BACKGROUND--Readmissions account for part of the increase in hospital admissions for asthma in childhood seen in many countries. METHODS--This observational study recorded demographic features and the severity, treatment and management of asthma in 1034 individual children admitted to hospital over a one year period, followed for a maximum of 33 months. RESULTS--Readmissions were common, with 33% readmitted by six months and 51% by two years. After controlling for a wide range of variables, factors that significantly increased readmission were: female sex (relative risk (RR) 1.23; 95% confidence interval (CI) 1.03 to 1.46), young age (age < 5 years RR 1.71; 95% CI 1.41 to 2.08), number of previous admissions (one previous admission RR 1.32; two, RR 1.68; three, RR 2.00; four or more, RR 2.80), and inpatient intravenous treatment (RR 1.29; 95% CI 1.08 to 1.55). Inpatient treatment with theophylline was used frequently (98.4%), but was associated with decreased readmissions (RR 0.51, 95% CI 0.28 to 0.92). Factors which did not predict readmission included ethnicity, respiratory and pulse rate, medical team, prescribed prophylactic treatment, type of follow up, or the use of action plans. CONCLUSIONS--Risk factors for readmission relate to the characteristics of the individual (age and sex), severity of the condition (intravenous treatment), and number of previous admissions which may reflect severity or behaviour of the illness. Medical treatment and management did not influence readmissions. Strategies to reduce the high readmission rate for asthma in childhood need to be developed.

OBJECTIVES--To measure effects on terminally ill cancer patients and their families of coordinating the services available within the NHS and from local authorities and the voluntary sector. DESIGN--Randomised controlled trial. SETTING--Inner London health district. PATIENTS--Cancer patients were routinely notified from 1987 to 1990. 554 patients expected to survive less than one year entered the trial and were randomly allocated to a coordination or a control group. INTERVENTION--All patients received routinely available services. Coordination group patients received the assistance of two nurse coordinators, whose role was to ensure that patients received appropriate and well coordinated services, tailored to their individual needs and circumstances. MAIN OUTCOME MEASURES--Patients and carers were interviewed at home on entry to the trial and at intervals until death. Interviews after bereavement were also conducted. Outcome measures included the presence and severity of physical symptoms, psychiatric morbidity, use of and satisfaction with services, and carers' problems. Results from the baseline interview, the interview closest to death, and the interview after bereavement were analysed. RESULTS--Few differences between groups were significant. Coordination group patients were less likely to suffer from vomiting, were more likely to report effective treatment for it, and less likely to be concerned about having an itchy skin. Their carers were more likely to report that in the last week of life the patient had had a cough and had had effective treatment for constipation, and they were less likely to rate the patient's difficulty swallowing as severe or to report effective treatment for anxiety. Coordination group patients were more likely to have seen a chiropodist and their carers were more likely to contact a specialist nurse in a night time emergency. These carers were less likely to feel angry about the death of the patient. CONCLUSIONS--This coordinating service made little difference to patient or family outcomes, perhaps because the service did not have a budget with which it could obtain services or because the professional skills of the nurse-coordinators may have conflicted with the requirements of the coordinating role.

Aims:

BRCA1 gene mutations have been extensively studied in relation to breast and ovarian cancer susceptibility. Various genotype–phenotype correlation attempts have yielded important data pertaining to the consequences of BRCA1 mutations. However, little is known about the effects of recurrent BRCA mutations on expressivity and the age of onset of cancer in a population. This study addresses whether different exon mutations have variable expressivity especially in relation to the age of onset of breast cancer.

Methods:

Using a step-wise systematic approach, culminating in the sequencing of all BRCA1 and BRCA2 exons with the addition of multiplex ligation-dependent probe amplification, the relationship between disease phenotypes and gene mutations in 219 individuals and their family members was examined.

Results:

It is shown that different BRCA1 gene mutations have distinct effects that influence the age of onset of breast or ovarian cancer. Mutations in exon 2 of the BRCA1 gene had significantly lower penetrance compared with mutations of exons 11, 13 and 20. The median age of affliction with breast cancer was 55 years for 185delAG in exon 2 (95% confidence interval (CI) 46.7 to 59.5), 47 years for the 4184delTCAA mutation in exon 11 (95% CI 39 to 55.4), and 41 years for exon 13 duplication (95% CI 32.9 to 49.7) of the BRCA1 gene. Moreover, 14 novel mutations in BRCA1 and BRCA2 genes in the Yorkshire/Humberside population were identified.

