BabyGel pilot: a pilot cluster randomised trial of the provision of alcohol handgel to postpartum mothers to prevent neonatal and young infant infection-related morbidity in the community.

BACKGROUND: Alcohol-based hand rub (ABHR) is widely used in both health and social facilities to prevent infection, but it is not known whether supplying it for regular perinatal use can prevent newborn sepsis in African rural homes. Our study piloted a cluster randomised trial of providing ABHR to postpartum mothers to prevent neonatal infection-related morbidity in the communities. METHODS: We conducted a pilot parallel cluster randomised controlled trial across ten villages (clusters) in rural Eastern Uganda. Pregnant women of over 34 weeks' gestation were recruited over a period of 3 months. Both clusters received the standard of care of antenatal health education, Maama Kit, and clinic appointments. In addition, women in the intervention villages received ABHR, instructions on ABHR use, a poster on the 'three moments of hand hygiene', and training. We followed up each mother-baby pair for 3 months after birth and measured rates of consent, recruitment, and follow-up (our target rate was more than 80%). Other measures included ABHR use (the acceptable use was more than four times a day) and its mode of distribution (village health workers (VHWs) or pharmacy), acceptability of study protocol and electronic data capture, and the use of WHO Integrated Management of Childhood Illness (IMCI) tool to screen for newborn infection. RESULTS: We selected 36% (10/28) of villages for randomisation to either intervention or control. Over 12 weeks, 176 pregnant women were screened and 58.5% (103/176) were eligible. All, 100% (103/103), eligible women gave consent and were enrolled into the trial (55 intervention and 48 control). After birth, 94.5% (52/55) of mothers in the intervention and 100% (48/48) of mothers in the control villages were followed up within 72 h. Most, 90.9% (50/55), of the mothers in the intervention villages (96.2% of live births) and 95.8% (46/48) of mothers in the control villages (95.9% of live births) were followed up at 3 months. In intervention villages, the average hand rub use was 6.6 times per day. VHWs accounted for all ABHR stock, compared to the pharmacy that could not account for 5 l of ABHR. The screening tool was positive for infection among a third of babies, i.e. 29.2% (14/48) in the intervention villages versus 31.4% (16/51) in the control villages.VHWs completed the first four questions of IMCI screening tool with ease and accuracy. There were no adverse reactions with the ABHR. CONCLUSION: It is feasible to conduct a cluster-randomised controlled trial (cRCT) of the provision of ABHR to postpartum mothers to prevent neonatal infection-related morbidity in the community in resource-poor settings. Our results indicate that home recruitment promotes excellent follow-up and retention of participants in community trials. The intervention was safe. This pilot study informed the substantial changes necessary in the larger cRCT, including a change in the primary outcome to a composite outcome considering multiple methods of infection detection. A large BabyGel cluster randomised controlled trial is now required. TRIAL REGISTRATION: ISRCTN67852437, registered March 02, 2015. TRIAL FUNDING: Medical Research Council/WellcomeTrust/DfID (Global Health Trials Scheme).

In search of a primary outcome for community-based newborn infection trials in Eastern Uganda: a nested cohort study within the BabyGel pilot trial.

