NHS Health Check programme: a rapid review update.

OBJECTIVE: To update a rapid review published in 2017, which evaluated the NHS Health Check programme. METHODS: An enlarged body of evidence was used to readdress six research objectives from a rapid review published in 2017, relating to the uptake, patient experiences and effectiveness of the NHS Health Check programme. Data sources included MEDLINE, PubMed, Embase, Health Management Information Consortium (HMIC), Cumulative Index of Nursing and Allied Health Literature (CINAHL), Global Health, PsycINFO, the Cochrane Library, NHS Evidence, Google Scholar, Google, ClinicalTrials.gov and the ISRCTN registry, Web of Science, Science Citation Index, The Cochrane Library, NHS Evidence, OpenGrey and hand searching article reference lists. These searches identified records from between January 1996 and December 2019. Screening, data extraction and quality appraisal using the Critical Appraisals Skills Programme checklists were performed in duplicate. Grading of Recommendations Assessment, Development and Evaluations was implemented. Data were synthesised narratively. RESULTS: 697 studies were identified, and 29 new studies included in the review update. The number of published studies on the uptake, patient experiences and effectiveness of the NHS Health Check programme has increased by 43% since the rapid review published in 2017. However, findings from the original review remain largely unchanged. NHS Health Checks led to an overall increase in the detection of raised risk factors and morbidities including diabetes mellitus, hypertension, raised blood pressure, cholesterol and chronic kidney disease. Individuals most likely to attend the NHS Health Check programme included women, persons aged ≥60 years and those from more socioeconomically advantaged backgrounds. Opportunistic invitations increased uptake among men, younger persons and those with a higher deprivation level. CONCLUSIONS: Although results are inconsistent between studies, the NHS Health Check programme is associated with increased detection of heightened cardiovascular disease risk factors and diagnoses. Uptake varied between population subgroups. Opportunistic invitations may increase uptake.

A sensitive method for the recovery of Escherichia coli serogroup O55 including Shiga toxin-producing variants for potential use in outbreaks.

AIM: Shiga toxin-producing Escherichia coli (STEC) cause bloody diarrhoea, kidney failure and occasionally death. However, identifying the source of infection caused by STEC other than serogroup O157 is hampered by the availability of sensitive methods for detecting these pathogens. In this study, we developed novel tools for detecting E. coli O55 that is potentially associated with human outbreaks. METHODS AND RESULTS: Overall specificity of immuno-magnetic separation (IMS) beads coated with anti-O55 serum was good with exception of cross-reactivity with E. coli O22 and O23, which was eliminated using an O55-specific PCR. Limit of detection for E. coli O55 using O55-IMS beads in spiked cattle faeces was on average 50 CFU per ml (range 1-90), and improved to <10 CFU per ml using the O55-specific PCR, following IMS on samples enriched for 2 h with E. coli O55. Application of these tools to test cattle faeces collected on-farm allowed the isolation of O55:H19, which through whole genome sequencing was compared to STEC O55:H7 human outbreak strains. CONCLUSION: These tools provide a sensitive method which could be used to screen samples for STEC O55, whether environmental or human clinical. SIGNIFICANCE AND IMPACT OF THE STUDY: Several human outbreaks reported in England were caused by STEC O55:H7. Tools developed here could assist in identification of the environmental source for these isolates, which has not yet been established.

How do pig farms maintain low Salmonella prevalence: a case-control study.

Salmonella prevalence in UK pigs is amongst the highest in Europe, highlighting the need to investigate pig farms which have managed to maintain a low Salmonella seroprevalence. A total of 19 pig farms that had a consistently low (<10%) seroprevalence over 4 years (named Platinum farms) were compared against 38 randomly selected Control farms, chosen to match the same distribution of production types and geographical distribution of the Platinum farms. Each farm was visited and floor faeces and environmental samples were collected. It was shown that Control farms had a significantly higher median percentage of pooled faecal samples positive for Salmonella compared with the Platinum farms (12.1% and 0.4% for pooled faecal samples, respectively) and were more likely to have serovars of public health importance detected (S. Typhimurium/ monophasic variants or S. Enteritidis). Considering the comprehensive on-farm sampling, the identification of farms negative for Salmonella, along with the identification of those that had maintained low prevalence over a long period is important. The risk factor analyses identified pelleted feed, feed deliveries crossing farm perimeter and regular antibiotic use as associated with being a Control farm. Performance data indicated that Platinum farms were performing better for slaughter live weight than Controls. Limited assessments of available pig movement records suggested that the source of pigs was not key to Platinum status, but further study would be needed to confirm this finding. These results emphasise that maintaining very low prevalence on UK farms is achievable.

