitis B vaccination followed by a post-vaccination serological test. We concluded that hepatitis B vaccination of drug users in primary care is both feasible and effective. This study was unable to identify a group at risk of vaccine failure, however, it found post-vaccination serological testing to be problematic and potentially misleading. Therefore, we would not recommend its routine use in a primary care setting. Significantly, prolonged primary courses were not associated with reduced efficacy. The findings indicate that an appropriate vaccination schedule for primary care should be flexible to maximise compliance.

Changing patterns in causes of death in a cohort of injecting drug users, 1980-2001.

BACKGROUND: High mortality among drug users has been widely recognized. This study investigates, in a large family practice of 10 000 patients in Edinburgh, Scotland, whether there has been a change in causes of mortality over time. Patients known to have ever injected drugs were recruited into a cohort study from 1980 until 2001. METHODS: Death certificates and clinical notes were scrutinized and data relating to demographic features, drug use, and causes of death were recorded. RESULTS: Of 667 patients, there were 153 deaths at follow-up (110 men and 43 women). Average annual mortality rate was 2.3%. Death rate peaked in the early to mid-1990s, reflecting the development of advanced human immunodeficiency virus (HIV) from the early epidemic in 1982-1984 and the onset of the effect of antiviral chemotherapy. Drug deaths and suicide were the same in both sexes but tended to occur in younger subjects. Principal cause of death was overdose in the early years and HIV/AIDS in later years. Toward the close of the study period, hepatitis C emerged as a cause of death. CONCLUSIONS: Injecting drug users have a very high risk of mortality. Infectious diseases from nonsterile injecting are the most obvious preventable cause of death. Use of death certificate information alone is inaccurate in analyzing drug-related deaths and greatly underestimates the full impact of the HIV epidemic. This study provides some of the most convincing evidence so far that harm minimization, in its broadest sense, is effective in reducing drug-related mortality.

A randomised controlled trial of senior Lay Health Mentoring in older people with ischaemic heart disease: The Braveheart Project.

OBJECTIVE: to examine the effects and feasibility of educating and empowering older people with ischaemic heart disease using trained senior lay health mentors. DESIGN: randomised controlled trial with blinded evaluation. SETTING: Falkirk and District Royal Infirmary. PARTICIPANTS: inpatients and outpatients aged 60 or over attending secondary care with a diagnosis of angina or acute myocardial infarction. Three-hundred and nineteen entered and 289 completed exit assessments. The intervention group took part in mentoring groups for 1 year, meeting monthly for 2 hours, each led by two trained lay health mentors in addition to standard care. MAIN OUTCOME MEASURES: primary outcome measures were changes in coronary risk factors, medication usage and actual use of secondary care health services. Secondary outcomes were total and cardiovascular events; changes in medication compliance, non-medical support requirement, health status and psychological functioning, and social inclusion. RESULTS: there were significant improvements in a reported current exercise score (mean +0.33, +0.02 to +0.52), in the average time spent walking per week by 72 minutes (+1 to +137 minutes), and in the SF36 Physical Functioning Score (+6.1, +2.4 to +9.5). There was a 1.0% reduction in total fat (95% CI -3.0% to -0.6%) and a 0.6% reduction in saturated fat (95% CI -1.5% to -0.03%). The intervention group showed reduced outpatient attendance for coronary heart disease (-0.25 appointments, -0.61 to -0.08). Attendance rates were high. Socio-economic grouping did not affect participation. CONCLUSIONS: Lay Health Mentoring is feasible, practical and inclusive, positively influencing diet, physical activity, and health resource utilisation in older subjects with ischaemic heart disease without causing harm.