BACKGROUND: Due to their immature immune system, neonates are at high risk of infection. This vulnerability when combined with limited resources and health education in developing countries can lead to sepsis, resulting in high global neonatal mortality rates. Many of these deaths are preventable. The BabyGel pilot trial tested the feasibility of conducting the main randomised trial, with the provision of alcohol handgel to postpartum mothers for prevention of neonatal infective morbidity in the rural community. This secondary analysis sought to evaluate the methods of detecting infections in babies up to 3 months of age. METHODS: The pilot two-arm cluster randomised controlled trial took place in 10 villages around Mbale, Eastern Uganda. Women were eligible and recruited antenatally if their gestation was ≥ 34 weeks. All infants of mothers participating in the BabyGel pilot trial were followed up for the first 3 months of life. Evidence for infant infection was collected using five different methods: clinician diagnosed infection, microbiologically confirmed infection, maternally reported infection, a positive infection screen using the World Health Organization (WHO) Integrated Management of Childhood Illness (IMCI) screening criteria, and reported antibiotic use identified during home and clinic visits. These methods were assessed quantitatively regarding the detection rates of suspected infections and qualitatively by exploring the challenges collecting data in the rural community setting. RESULTS: A total of 103 eligible women participated in the BabyGel pilot trial, with 1 woman delivering twins. Of the 99 mother-infant pairs who consented to participate in the study, 55 infants were identified with infection in total. Maternal report of illness provided the highest estimate, with mothers reporting suspected illness for 45 infants (81.8% of the total suspected infections identified). The WHO IMCI screening criteria identified 30 infants with suspected infection (54.5%), and evidence for antibiotic use was established in 22 infants (40%). Finally, clinician-diagnosed infection identified 19 cases (34.5%), which were also microbiologically confirmed in 5 cases (9.1%). Data collection in the rural setting was hindered by poor communication between mothers and the research team, limited staff awareness of the study in health centres resulting in reduced safeguarding of clinical notes, and widespread use of antibiotics prior to notification and clinical review. Furthermore, identification of suspected infection may not have been limited to severe infections, with ambiguity and no official clinical diagnosis being given to those identified solely by maternal report of infection. CONCLUSIONS: A high rate of suspected infection was identified spanning the five sources of data collection, but no ideal method was found for detection of community neonatal infection. Although maternal self-reports of infant infection provided the highest detection rate, data collection via each source was limited and may have identified minor rather than major infections. Future studies could utilise the IMCI screening tool to detect severe community infection leading to referral for clinical confirmation. This should be combined with weekly contact with mothers to detect maternally suspected illness. Obtaining more details of the symptoms and timescale will improve the accuracy when detecting the total burden of suspected disease, and advising participants to retain medication packaging and prescriptions will improve identification of antibiotic use. TRIAL REGISTRATION: Babygel pilot trial - trial registration: ISCRCTN 67852437. Registered 02/03/2015.

Hypoadrenalism is not associated with early mortality during tuberculosis treatment in Malawi.

SETTING: In the developing world, early mortality within 1 month of commencing tuberculosis (TB) treatment is high, particularly with human immunodeficiency virus (HIV) co-infection. In Malawi, 40% of those who die do so in the first month of treatment. Reasons remain unclear and may include delayed diagnosis, opportunistic infections, immune restoration inflammatory syndrome (IRIS) or malnutrition. One possible contributing factor is underlying hypoadrenalism associated with TB-HIV, exacerbated by rifampicin (RMP) induction of P450 and glucocorticoid metabolism. OBJECTIVE: To assess the prevalence of hypoadrenalism in TB patients before and after commencement of TB treatment, and relationship with early mortality. DESIGN: Prospective descriptive study assessing hypoadrenalism before and after anti-tuberculosis treatment, HIV status and outcome up to 3 months post-treatment. RESULTS: Of 51 patients enrolled, 29 (56.9%) were female (median age 32 years, range 18-62). Of 43 patients HIV-tested, 38 (88.3%) were HIV-positive and 15.7% died within the first month. At 3 months, 11 (21.6%) were known to have died. Adequate cortisol levels were found in 49/51 (95.9%) before commencing RMP. Neither of the two with reduced response died. All 34 patients revealed adequate cortisol responses at 2 weeks. CONCLUSION: No evidence of hypoadrenalism was found in this first study to assess adrenal function and outcome of anti-tuberculosis treatment.

The relationship between job satisfaction and health: a meta-analysis.