Is there a correlation between malaria incidence and IRS coverage in western Zambezi region, Namibia?

Setting: A comparison of routine Namibia National Malaria Programme data (reported) vs. household survey data (administrative) on indoor residual spraying (IRS) in western Zambezi region, Namibia, for the 2014-2015 malaria season. Objectives: To determine 1) IRS coverage (administrative and reported), 2) its effect on malaria incidence, and 3) reasons for non-uptake of IRS in western Zambezi region, Namibia, for the 2014-2015 malaria season. Design: This was a descriptive study. Results: IRS coverage in western Zambezi region was low, ranging from 42.3% to 52.2% for administrative coverage vs. 45.9-66.7% for reported coverage. There was no significant correlation between IRS coverage and malaria incidence for this region (r = -0.45, P = 0.22). The main reasons for households not being sprayed were that residents were not at home during spraying times or that spray operators did not visit the households. Conclusions: IRS coverage in western Zambezi region, Namibia, was low during the 2014-2015 malaria season because of poor community engagement and awareness of times for spray operations within communities. Higher IRS coverage could be achieved through improved community engagement. Better targeting of the highest risk areas by the use of malaria surveillance will be required to mitigate malaria transmission.

Contexte : Une comparaison des données de routine du programme national de lutte centre le paludisme de Namibie (rapportées) et des données d'enquête dans les foyers (administratives) relatives à la pulvérisation d'insecticide à effet rémanent (IRS) dans la région ouest du Zambèze, en Namibie, pour la saison 2014­2015 du paludisme.Objectifs : Déterminer 1) la couverture de l'IRS (administrative et rapportée), 2) son effet sur l'incidence du paludisme, et 3) les raisons de la non couverture de l'IRS dans la région ouest du Zambèze, Namibie, pendant la saison 2014­2015 du paludisme.Schéma : Une étude descriptive.Résultats : La couverture de l'IRS dans la région ouest du Zambèze a été faible, allant de 42,3% à 52,2% pour la couverture administrative contre 45,9% à 66,7% pour la couverture rapportée. Il n'y a pas eu de corrélation significative entre couverture de l'IRS et incidence du paludisme dans cette région (r = −0,45 ; P = 0,22). Les raisons majeures pour lesquelles les foyers n'ont pas bénéficié de pulvérisations ont été l'absence des résidents à leur domicile lors de la pulvérisation ou, inversement, la non-venue des opérateurs de pulvérisation dans les foyers.Conclusions : La couverture de l'IRS dans la région ouest du Zambèze, Namibie, a été faible pendant la saison 2014­2015 du paludisme en raison de l'engagement médiocre de la communauté et de la méconnaissance des dates d'opérations de pulvérisation dans les communautés. Une couverture plus élevée de l'IRS pourrait être obtenue avec une meilleur engagement de la communauté. Un meilleur ciblage des zones à risque les plus élevés en utilisant la surveillance du paludisme sera requis pour atténuer la transmission du paludisme.

Marco de referencia: Una comparación de los datos corrientes del Programa Nacional contra el Paludismo de Namibia (notificados), con los datos de una encuesta domiciliaria (administrativos) sobre la fumigación de interiores con insecticidas de efecto residual (IRS) en la región occidental de Zambezi en Namibia, durante la temporada de paludismo del 2014­2015.Objetivos: Determinar 1) la cobertura de la IRS (administrativa y notificada), 2) su efecto sobre la incidencia de paludismo, y 3) las razones de la falta de IRS en la región occidental de Zambezi, en Namibia, durante la temporada de paludismo del 2014­2015.Método: Un estudio descriptivo.Resultados: La cobertura de la IRS en la región occidental de Zambezi fue baja, del 42,3% al 52,2% según la cobertura administrativa, en comparación con el 45,9% al 66,7% según la cobertura notificada. paludismo en la región (r = −0,45; P = 0,22). Las principales razones por las cuales no se fumigaron los domicilios fueron que los residentes no se encontraban presentes en el momento de la fumigación o que los operadores de fumigación no visitaron los hogares.Conclusiónes: La cobertura de la fumigación de interiores con insecticidas de efecto residual en la región occidental de Zambezi, en Namibia, fue baja durante la temporada de paludismo del 2014­2015 por falta de participación comunitaria y de conocimiento de los horarios de fumigación en las comunidades. La cobertura se puede ampliar si se fomenta el compromiso comunitario y es necesario dirigir mejor las campañas a las zonas de mayor riesgo, según lo indiquen los datos de la vigilancia del paludismo, con el propósito de disminuir la transmisión de la enfermedad.

