Ethnic differences in control of cardiovascular risk factors in patients with type 2 diabetes attending an Inner London diabetes clinic

Background

South Asians have higher risk of diabetic complications compared with white Europeans. The aim of this study was to compare management of cardiovascular risk factors between Bangladeshis and white Europeans.

Methods

A retrospective survey of all diabetic patients attending an Inner London hospital diabetic clinic over one year was undertaken. Data were obtained from the hospital diabetes database: presence of macrovascular (myocardial infarction, angina, stroke, transient ischaemic attack, cardiac intervention) and microvascular disease (neuropathy, retinopathy, and nephropathy), glycated haemoglobin, blood pressure, lipids, smoking, and body mass index (BMI) were all determined.

Results

A total of 1162 white European and 912 Bangladeshi patients with full data available were included in the analyses. The groups were equivalent in age, sex, duration of diabetes. Compared with white Europeans, Bangladeshis had more macrovascular disease (19.5% v 11.9% p<0.01), sight threatening retinopathy (7.2% v 3.8%, p<0.01), and nephropathy (15.3% v 9.1%, p<0.01). In addition, Bangladeshis had significantly more male smokers (28.1% v 22.1%, p<0.01), poorer glycaemic control (mean HbA1c 8.6% v 8.1%, p = 0.039), greater proportion with uncontrolled hypercholesterolaemia (total cholesterol >5.0 mmol/l, 31.6% v 26% p = 0.05), and poorer control of blood pressure (proportion with BP >140/80 mm Hg, 43.2% v 32.1%, p<0.01).

Conclusions

South Asians with type 2 diabetes have poorer glycaemic, blood pressure, and lipid control than white Europeans. The reasons for this are probably multifactorial.     

Long term clinical outcome and bleeding complications among hospital survivors with acute coronary syndromes

Objective

To examine the 21 month clinical outcome and bleeding complications in hospital survivors with non‐ST segment elevation acute coronary syndromes (NSTEACS) who were discharged with combined clopidogrel and aspirin anti‐thrombotic therapy, and compare with those having ST segment elevation myocardial infarction (STEMI) who were discharged with aspirin alone.

Design

Observational study.

Setting

A large university hospital.

Patients

224 patients were admitted to hospital with either NSTEACS or STEMI, and survived to discharge between 1 October 2001 and 31 December 2002.

Main outcome measures

Cardiovascular death, total death, new myocardial infarction, unstable angina requiring hospitalisation, stroke or transient ischaemic attack, coronary revascularisation; and fatal, life threatening, major and minor bleeding over 21 months after discharge.

Results

Despite having no or small infarct (median maximum creatine kinase 155 v 1295 u/l; p<0.001) and taking more antianginal drugs, patients with NSTEACS had similar rates of cardiovascular death (9.5% v 8.3%; p = NS), new myocardial infarction (9.5% v 6.5%; p = NS) or unstable angina requiring hospitalisation (15.5% v 10.2%; p = NS) when compared with STEMI. Fatal, life threatening or major bleeding were <1% in both groups (p = NS); and minor bleeding occurred in 4.3% NSTEACS and 2.8% STEMI patients respectively (p = NS).

Conclusions

Patients with NSTEACS had a similar and unfavourable long term outcome when compared with STEMI. There was no difference in serious bleeding complications between both groups.     

Effect of methionine loading on pulse wave analysis in elderly volunteers

Objective

To test the hypothesis that an acute increase in plasma homocysteine produced by methionine is associated with an acute increase in pulse wave velocity.

Design

A double blind, cross over, placebo controlled design was used and pulse wave velocity, plasma homocysteine, total cholesterol: high density lipoprotein ratio, plasma triglyceride, oxidised low density lipoprotein cholesterol concentrations, apolipoproteins A1 and B, and C reactive protein were measured between 12.5 and 20 hours after methionine loading or placebo.

Results

Between 12.5 and 20 hours after exposure to a methionine loading test, arterial pulse wave velocity showed no significant difference compared with placebo. At 12 hours after exposure to the methionine loading test, in the presence of a controlled diet, triglyceride concentration significantly increased by 32.6% (p<0.02), cholesterol: high density lipoprotein ratio increased significantly by 22.5% (p<0.05) compared with placebo. Simultaneously, systolic blood pressure increased significantly by 4.9% (p<0.02).