BACKGROUND: A vast number of published studies have suggested a link between job satisfaction levels and health. The sizes of the relationships reported vary widely. Narrative overviews of this relationship have been published, but no systematic meta-analysis review has been conducted. METHODS: A systematic review and meta-analysis of 485 studies with a combined sample size of 267 995 individuals was conducted, evaluating the research evidence linking self-report measures of job satisfaction to measures of physical and mental wellbeing. RESULTS: The overall correlation combined across all health measures was r = 0.312 (0.370 after Schmidt-Hunter adjustment). Job satisfaction was most strongly associated with mental/psychological problems; strongest relationships were found for burnout (corrected r = 0.478), self-esteem(r = 0.429), depression (r = 0.428), and anxiety(r = 0.420). The correlation with subjective physical illness was more modest (r = 0.287). CONCLUSIONS: Correlations in excess of 0.3 are rare in this context. The relationships found suggest that job satisfaction level is an important factor influencing the health of workers. Organisations should include the development of stress management policies to identify and eradicate work practices that cause most job dissatisfaction as part of any exercise aimed at improving employee health. Occupational health clinicians should consider counselling employees diagnosed as having psychological problems to critically evaluate their work-and help them to explore ways of gaining greater satisfaction from this important aspect of their life.

Does apolipoprotein E polymorphism influence susceptibility to malaria?

Outcome of infection varies greatly among people, and in the case of three very different viruses, it is determined by apolipoprotein E (APOE) genotype. APOE might affect outcome of malaria infection also, since apoE protein and the protozoon (like the viruses) share cell entry mediators (heparan sulphate proteoglycans and/or specific apoE receptors). APOE polymorphisms give rise to protein variants that differ in binding strength to these mediators; thus, the extent of competition between apoE and protozoon for cell entry, and hence magnitude of protozoan damage, might depend on apoE isoform. Genotypes of infants infected with malaria were examined. It was found that APOE epsilon 2 homozygotes became infected at an earlier age than those carrying the other genotypes, the difference being statistically significant. Parasite densities, all of which were low, did not differ significantly. This effect, although based on small numbers, suggests that APOE epsilon 2 may be a risk factor for early infection.

Carotid sinus nerve blockade during carotid surgery: a randomised controlled trial.

OBJECTIVES: we investigated whether carotid sinus nerve infiltration with lignocaine reduced blood pressure lability during the first 24h following carotid endarterectomy (CEA). DESIGN: prospective randomised double-blind controlled trial. MATERIALS: eighty patients undergoing CEA for significant symptomatic stenosis of the internal carotid artery. METHODS: after initial dissection, 5 ml of 1% lignocaine or normal saline placebo according to randomisation was infiltrated around the carotid sinus nerve. Blood pressure was measured by intra-arterial cannula during surgery and for four hours afterwards every 15 min, then manually, hourly for 18 h. RESULTS: patients having excision of the carotid sinus nerve were grouped separately for analysis: 29 patients had lignocaine, 33 placebo and 17 excision (one early death with incomplete data was excluded). Mean systolic, diastolic and pulse pressures did not differ significantly between the three groups before carotid sinus nerve infiltration. After infiltration, those patients who had carotid sinus nerve excision, had significantly higher systolic [mean (SD)=155 (16)mmHg] and diastolic [75 (9)mmHg] pressures than those receiving LA [systolic=136 (15)mmHg, diastolic=65 (10)mmHg] or placebo [systolic=136 (19)mmHg, diastolic=65 (9)mmHg], (p<0.005 ANOVA). Nerve excision also resulted in wider variability of blood pressure as defined by the mean of individual standard deviations (systolic=25 mmHg, diastolic=13 mmHg) compared to LA (systolic=19 mmHg, diastolic=12 mmHg) or placebo (systolic=18 mmHg, diastolic=10 mmHg) (p<0.05 ANOVA). Normotensive patients had significantly lower mean diastolic pressures (p<0.001 ANOVA) and variability (p<0.05) if they received lignocaine although this did not influence pulse pressure. CONCLUSIONS: lignocaine injection of the carotid sinus nerve has no benefit in those patients with existing treated hypertension and only marginal effects in normotensives. It is more important to preserve the carotid sinus nerve if possible.

Knowledge and attitudes in multicultural health care.