Study of the impact on Salmonella of moving outdoor pigs to fresh land.

Anecdotal evidence has suggested that outdoor-kept pigs show an improvement to health and productivity after being moved to a new site. This study explores whether Salmonella occurrence reduced and was sustained after moving to a new site. Nine farms were followed for a year in which four sampling visits were completed. The highest detection of Salmonella was from pooled faecal dropping from pigs, run-off/ pooled water, rodents and wild birds. Descriptive summaries showed that the prevalence of both all Salmonella and serovars of public health importance were lower at all visits after the move. Some variability was shown in results from individual farms, but a year after the move, six farms still maintained a lower prevalence. A risk factor model showed that the prevalence at visits 2 and 3 after the move was significantly lower than baseline, after accounting for a number of significant factors that were included in the model. These were sample type and seasonality (included as a priori), presence of coughing in the sampled group and Glasser's disease on the farm, and the use of tent or kennel accommodation. This finding provides important evidence that more frequent site moves may help reduce Salmonella prevalence in outdoor herds.

Use of an attenuated live Salmonella Typhimurium vaccine on three breeding pig units: A longitudinal observational field study.

The study examined the effects of a licensed live Salmonella Typhimurium vaccine, administered to sows and gilts on three commercial pig units experiencing clinical salmonellosis associated with S. Typhimurium or its monophasic variant. After vaccination, clinical salmonellosis resolved and shedding of S. Typhimurium declined markedly and persistently on all breeding or breeding-finishing units, during the one- to two-year monitoring period. On two finishing units supplied in part by one of the vaccinated herds, pigs from the vaccinated herd were less likely to shed Salmonella than those from non-vaccinating herds, and Salmonella counts in faeces were also lower from the vaccine-linked animals. Non-Typhimurium Salmonella serovars were isolated typically in fewer than 10% of samples, and showed no clear temporal changes in frequency. Vaccination of dams alone with S. Typhimurium was associated with reduced shedding of closely-related serovars among all age groups in this commercial setting.

An in-vitro investigation into the efficacy of disinfectants used in the duck industry against Salmonella.

In 2010, 81 confirmed cases of Salmonella Typhimurium DT8 were reported across England and Northern Ireland - an increase of 26% from 2009 and 41% since 2008. Five cases were hospitalized and one death reported, with a strong association found between cases and the consumption of duck eggs. Once present on farms, Salmonella may become persistent and can survive for long periods of time in residual organic matter, increasing risk of infection for follow-on flocks if cleaning and disinfection is not carried out effectively. The aim of this study was to investigate the efficacy of a range of disinfectants used by the duck industry against Salmonella using laboratory models. Sixteen products were selected from seven chemical groups and the Minimum Inhibitory Concentration and Minimum Bactericidal Concentrations determined. Each product was also tested at the recommended general orders (GO) concentration using a faecal suspension model to mimic boot dips and a surface contamination model to simulate contaminated building fabric and equipment. In the faecal suspension model, all products were effective at 2 × GO concentration, and activity was more inconsistent at GO concentration. At 0.5 × GO concentration, iodine-based and quaternary-ammonium-compound-based products were significantly less effective than products within other chemical groups (P < 0.001). Glutaraldehyde-based products were significantly more effective than the other products in the surface contamination tests (P < 0.001). Chlorocresol-based products were found to be most effective for use in boot dips and aldehyde-based products for surface disinfection, although there was variability between products within a chemical group.

Investigation of laboratory testing issues in the context of the Salmonella National Control Programme in Great Britain.

1. The objective of this study was to identify any issues arising during the laboratory testing of samples collected under the National Control Programme for Salmonella. 2. A questionnaire-based survey was conducted among Defra (Department for Environment, Food and Rural Affairs)-approved testing laboratories in order to identify any complicating factors that the laboratories may encounter during the processing of samples. 3. Samples were reported to arrive in good condition and within the specified time frame after collection. The only concern was that new clients may be unaware of the procedure or correct sampling consumables to use. 4. There was evidence of variability between laboratories regarding the sample testing procedure used, with deviation from the guidelines in some cases. 5. This finding suggests that further guidance for laboratories on methodology is likely to be beneficial as this could help improve the detection of low levels of Salmonella.