Conclusion

In elderly volunteers, acute hyperhomocysteinaemia induced by methionine loading resulted in no overall significant delayed reduction in peripheral arterial distensibility. A significant deterioration in the lipid profile and increased blood pressure was seen during acute hyperhomocysteinaemia.     

Investigation and management of severe hyponatraemia in a hospital setting

Aims

To evaluate the assessment and management of severe hyponatraemia in a large teaching hospital.

Methods

Inpatients with serum sodium <125 mmol/l were identified prospectively from a laboratory database over a six month period. Notes were examined and data extracted. Case notes were carefully reviewed retrospectively by a consultant endocrinologist with regard to accuracy of the diagnosis and the appropriateness of investigations and management.

Results

104 patients with a serum sodium <125 mmol/l were identified. Mean (SD) age was 69 (14), 52% were female, mean hospital stay was 16 (12) days, and overall mortality 27%. Adequate investigations were rarely performed. Only 28 (26%) had plasma osmolality measured, 29 (27%) urine osmolality, 11 (10%) urinary sodium, 8 (8%) plasma cortisol, and 2 (2%) a short Synacthen test. Comparing the “ward” and “specialist review” diagnoses, there were significant discrepancies for “no cause found” (49% v 27%, p<0.001), alcohol (6% v 11% p<0.01), and syndrome of inappropriate antidiuresis (20% v 32%, p = 0.001). Treatment was often illogical with significant management errors in 33%. These included fluid restriction and intravenous saline given together (4%) and fluid restriction in diuretic induced hyponatraemia (6%). Mortality was higher in the group with management errors (41% v 20% p = 0.002).

Conclusion

Severe hyponatraemia is a serious condition, but its investigation and evaluation is often inadequate. Some treatment patterns seem to be arbitrary and illogical, and are associated with higher mortality.     

Long term prognosis of heart failure after acute coronary syndromes without ST elevation

Background

Information about long term outcomes of patients with acute coronary syndromes (ACS) who have clinically diagnosed heart failure is scarce.

Methods

In a UK registry, this study evaluated patients with non‐ST elevation ACS, recording treatment, and clinical outcomes for six months. In a subgroup, a four year mortality follow up was performed to estimate the impact of the clinical diagnosis of heart failure on survival.

Results

Of 1046 patients, 139 (13%) had a history of clinically diagnosed heart failure. At discharge, ACE inhibitors were prescribed for 58% and 28%, of those with and without a history of heart failure respectively (p<0.001). Rates of angiography, percutaneous intervention, and coronary artery bypass graft were 17.3% and 29.2% (p = 0.003), 5.0% and 8.4% (p = 0.17), and 5.0% and 7.5% (p = 0.3) for these groups respectively. Death or new myocardial infarction at six months occurred in 22% and 10% (p<0.001) and at four years death occurred in 60% and 20% of these groups respectively (p<0.001). In a multivariate analysis prior heart failure carried an odds ratio of 2.0 (p = 0.001) for death or myocardial infarction at six months and 2.4 (p<0.001) for death over four years. New heart failure was associated with an increased risk of death at six months (20% compared with 5%, p<0.001).

Conclusion

A clinical history of heart failure carries a substantial risk of death in patients admitted with ACS without ST elevation. Nearly 60% of those with prior heart failure are dead after four years. After adjustment for confounding factors, prior heart failure more than doubles the risk compared with those with no history.     

Evaluation of the need for endoscopy to identify low-risk patients presenting with an acute upper gastrointestinal bleed suitable for early discharge

Aims

To audit the safety of differing protocol‐driven early‐discharge policies, from two sites, for low‐risk acute upper gastrointestinal (GI) bleeding and determine if default early (<24 h) in‐patient endoscopy is necessary.

Methods

All patients with low‐risk acute upper GI bleeding presenting to two separate hospital sites in Leeds from August 2002 to March 2005 were identified. Both hospitals operate nurse‐led process‐driven protocols for discharge within 24 h, but only one includes default endoscopy. Relevant information was obtained from patients'' notes, patient administration systems, discharge letters and endoscopy records.