Health professionals' knowledge of ethnic minority cultures and lifestyles was assessed to determine whether the respondents' cultural background and experience of working with ethnic minorities affected the health care delivered by them and to assess the need for training. Improving access to health services for ethnic minorities requires continuing education and training of all health professionals.

Cerebral injury during cardiopulmonary bypass: emboli impair memory.

OBJECTIVES: Cognitive deficits occur in up to 80% of patients after cardiac surgery. We investigated the influence of cerebral perfusion and embolization during cardiopulmonary bypass on cognitive function and recovery. METHODS: Cerebrovascular reactivity was measured in 70 patients before coronary operations in which nonpulsatile bypass was used. Throughout the operations, middle cerebral artery flow velocity and embolization were recorded by transcranial Doppler and regional oxygen saturation was recorded by near-infrared spectroscopy. Cognitive function was measured by a computerized battery of tests before the operation and 1 week, 2 months, and 6 months after surgery. Elderly patients undergoing urologic surgery served as controls. RESULTS: Cerebrovascular reactivity was impaired preoperatively in 49 patients. Median (interquartile range) regional cerebral oxygen saturation fell during bypass by 10% (6%-15%), indicating increased oxygen extraction, whereas mean middle cerebral flow velocity increased significantly by a median of 6 cm/s (both P <.0001, Wilcoxon), suggesting increased arterial tone. More than 200 emboli were detected in 40 patients, mainly on aortic clamping and release, when bypass was initiated, and during defibrillation. Cognitive function deteriorated more in patients having cardiopulmonary bypass than in control patients having urologic operations but recovered in most tests by 2 months. Measures of cerebral perfusion (poor cerebrovascular reactivity, low arterial pressures, and flow velocity in the middle cerebral artery) predicted poor attention at 1 week (r = 0.3, P <.01, Spearman). Emboli were associated with memory loss (r = 0.3, P <.02, Spearman). CONCLUSIONS: Cognitive deficits were common after cardiopulmonary bypass. Occult cerebrovascular disease was more severe than expected and predisposed to attention difficulties, whereas emboli caused memory deficits. We believe this to be the first report of differing cognitive effects from emboli and hypoperfusion.

Unpacking the black box of nursing and therapy practice for post-stroke shoulder pain: a precursor to evaluation.

OBJECTIVES: To describe current nursing and therapy interventions for the prevention and treatment of post-stroke shoulder pain and to explore the extent of their reported use in England. DESIGN: Semi-structured, the med interviews followed by a postal questionnaire. PARTICIPANTS: Six nurses, five occupational therapists (OTs) and six physiotherapists (PTs) were interviewed. Twelve nurses, 12 OTs and 12 PTs were sent the pilot questionnaire and the main questionnaire was posted to 332 nurses, 332 OTs and 332 PTs. SETTING: NHS Trusts in England which provide acute stroke care/rehabilitation. PROCEDURE: Two researchers independently condensed the transcripts of the interviews into a list of interventions which were then transformed into a pilot postal questionnaire. Following the pilot small changes were made. Participants sent the main questionnaire were given three weeks to return it before being posted a reminder. After a further two weeks a researcher gave a telephone reminder. RESULTS: One hundred and seventy-five different types of interventions were identified. The main questionnaire (57.8% response rate) found that all of the interventions were used by at least one respondent and that only 22.9% of the interventions were used to the same extent by nurses, OTs and PTs. The data also suggest variation in reported use within professions. CONCLUSIONS: This study has found a large number of interventions for post-stroke shoulder pain which are reported to be used. This might reflect different causes of shoulder pain or variation between clinicians. Answers to these questions are expected to guide future evaluative research.

Reliability of a measure of post-stroke shoulder pain in patients with and without aphasia and/or unilateral spatial neglect.