Evaluation of the sensitivity of faecal sampling for detection of monophasic Salmonella Typhimurium and other Salmonella in cattle and pigs.

There has been a rapid rise in the prevalence of cases of monophasic Salmonella Typhimurium (mST) in both humans and farm animals, and it has been found in pigs, cattle and poultry. It is therefore vital to have a good understanding of how to efficiently detect infected farms. The objective of this project was to determine sample type sensitivity in the detection of Salmonella to detect infected groups of animals on both pig (breeder, grower and finisher sites) and cattle (beef and dairy) farms, using data collected from a study investigating farms that were positive for mST, and to explore any variation between different age groups and management practices. A Bayesian approach in the absence of a gold standard was adopted to analyse the individual and pooled faecal sample data collected from each epidemiological group on each of the farms. The sensitivity of pooled sampling depended on the prevalence of infection in the group being sampled, with a higher prevalence leading to higher sensitivity. Pooled sampling was found to be more efficient at detecting positive groups of animals than individual sampling, with the probability of a random sample from a group of animals with 5% prevalence testing positive being equal to 15·5% for immature pigs (3·6% for an individual faecal sample, taking into account the sensitivity and infection prevalence), 7·1% for adult pigs (1·2% for individual sampling), 30% for outdoor cattle (2% for individual sampling) and 34% for indoor cattle (1% for individual sampling). The mean prevalence of each epidemiological group was higher in outdoor farms than indoor for both pigs and cattle (mean within-farm prevalence of 29·4% and 38·7% for outdoor pigs and cattle, respectively, compared to 19·8% and 22·1% for indoor pigs and cattle).

Assessment of producers' response to Salmonella biosecurity issues and uptake of advice on laying hen farms in England and Wales.

High standards of biosecurity are known to reduce the risk of disease outbreaks; however, uptake of advice and implementation of biosecurity measures are dependent on many factors. This study assessed the uptake of targeted biosecurity advice by 60 laying hen farms provided during biosecurity audit visits. Advice was provided as bullet point cards focusing on specific areas identified as benefitting from improvement. These covered site entrance, site tidiness, vaccination, boot hygiene, hand hygiene, house tidiness, rodent control, fly control, red mite control and cleaning and disinfection between flocks. Background knowledge of Salmonella and biosecurity and farmers' willingness and intent to implement additional measures were assessed. About 50% of the principal decision-makers had basic background knowledge of Salmonella, with 22% considered well informed; almost all agreed that biosecurity could impact on Salmonella control and many appeared willing to implement additional biosecurity measures. Sixty-three per cent of study farms were categorised using the Defra Farmer Segmentation Model as Modern Family Businesses (MFBs), with 7-11% of farms being categorised as Custodian, Lifestyle Choice, Pragmatist or Challenged Enterprise; however, categorisation, did not determine uptake of advice. The most frequently used advice cards were boot hygiene, red mite control, hand hygiene, site entrance and cleaning and disinfection; uptake of advice ranged from 54 to 80% depending on the advice card. Uptake of advice by the farmers was encouraging, especially considering it was being provided by people other than their usual source of biosecurity information. Those who did not implement the recommended measures cited cost, difficulty of enforcement and practicality as the main reasons. However, the positive uptake of advice and implementation of recommended measures by many farmers demonstrates that targeted advice, discussed face to face with farmers, on a small number of key areas, is a potentially effective method of providing biosecurity information to complement more lengthy formal advisory reports.

A review of the official sampling of flocks of laying hens in the Salmonella National Control Programme in Great Britain.

In line with European legislation and the UK National Control Programme for Salmonella, poultry farms are sampled to establish their Salmonella status. Regular samples are collected by the farmer (operator), with annual routine (official) samples being collected by the competent authority to verify achievement of the Salmonella programme reduction target. To confirm sampling was being carried out effectively, a questionnaire-based survey was conducted. The aim was to identify any complicating factors the samplers encountered and the decisions made in these circumstances. There was good compliance with the official sampling visits, with few delays reported. However, farm-specific clothing/separate boots for non-caged houses were rarely provided by the operator, whereas boot dips and hand washing facilities were usually available. The collection of dust was often a problem for official samplers, operator boot swabs were not always moistened before sampling and both sampler groups did not always follow the recommended method for the collection of faeces from belts and scrapers. Overall, there was a good application of the sampling protocol, although a few areas for improvement were identified.