Conclusions: The 185delAG mutation of the BRCA1 gene is a low penetrance mutation that is age dependent especially when compared with the exon 13 duplication mutation. The data have important ramifications on screening, genetic counselling and prophylactic treatment of BRCA1 gene mutation carriers.

STUDY OBJECTIVE--The aim was to investigate the effects of social factors (education, income, marital status, partners' employment status, housing tenure, social class), smoking, and maternal height on the dietary intake of pregnant women. DESIGN--The study was a prospective investigation on a two phase sample. SETTING--The study involved women attending the antenatal clinic at a district general hospital. PATIENTS--A group of pregnant Caucasian women, selected because they were heavy smokers (15+ cigarettes/day) (n = 94) and a randomly selected sample of never smokers (n = 112) were studied. MEASUREMENTS AND MAIN RESULTS--Data on social factors were collected by interviewer administered questionnaire. A 7 day weighed intake method was used to determine dietary intake at 28 weeks gestation. In univariate analyses, income, housing tenure and social class had significant effects on intakes of both macro- and micronutrients, and maternal education and smoking had significant effects on intakes of micronutrients. Using a stepwise multivariate analysis with income, smoking and maternal education, income was a significant factor in the intake of most nutrients but this effect disappeared when social class and housing tenure factors were entered into the model. Only social class and housing tenure had any significant effect on intakes of macronutrients--energy, protein and fat. Smoking and maternal education were the most important determinants of quality of diet (nutrient density); other factors had only negligible effects. Income was the only significant factor in alcohol intake. It is suggested that the effects of social class and income are overlapping. CONCLUSIONS--Smoking, being renters of accommodation, and being of minimum education and low social class are risk factors for poor dietary intake. It is recommended that such higher risk groups be specifically targeted for nutritional advice in pregnancy.

OBJECTIVES: A previous study of the short term effects of air pollution in London from April 1987 to March 1992 found associations between all cause mortality and black smoke and ozone, but no clear evidence of specificity for cardiorespiratory deaths. London data from 1992 to 1994 were analysed to examine the consistency of results over time and to include particles with a mean aerodynamic diameter of 10 microns (PM10) and carbon monoxide. METHODS: Poisson regression was used of daily mortality counts grouped by age and diagnosis, adjusting for trend, seasonality, calendar effects, deaths from influenza, meteorology, and serial correlation. The pollutants examined were particles (PM10 and black smoke), nitrogen dioxide, ozone, sulphur dioxide, and carbon monoxide with single and cumulative lags up to 3 days. RESULTS: No significant associations were found between any pollutant and all cause mortality, but, with the exception of ozone, all estimates were positive. Each pollutant apart from ozone was significantly associated with respiratory mortality; PM10 showed the largest effect (4% increase in deaths of all ages for a 10th-90th percentile increment). The pollutants significantly associated with cardiovascular deaths were nitrogen dioxide, ozone, and black smoke but there was no evidence of an association with PM10. In two pollutant models of respiratory deaths, the effect of black smoke, which in London indicates fine particles of diesel origin, was independent of that of PM10, but not vice versa. CONCLUSION: These results from a new data set confirm a previous report that there are associations between various air pollutants and daily mortality in London. This new study found greater specificity for associations with respiratory and cardiovascular deaths, and this increases the plausibility of a causal explanation. However, the effects of ozone found in the earlier study were not replicated. The fraction of PM10 which comprises black smoke accounted for much of the effect of PM10.