OBJECTIVE: To determine the inter/intra-rater reliability of expert physiotherapists (PTs) measuring post-stroke shoulder pain with 100 mm vertical visual analogue scales (VAS; intensity, frequency and affective response) and a categorical site-of-pain scale. DESIGN: Three PTs independently rated subjects (normal clinical procedure but with a standardized starting position) on three days, at the same time of day, during one week in a randomized order determined by a nested latin square. Reliability for VAS scores was determined with the intraclass correlation coefficient (ICC) and for site-of-pain with the kappa statistic (kappa). Acceptable reliability was set at 0.75. The limits of agreement were also calculated. SETTING: Community. SUBJECTS: Thirty-three patients, mean time post stroke 42 months (range 7-360). RESULTS: Mean inter-rater reliability was 0.79 for intensity, 0.75 for frequency and 0.62 for affective response (ICC). The limits of agreement were wide and rater bias was significant for 6/27 ratings. Mean intra-rater reliability was 0.70 for intensity, 0.77 for frequency and 0.69 for affective response (ICC). For site-of-pain inter-rater reliability ranged from 0.156 (kappa) to 0.385 (kappa) and intrarater reliability ranged from 0.300 (kappa) to 0.559 (kappa). CONCLUSIONS: Although inter-rater reliability was acceptable for intensity and frequency there was a consistently large systematic bias between pairs of raters. Agreement might be improved if a standardized assessment procedure was used and/or if training in pain behaviour interpretation was provided.

Building sickness syndrome in healthy and unhealthy buildings: an epidemiological and environmental assessment with cluster analysis.

OBJECTIVES: Building sickness syndrome remains poorly understood. Aetiological factors range from temperature, humidity, and air movement to internal pollutants, dust, lighting, and noise factors. The reported study was designed to investigate whether relations between symptoms of sick building syndrome and measured environmental factors existed within state of the art air conditioned buildings with satisfactory maintenance programmes expected to provide a healthy indoor environment. METHODS: Five buildings were studied, three of which were state of the art air conditioned buildings. One was a naturally ventilated control building and one a previously studied and known sick building. A questionnaire was administered to the study population to measure the presence of building related symptoms. This was followed by a detailed environmental survey in identified high and low symptom areas within each building. These areas were compared for their environmental performance. RESULTS: Two of the air conditioned buildings performed well with a low prevalence of building related symptoms. Both of these buildings out performed the naturally ventilated building for the low number of symptoms and in many of the environmental measures. One building (C), expected to perform well from a design viewpoint had a high prevalence of symptoms and behaved in a similar manner to the known sick building. Environmental indices associated with symptoms varied from building to building. Consistent associations between environmental variables were found for particulates (itchy eyes, dry throat, headache, and lethargy) across all buildings. There were persisting relations between particulates and symptoms (headache, lethargy, and dry skin) even in the building with the lowest level of symptoms and of measured airborne particulates (building B). There were also consistent findings for noise variables with low frequency noise being directly associated with symptoms (stuffy nose, itchy eyes, and dry skin) and higher frequency noise being relatively protective across all buildings. CONCLUSIONS: This is the first epidemiological study of expected state of the art, air conditioned buildings. These buildings can produce an internal environment better than that of naturally ventilated buildings for both reported symptoms and environmental variables. The factors associated with symptoms varied widely across the different buildings studied although consistent associations for symptoms were found with increased exposure to particulates and low frequency noise.

The unreliability of clinical measures of muscle tone: implications for stroke therapy.

BACKGROUND: the central tenet of the neurofacilitatory approach to stroke therapy is that muscle tone needs to be normal before normal movement can occur. A reliable clinical measure of the full spectrum of muscle tone is needed to test: (i) the purported relationship between muscle tone, other motor impairments and disability, and (ii) the effectiveness of stroke therapy to restore movement. AIM: the purpose of the study was to test the inter-rater reliability of clinical categorization of muscle tone (spastic/normal/flaccid) and also a visual analogue scale with anchor points of 'lowest tone possible' (score 0) and 'highest tone possible' (score 100). METHODS: four independent raters assessed tone of elbow flexors and knee extensors of 14 stroke rehabilitation inpatients using the categorical scale. Six independent raters assessed tone of elbow flexors and knee extensors of 25 chronic stroke patients and two healthy volunteers using the visual analogue scale. All assessment orders were randomized. RESULTS: both scales were unreliable, with K coefficients for the categorical scale ranging from -0.046 to 0.56 for the categorical scale, and intra-class correlation coefficients for the visual analogue scale of 0.595 for elbow flexors and 0.451 for knee extensors. Assessment order effects for the visual analogue scale were non-significant for elbow flexors (P= 0.545) and knee extensors (P= 0.911). CONCLUSIONS: these results, and those of earlier studies, suggest that clinical measures of muscle tone are consistently unreliable. Systematic investigation of the therapy rationale for planning and evaluating treatment is required before relevant clinical measures can be developed.