Development and testing of external quality assessment samples for Salmonella detection in poultry samples.

Salmonella-contaminated poultry house dust plus 10 g chicken faeces inoculated with Salmonella Enteritidis and then frozen for storage and transport were used as candidate external quality assurance test samples. Variations in faeces sample preparation, storage and culture were examined initially. This indicated that, within modest limits, the age of the inoculating culture and of the faeces did not affect detection, nor did swirling the pre-enrichment culture or extending its duration. Under optimal conditions of preparation and storage, Salmonella numbers of 70 colony-forming units (CFU) and above were reliably detected at the originating laboratory. A ring trial was performed, involving 13 external UK laboratories plus the originating laboratory. Faeces samples inoculated with Salmonella Enteritidis were frozen, transported on dry ice and tested by the ISO 6579:2002 (Annex D) method. Detection by the originating laboratory was consistent with the previously established lower limit for reliability of 70 CFU. However, the sensitivity of detection by the external laboratories was apparently poorer in several cases, with significant interlaboratory variation seen at the lowest inoculum level, using Fisher's exact test. Detection of Salmonella in poultry house dust appeared to be more sensitive and uniform among laboratories. Significance and impact of the study: Salmonella surveillance and control regimes in the European poultry industry and elsewhere require sensitive culture detection of Salmonella in environmental samples, including poultry faeces. A ring trial was conducted, and the results highlighted that some of the participating laboratories failed to identify Salmonella. This suggests that contaminated frozen faeces cubes could be beneficial to assess proficiency, according to the results of this preliminary study. The data obtained in this study can be used as an indication for the design of realistic external quality assurance for laboratories involved in official testing of Salmonella in poultry flocks.

Risk factors for antimicrobial resistance in Escherichia coli found in GB turkey flocks.

Four models are presented investigating risks present on Great Britain (GB) turkey farms in breeding and fattening flocks for ciprofloxacin and cephalosporin resistance. Risk factors for ciprofloxacin resistance in fattening flocks were sourcing of feed from national compounders, antimicrobial use in the flock and evidence of mice. Disinfection of floors and walls at depopulation, older flocks and division of the flock with partitions reduced the risk. In breeding farms holding over 10,000 birds, administration of fluoroquinolones within the last year and horses on the neighbouring farm all increased the risk, whereas replenishing foot dips more than once a week reduced the risk. For cephalosporin-resistant Escherichia coli on fattening farms, being an independent farm, having a watercourse near the poultry houses, dividing the flock with partitions and providing staff with gloves reduced the risk. Factors that increased the risk included if staff worked with other livestock and if there were pigs on neighbouring farms. This work suggests that good hygiene and biosecurity, rodent control and responsible use of antimicrobials on turkey farms might help minimise the prevalence of fluoroquinolone and cephalosporin resistance in E coli, and restrict the spread of resistance genes to other organisms.

Ciprofloxacin resistance in E. coli isolated from turkeys in Great Britain.

Fluoroquinolones are a widely used group of antimicrobials in both human and animal medicine, with ciprofloxacin being a critically important fluoroquinolone for serious human infections. The present study reports on a 1-year survey for the presence of ciprofloxacin-resistant Escherichia coli in turkeys from Great Britain. Boot swabs were taken from 442 turkey flocks comprised of 125 breeding flocks and 317 meat flocks from 337 different farms over a 1-year period (2006 to 2007). CHROMagar ECC containing 1 mg/l ciprofloxacin was used to obtain ciprofloxacin-resistant isolates. Isolates were tested for sensitivity to 16 different antimicrobials. Isolates with ciprofloxacin minimum inhibitory concentrations ≥8 mg/l were tested for mutations in gyrA by polymerase chain reaction and DNA sequencing. Selected isolates were tested by multiplex polymerase chain reaction for qnrA, qnrB and qnrS, qepA and aac(6')-Ib-cr genes. Conjugations were performed to assess the transferability of resistance to quinolones. Ciprofloxacin-resistant E. coli was found in 22.4% of turkey breeding flocks and 60.9% of meat flocks. Two main mutations in gyrA, as well as a range of silent mutations, were identified in resistant isolates. Flocks with transferable resistance genes qnrB, qnrS, and aac(6')-Ib-cr were found at a low flock prevalence of 4.2%, 1.6% and 1.0%, respectively; however, under laboratory conditions only transfer of qnrS genes could be demonstrated. This work has confirmed the occurrence of ciprofloxacin-resistant E. coli strains throughout turkey breeding and meat flocks, with almost one-third of E. coli isolates being resistant to ciprofloxacin. Of those, more than 87% were also resistant to three or more antimicrobial classes.