 

OBJECTIVE: To be able to measure disability objectively in rheumatoid arthritis complicated by cervical myelopathy. METHODS: The responses to the Stanford health assessment questionnaire disability index were recorded from 250 consecutive patients (group 1) referred to our unit for spinal surgery. Using principal components analysis the questionnaire was reduced from 20 questions to 10 questions. In the second part of the study, the results of the questionnaire for those patients undergoing surgery from the original group of 250 patients were analysed with respect to outcome. RESULTS: The reduction in the number of questions results in no significant loss of information, reliability (internal consistency Cronbach's alpha = 0.968) or sensitivity. The new scale, the myelopathy disability index, measures only one dimension (Eigen value 6.97) and may be more finely tuned to the measurement of disability in these myelopathic patients. When administered to the 194 patients undergoing cervical spine (group 2) surgery the myelopathy disability index was an accurate predictor of neurological and functional outcome, as well as survival following surgery (P < 0.0001). CONCLUSIONS: The myelopathy disability index provides a much needed objective and reliable means of assessing disability in patients with rheumatoid involvement of the cervical spine and also in predicting outcome following surgical intervention. It also provides information for both the patient and surgeon alike, on what to realistically expect from surgery. Its adoption should facilitate comparisons between different forms of surgical intervention.

The blood loss resulting from total hip arthroplasty was studied in 53 patients. Calculated blood loss exceeded measured blood loss in all cases. The most significant predictor of postoperative packed-cell volume (PCV) was the preoperative PCV. In a further 37 patients the preoperative PCV was used successfully to predict the postoperative PCV and the need for transfusion.

Cecropin A (CA) fungicidal properties were explored. Nongerminated and germinated Aspergillus spp. and Fusarium spp. conidia were treated with CA. CA achieved complete lethality at < or = 25 microM (99 micrograms/ml) for germinating, but not nongerminating, conidia of Aspergillus spp. CA achieved total lethality for nongerminated and germinating conidia of Fusarium spp at 1.5 microM (6 micrograms/ml). MIC and minimal lethal concentration assays in buffered RPMI medium gave similar results.

Long term results of joint replacement are frequently expressed as survivorship; it therefore becomes increasingly important to have the ability to make valid comparisons between survivorship tables in order to determine accurately the statistical significance of published differences. We present a statistical method for direct comparison of survivorship tables. We have applied this technique to evaluate the survivorship of the unconstrained, uncemented Ring total knee replacement first implanted in 1975 and compare this to contemporaneous constrained prostheses. There is a significant improvement in survival, which suggests a beneficial long-term effect on the bone/implant interface of this changing design concept.

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The link between chest illnesses in childhood to age 7 and the prevalence of cough and phlegm in the winter reported at age 23 was investigated in a cohort of 10 557 British children born in one week in 1958 (national child development study). Both pneumonia and asthma or wheezy bronchitis to age 7 were associated with a significant excess in the prevalence of chronic cough and phlegm at age 23 after controlling for current smoking. This excess was largely attributable to the association of cough and phlegm at age 23 with a history of asthma or wheezy bronchitis from age 16. When adjustment was made for recent wheezing, current cigarette consumption, previous smoking habit, and passive exposure to smoke the relative odds of cough or phlegm, or both, in subjects with a history of childhood chest illness was 1·11 (95% confidence interval 0·97 to 1·27). When analysed separately asthma, wheezy bronchitis, and pneumonia up to age 7 did not significantly increase the prevalence of either cough or phlegm.

The explanation for the observed continuity between chest illness in childhood and respiratory symptoms in later life may lie more in the time course of functional disturbances related to asthma than in the persistence of structural lung damage.

In a population of 5689 primary schoolchildren there were few important differences between children of European (n = 5287), African (n = 198), and Indian origin (n = 204) in the prevalence of a history of past respiratory illnesses or current respiratory symptoms. The reported 12 month period prevalence of the symptom "ever wheezy" was 15%, 18%, and 17% respectively in the three ethnic groups (differences not significant). In a subsample of 973 European, 47 African, and 40 Indian children forced expiratory volume in one second (FEV1) and forced vital capacity (FVC) were significantly lower by 12% and 13% in Africans and by 8% and 9% in Indians than in Europeans after adjustment to the group mean height of 128 cm. No significant ethnic variation was found for forced mid expiratory flow, FEV1/FVC, or mean transit time. Since the lung function studies were performed on a sample from a large population with little variation in respiratory morbidity, the differences are likely to reflect human biological differences. Separate prediction equations need to be developed for the different ethnic groups in childhood.