Results

120 patients were admitted to site A and 74 to site B. Median length of stay on the clinical decisions unit was 12.6 h at site A and 9.4 h at site B (p = 0.045). Oesophagogastroduodenoscopy was performed on 89/120 (74%) patients at site A compared with only 7/74 (9%) at site B (p<0.001). Six of 120 (5%) patients from site A were admitted to hospital for further observation compared with 6/74 (8%) from site B (p = 0.38). Of the remaining patients, all were discharged within 24 h, and 8/114 (7%) at site A vs 17/68 (25%) at site B were given hospital clinic follow‐up (p<0.001). None of the 194 patients had further bleeding or complications within 30 days.

Conclusions

Patients admitted with a low‐risk acute upper GI bleeding can be managed safely by a nurse‐led process‐driven protocol, based on readily available clinical and laboratory variables, with early discharge <24 h. Avoiding in‐patient endoscopy appears to be safe but at the price of greater clinic follow‐up.     

Raised cardiac troponin T levels in patients without acute coronary syndrome

Objective

To investigate the frequency, diagnosis and outcome of patients admitted to hospital with acute coronary syndrome (ACS) or other conditions associated with raised levels of cardiac troponin T.

Design

Observational study.

Setting

A large university hospital.

Patients

Consecutive patients admitted over an 8‐week period who had a serum troponin T test as part of their clinical assessment were included. Patients were separated into those with raised (⩾0.01 μg/l) or normal (<0.01 μg/l) troponin T levels, and further categorised into those with or without a diagnosis of ACS.

Main outcome measures

In‐hospital mortality in all patients; and 6‐month hospital re‐admissions and all‐cause mortality in patients without or with ACS and raised levels of troponin T.

Results

Of 1021 patients, 118 patients had no ACS but raised troponin T levels, 195 had ACS with raised troponin T, 80 had ACS with normal troponin T and 628 had no ACS with normal troponin T. Their in‐hospital all‐cause mortalities were 36%, 18%, 0% and 3%, respectively (p<0.001, highest mortality v other groups). 6‐month all‐cause mortality remained higher in patients without ACS and with raised levels of troponin T than in those with ACS and raised troponin T (42% v 29%; p = 0.020).

Conclusions

Patients without ACS but with raised levels of troponin T comprised 38% of all hospitalised patients found to have raised troponin T. These patients had worse in‐hospital and 6‐month outcome than those having ACS with raised levels of troponin T.     

Effects of comorbidity and hospital care on 6-month mortality in patients with elevated cardiac troponin T

Objective

To examine the effects of comorbidity and hospital care on mortality in patients with elevated cardiac troponin T.

Design

Observational study.

Setting

A large university hospital with on‐site diagnostic cardiac catheter laboratory.

Patients

All hospitalised patients with elevated cardiac troponin T level (⩾0.01 μg/l) over an 8‐week period.

Main outcome measures

6‐month all‐cause mortality.

Results

Among 313 patients with elevated cardiac troponin T, 195 had acute coronary syndrome and 118 had other conditions. Multivariate analysis showed that among patients with acute coronary syndrome, increasing comorbidity score (odds ratio (OR) 1.23 per point increase, 95% confidence interval (CI) 1.00 to 1.51; p = 0.048), age (OR 1.08 per year, 95% CI 1.04 to 1.13; p<0.001), raised troponin T level (OR 2.22 per 10‐fold increase, 95% CI 1.27 to 3.89; p = 0.005), and ST depression (OR 3.12, 95% CI 1.38 to 7.03; p = 0.006) were independent adverse predictors, while cardiologist care (OR 0.22, 95% CI 0.09 to 0.51; p<0.001) was associated with a better survival. Increasing troponin T level (OR 3.33 per 10‐fold increase, 95% CI 1.24 to 8.91; p = 0.017) was found to predict a worse prognosis among patients without acute coronary syndrome, and cardiologist care did not affect outcome in this group. Among hospital survivors with acute coronary syndrome, increasing comorbidity score, age and a lack of cardiologist care were independently associated with lesser use of effective medications.