The role of antimalarial treatment in the elimination of malaria.

With declining transmission of malaria in several regions of the world and renewed interest in the elimination of malaria, strategies for malaria control using antimalarial drugs are being revisited. Drug-based strategies to reduce transmission of malaria need to target the asymptomatic carriers of infection. Drugs that are effective against gametocytes are few in number, but it may be possible to reduce gametocyte production by killing the asexual stages, for which more drugs are available. Drugs for use in large-scale programmes must be safe and tolerable. Strategies include improving access to treatment for malaria with an efficacious drug, intermittent-treatment programmes, and mass drug administration, with and without screening for malaria. Recent proposals have targeted high-risk groups for interventions. None of the strategies has been rigorously tested with appropriate control groups for comparison. Because of the lack of field evidence, modelling has been used. Models have shown, first, that for long-lasting effects, drug administration programmes should be linked with vector control, and second, that if elimination is the aim, programmes are likely to be more successful when applied to smaller populations of a few thousand or less. In order to sustain the gains following the scaling up of vector control and use of artemisinin combination therapies (ACTs), strategies that use antimalarials effectively need to be devised and evidence generated for the most cost-efficient way forward.

Intermittent preventive treatment of malaria in infants: how does it work and where will it work?

We discuss the potential public health impact of IPTi by estimating the cases of malaria, anaemia and hospital admissions likely to be averted in different transmission settings; and we review the mechanism of action, choice of drugs regimens, and the effect on immunity of IPTi. IPTi using an efficacious drug is likely to substantially reduce cases of clinical malaria in moderate to high transmission settings. However, geographical heterogeneity in malaria transmission could hamper rolling out IPTi as a national policy.

Prevalences of Pneumocystis jiroveci, Mycobacterium tuberculosis and Streptococcus pneumoniae infection in children with severe pneumonia, in a tertiary referral hospital in northern Tanzania.

At the Kilimanjaro Christian Medical Centre, a tertiary referral hospital in northern Tanzania, both the number of paediatric cases of lower respiratory-tract infection (LRTI) and the associated mortality increased between 2000 and 2001. Molecular diagnostic tools were used to enhance the identification of the pathogens responsible for this perceived increase. All 72 children aged between 2 and 60 months who were admitted with LRTI over a 3-month period were enrolled in the study. Induced sputum was collected from each child and, if the parents consented, the subjects were also tested for HIV. The sputum samples were each checked for bacteria by culture and, in amplification assays, for the DNA of Pneumocystis jiroveci, Mycobacterium tuberculosis and Streptococcus pneumoniae. Twenty-two (50%) of the 44 children tested for HIV had HIV-1 antibodies. Although only two children, both aged <6 months, were found PCR-positive for P. jiroveci, and only one was found positive for M. tuberculosis, 46 (including one of those found positive for P. jiroveci and the child found positive for M. tuberculosis) were found PCR-positive for S. pneumoniae. It therefore appears that most paediatric cases of LRTI who present at the hospital are attributable to S. pneumoniae, and that infections with this pathogen are entirely responsible for the observed increase in the incidence of LTRI in the local children. The increase seen in LRTI-associated mortality among the children may be the result of pneumococcal antibiotic resistance.

Best practice in primary care pathology: review 2.

This second best practice review examines five series of common primary care questions in laboratory medicine: (1) laboratory testing for allergy, (2) diagnosis and monitoring of menopause, (3) the use of urine cytology, (4) the usefulness of the erythrocyte sedimentation rate, and (5) the investigation of possible urinary tract infection. The review is presented in a question-answer format. The recommendations represent a précis of guidance found using a standardised literature search of national and international guidance notes, consensus statements, health policy documents, and evidence based medicine reviews, supplemented by MEDLINE EMBASE searches to identify relevant primary research documents. They are standards but form a guide to be set in the clinical context. Most are consensus rather than evidence based. They will be updated periodically to take account of new information.