The effect of body position on arterial oxygen saturation in acute stroke.

BACKGROUND: Evidence suggests that respiratory function is impaired poststroke. Body position is known to influence respiratory function in normal subjects and those with respiratory pathologies. Its effect on respiratory function after stroke has received little attention. However, one study suggests that some positions used in clinical practice may adversely influence respiratory function. This study therefore aimed to identify resting positions that maintain arterial oxygen saturation (SaO2) at optimal levels, changes in SaO2 during time spent in the test position, and differences in SaO2 among the positions investigated. METHOD: A within-subject, two-center clinical study was made. Patients in the first 72 hours following mild to moderately severe stroke were allocated a randomized sequence of four positions. One hour was spent in each position. SaO2 was recorded each minute by pulse oximetry with a finger probe. Mean values for the hour were calculated. RESULTS: Mean arterial oxygen saturation values for all patients were >90% for the hour spent in each test position for all patients. There were no changes in arterial oxygen saturation across the hour spent in the test positions (repeated-measures analysis of variance). No differences in arterial oxygen saturation were identified among positions (analysis of covariance). DISCUSSION: The saturation levels recorded corresponded to those observed in studies of normal elderly persons. The positions tested may be recommended for use in clinical practice to maintain arterial oxygen saturation in patients in the first 72 hours following mild to moderately severe stroke.

Response variability in the visual field: comparison of optic neuritis, glaucoma, ocular hypertension, and normal eyes.

PURPOSE: To compare the relationship between sensitivity and response variability in the visual field of normal eyes and eyes with optic neuritis (ON), glaucoma (POAG), and ocular hypertension (OHT). METHODS: Frequency-of-seeing (FOS) data were collected from four visual field locations in one eye of 71 subjects (12 ON, 25 POAG, 11 OHT, and 23 normal), using a constant stimulus method on an Henson 4000 perimeter (Tinsley Instruments, Croydon, UK). At each location, at least 20 stimuli (subtending 0.5 degrees) were presented for 200 ms at six or more intensities above and below the estimated threshold. The mean and SD of the probit fitted cumulative Normal function were used to estimate sensitivity and response variability. Cluster regression analysis was carried out to determine whether there were differences in the sensitivity-log (variability) relationship between the four groups. RESULTS: Variability was found to increase with decreased sensitivity for all four groups. The combined data from the four groups was well represented (R2 = 0.57) by the function log(e)(SD) = A.sensitivity (dB) + B, where the constants A and B were -0.081 (SE, +/-0.005) and 3.27 (SE, +/-0.15), respectively. Including other statistically significant covariates (false-negative errors, P = 0.004) and factors (diagnosis, P = 0.005) into the model increased the proportion of explained variance to 62% (R2 = 0.62). Stimulus eccentricity (P = 0.34), patient age (P = 0.33), fixation loss rate (P = 0.10), and false-positive rate (P = 0.66) did not reach statistical significance as additional predictors of response variability. CONCLUSIONS: The relationship between response variability and sensitivity is similar for ON, POAG, OHT, and normal eyes. These results provide supporting evidence for the hypothesis that response variability is dependent on functional ganglion cell density.

Hormonally-regulated proteins in breast secretions are markers of target organ sensitivity.