Conclusions

Comorbidity was associated with a higher 6‐month mortality in patients having acute coronary syndrome, and lesser use of effective medicines among hospital survivors. Cardiologist care was associated with better 6‐month survival in patients with acute coronary syndrome, but not in those without acute coronary syndrome.Prognostic indices including the original Charlson''s comorbidity index¹ have shown that comorbidity was important in determining the short and long term outcome in patients with various medical conditions, including those with acute myocardial infarction.^2,3,4,5 Among patients admitted to hospital with suspected acute coronary syndrome, an abnormally raised cardiac troponin level can be found in patients with, and also without, acute coronary syndrome.^6,7 An increasing cardiac troponin level was associated with increasing mortality in patients with acute coronary syndrome,⁸ and also those without acute coronary syndrome.⁹ Despite the availability of international management guidelines, care provided for patients with acute coronary syndrome varied in hospitals with or without interventional facilities, and was affected by whether patients received cardiologist care.¹⁰ We examine the effects of comorbid diseases, including a validated comorbidity index,¹¹ and hospital care on the 6‐month outcome among patients with elevated cardiac troponin T, caused by acute coronary syndrome and other conditions.     

Paediatric acute peritoneal dialysis in southern Nigeria

Background

Acute peritoneal dialysis (APD) is the preferred treatment for isolated failure of the kidney. The authors reviewed children with acute renal failure (ARF) who had APD in Port Harcourt, Nigeria.

Results

221 patients, 147 boys and 74 girls (M: F, 1.99:1), mean (SD) age 5.4 (4.9) years had ARF. Dialysis was indicated in 112 cases. The main clinical indication being convulsion/uraemia 30 (26.8%) Only 27 patients (21 boys and 6 girls) had APD, giving an access rate of 24.1%. The commonest dialysis related complication was catheter malfunction 12 (44.4%). The mortality rate among the dialysed patients was 22.2%. Lack of dialysis and intractable hypertension significantly increased mortality (χ² = 7.13, p<0.01) and (χ² = 14.9, p<0.001) respectively.

Conclusion

APD is effective in reducing mortality of children with ARF. However, there were low dialysis access rate and few complications.     

Pulmonary leptospirosis: an excellent response to bolus methylprednisolone

Background

This case series analyses the beneficial effect of methylprednisolone in pulmonary leptospirosis, which usually has an aggressive course and grave outcome.

Methods

30 patients of pulmonary leptospirosis were evaluated. The initial 13 patients did not receive corticosteroids while the remaining 17 all received bolus methylprednisolone one gram intravenously for three days followed by oral prednisolone 1 mg/kg for seven days, on the basis of occasional case reports of benefit in pulmonary leptospirosis. APACHE III and lung injury scores of similar severity were considered while comparing outcomes in those who received methylprednisolone with those who did not.

Results

Dyspnoea and haemoptysis were the commonest symptoms in those with pulmonary manifestations. Overall mortality was 18% (3 of 17) in patients who received methylprednisolone, as compared with 62% (8 of 13 patients) in those who did not (p<0.02). In patients with established acute lung injury (ALI score >2.5), five of eight patients survived in the subgroup with corticosteroids (37% mortality) while only one of nine patients survived in the group that did not receive corticosteroids (89% mortality). Corticosteroids affected outcome only if given within the first 12 hours after the onset of pulmonary manifestations. Mortality seemed to correlate with the APACHE scores, and number of quadrants affected on chest radiographs, more than with blood gas pressures.

Conclusions

Corticosteroids reduce mortality and change outcome significantly when used early in the management of pulmonary leptospirosis.     

Analysis of predictors of success in the MRCP (UK) PACES examination in candidates attending a revision course

Objective

To determine factors that predict success of candidates taking a revision course in preparation for the MRCP (UK) PACES (practical assessment of clinical examination skills) examination.

Design

A questionnaire survey of candidates attending a PACES revision course. Results were correlated with subsequent pass lists published by the Colleges of Physicians

Setting and subjects

Candidates attending courses in June and October 2002. In total, 523 candidates completed questionnaires, evenly balanced between UK and overseas graduates.