Anti-oestrogen therapy is being used in an attempt to prevent breast cancer but no intermediate end points of the effect of tamoxifen on the normal breast are available. Therefore, the purpose of this study was to develop a physiological measure of oestrogen action on the breast. We measured oestrogen-stimulated and -inhibited proteins in breast secretions from women on and off anti-oestrogen therapy. Two oestrogen-stimulated proteins (pS2 and cathepsin D) and oestrogen-inhibited proteins (CP15, gross cystic disease fluid protein 15; Apo,: apolipoprotein D) were measured. Premenopausal women had significantly higher pS2 and cathepsin D in association with lower Apo D and CP15 secretion levels compared to post-menopausal women. Sequential nipple aspirates from women treated with the luteinizing hormone releasing hormone agonist goserelin (n = 9), tamoxifen (n = 9) and hormone replacement therapy (HRT) (n = 26) were measured. Following treatment with goserelin, median nipple secretion levels of pS2 fell (P < 0.02) and Apo D and CP15 rose significantly (P < 0.03 and P < 0.05 respectively). Similar changes were seen on tamoxifen therapy but not in untreated control women. Treatment with HRT resulted in a rise of pS2 (P < 0.001) and a fall in Apo D (P < 0.05). Measurement of pS2 and Apo D in nipple aspirates may prove useful intermediate end point of breast responsiveness to anti-oestrogens.

Respiratory symptoms in Lancashire textile weavers.

OBJECTIVES: To investigate a large population of cotton textile weavers for reported respiratory symptoms relative to occupational factors, smoking, and exposure to dust. Cotton processing is known to produce a respiratory disease known as byssinosis particularly in the early processes of cotton spinning. Relatively little is known about the respiratory health of the cotton weavers who produce cloth from spun cotton. By the time cotton is woven many of the original contaminants have been removed. METHODS: 1295 operatives from a target population of 1428 were given an interviewer led respiratory questionnaire. The presence of upper and lower respiratory tract symptoms were sought and the work relatedness of these symptoms determined by a stem questionnaire design. Also occupational and demographic details were obtained and spirometry and personal dust sampling performed. RESULTS: Byssinosis was present in only four people (0.3%). Chronic bronchitis had a moderate overall prevalence of about 6% and was related predominantly to smoking. There were several other work related respiratory symptoms (persistent cough 3.9%, chronic production of phlegm 3.6%, chest tightness 4.8%, wheezing 5.4%, and breathlessness 2.3%). All of these were predicted predominantly by smoking (either past or present), with no consistent independent effect of exposure to dust. Work related eye and nasal symptoms were more common (10.4% and 16.9% respectively). CONCLUSION: Byssinosis is a rare respiratory symptom in cotton weaving. Other work related respiratory symptoms were reported but their presence was predominantly related to smoking with no consistent effects of exposure to dust.

Scales to measure dimensions of hallucinations and delusions: the psychotic symptom rating scales (PSYRATS).

BACKGROUND: Scales to measure the severity of different dimensions of auditory hallucinations and delusions are few. Biochemical and psychological treatments target dimensions of symptoms and valid and reliable measures are necessary to measure these. METHOD: The inter-rater reliability and validity of the Psychotic Symptom Rating Scales (PSYRATS: auditory hallucination subscale and delusions subscale), which measure several dimensions of auditory hallucinations and delusions were examined in this study. RESULTS: The two scales were found to have excellent inter-rater reliability. Their validity as compared with the KGV scale (Krawiecka et al. 1977) was explored. CONCLUSIONS: It is concluded that the PSYRATS are useful assessment instruments and can complement existing measures.

Specific immunoglobulin E to peanut, hazelnut and brazil nut in 731 patients: similar patterns found at all ages.

BACKGROUND: Previous studies have reported reactions to an increasing range of nuts as patients with nut allergy grow older. Most patients with symptoms suggesting nut allergy have specific IgE to more than one nut. Furthermore, fatal reactions have followed eating nuts different from any causing the deceased's previous reactions. OBJECTIVE: To explore the pattern of specific IgE to three distantly related nuts in patients of all ages with nut allergy. METHODS: This study includes all patients referred to our laboratory for nut allergy testing from January 1994 to August 1998 who were tested for peanut, hazelnut and brazil nut, and had specific IgE to at least one of these nuts. All tests were performed using the Pharmacia Unicap system. RESULTS: Seven hundred and thirty-one patients (age 7 months to 65 years, median 6.6 years) had specific IgE >0.35 kU(A)/L to at least one of these three nuts: 282 had IgE to one nut, 130 to two nuts, and 319 to all three nuts. When analysed by gender and age quartile, very similar patterns were found in all subgroups though significant age trends and age interactions were found for IgE to individual nuts and combinations of nuts. CONCLUSIONS: The probability of a patient with nut allergy having specific IgE to a particular combination of peanut, hazelnut and brazil nut is similar, whatever their age or sex. The apparent increase in multiple nut reactivity with increasing age may therefore be due to exposure of previously unchallenged sensitivity. The frequency of multiple-nut specificity is sufficiently high that patients should always be tested for allergy to a range on nuts if they have a history of reacting to any nut.

Aftercare and clinical characteristics of people with mental illness who commit suicide: a case-control study.

BACKGROUND: Suicide prevention is now a health priority in many countries. In the UK, there are specific targets for reducing the suicide rate in the general population and in people with mental illness. However, there is almost no evidence for the effectiveness of health services in reducing suicide, and little evidence linking suicide to any aspect of health-service care. METHOD: We conducted a case-control study of people who committed suicide after discharge from psychiatric inpatient care. Cases were a 30-month sample of 149 people who had received an inquest verdict of suicide or open verdict in Greater Manchester, and who had a history of psychiatric admission in the 5 years before death. Controls were surviving psychiatric patients individually matched for age, sex, diagnosis, and date of last admission. Cases and controls were compared on aspects of psychiatric care, and on clinical and social variables, information being obtained from case notes. FINDINGS: Those who took their own lives were more likely to have had their care reduced (odds ratio 3.7 [95% CI 1.8-7.6]) at the final appointment in the community before death. Suicide was also associated with a history of self-harm (3.1 [1.7-5.7]), suicidal thoughts during aftercare (1.9 [1.0-3.5]) and the most recent admission as the first illness (2.0 [1.1-3.6]). The associations reported above took account of a number of confounding factors, including the predictable risk of suicide judged from case notes. Only 34% of suicides had an identifiable key worker, the essence of the Care Programme Approach. This frequency was no higher than that for controls, reflecting the difficulty of identifying those likely to commit suicide. INTERPRETATION: Reductions in care are strongly associated with suicide by people with mental illness, and may be contributory. The implication is that maintaining care beyond the point of clinical recovery is important in protecting high-risk individuals. Several clinical variables indicate high risk but greater risk is not generally addressed in health service provisions.

Significance of vomiting after head injury.

OBJECTIVES: To determine whether the presence and severity of post-traumatic vomiting can predict the risk of a skull vault fracture in adults and children. METHODS: Data were analysed relating to a consecutive series of 5416 patients including children who presented to an emergency service in the United Kingdom during a 1 year study period with a principal diagnosis of head injury. Characteristics studied were age, sex, speed of impact, level of consciousness on arrival, incidence of skull fracture, and the presence and severity of post-traumatic vomiting. RESULTS: The overall incidence of post-traumatic vomiting was 7% in adults and 12% in children. In patients with a skull fracture the incidence of post-traumatic vomiting was 28% in adults and 33% in children. Post-traumatic vomiting was associated with a fourfold increase in the relative risk for a skull fracture. Nausea alone did not increase the risk of a skull fracture and multiple episodes of vomiting were no more significant than a single episode. In patients who were fully alert at presentation, post-traumatic vomiting was associated with a twofold increase in relative risk for a skull fracture. CONCLUSION: These results support the incorporation of enquiry about vomiting into the guidelines for skull radiography. One episode of vomiting seems to be as significant as multiple episodes.