Results

Of 483 candidates who took the examination immediately after the course, 219 (45.3%) passed. UK graduates were more likely to pass (67.0%) than overseas graduates (26.2%) (p = 0.003, odds ratio 5.72). For UK graduates, pass rates were higher for white candidates (73%) than for ethnic minorities (56%) (p = 0.012, OR 2.15) and for those who passed at the first attempt in the MRCP (UK) part 2 written paper (p = 0.003, OR 2.90). For overseas graduates, those who had been qualified for less than eight years were more likely to pass (p = 0.001, OR 2.78). More overseas (45.7%) than UK (30.8%) graduates were confident that they would pass, but confidence did not predict success.

Conclusion

Among candidates taking a revision course, UK graduates are more likely to pass the PACES examination than non‐UK graduates. Ethnic minority UK graduates seem to have a significantly poorer success rate, although this requires confirmation in an independent sample. If confirmed, these differences merit further investigation to assess whether they reflect genuine differences in ability.     

Clinical presentation and incidence of complications in patients with coeliac disease diagnosed by relative screening

Background

There is an increased prevalence of coeliac disease (CD) among relatives of those with the disease.

Aims

To compare the clinical features in patients with CD detected via family screening with those in patients diagnosed routinely.

Methods

Information on screening was provided to relatives of patients. Those who wished to be screened were tested for endomysial and/or tissue transglutaminase antibodies. Duodenal biopsy was performed in those with positive antibodies. The clinical details of the relative screening group were compared with those of 105 patients diagnosed routinely.

Results

183 relatives underwent screening, of whom 32 had positive serology, 24 had histology diagnostic of CD, six had normal biopsies and two declined duodenal biopsy. Patients in the relative screening group were younger with a median age of 33 years (range 17–72 years) compared to the routine group which had a median age of 54 years (range 25–88 years). In the relative screening group, there was a male preponderance (M:F ratio 16:8), anaemia at presentation was significantly less common (13% v 58%; p<0.001) and osteoporosis was less frequent (9% v 22%; p<0.244) compared with the routine group. 65% of the relative screening group had gastrointestinal symptoms or anaemia at diagnosis.

Conclusions

Patients detected by family screening are younger with a male preponderance, but fewer had anaemia and osteoporosis.     

A 30 year perspective of the quality of evidence published in 25 clinical journals: Signs of change?

Methods

The quality of clinical studies published in five different specialties, over three decades was evaluated. Computerised search of the Medline database was undertaken to evaluate the articles published in 25 clinical journals in 1983, 1993, and 2003 from five different specialties (medicine, surgery, paediatrics, anaesthesia, and psychiatry). The number of randomised controlled trials (RCTs), meta‐analyses, and other clinical trials (non‐RCT) were noted.

Results

From the 27 030 articles evaluated, there were 2283 (8.4%) RCTs, 166 (0.6%) meta‐analyses, and 4153 (15.4%) other clinical trials. For the proportion of RCTs, the rank order of the specialties was; anaesthesia (503; 18%), psychiatry (294; 9.6%), medicine (899; 8.1%), paediatrics (326; 6.4%), and surgery (261; 5.3%) (p<0.001). For the proportion of meta‐analysis, the rank order of the specialties was; psychiatry (36; 1.2%), medicine (105; 0.9%), paediatrics (15; 0.3%), anaesthesia (6; 0.2%), and surgery (4; 0.1%) (p<0.001). Overall, from 1983 to 2003, there were increases in the proportion of RCTs (449, 5.9% to 1027, 9.6%), meta‐analysis (0, 0% to 127, 1.2%), and other clinical trials (897, 12% to 1983, 19%) (p<0.001). This trend was apparent in each clinical specialty (p<0.001).

Conclusions

Over the three decades evaluated, clinical trials, notably RCTs and meta‐analysis form only a small proportion of articles published in prominent journals from five clinical specialties. This is notwithstanding the modest increases in the proportions of RCTs and meta‐analysis over the same period.     

Research productivity of the medical faculty at the American University of Beirut

Objective

To analyse the quality and quantity of scientific publications of the medical faculty at the American University of Beirut (AUB) during a six year period (1996–2001)

Methods

The study included all faculty members in the medical school of AUB in the year 2001. A Medline search inclusive of the years 1996–2001 was done for each faculty member and a total number of 881 publications was obtained.

Results

The faculty consisted of 203 members. Their average productivity rate (mean (SD)) was 1.24 (1.38) publications/faculty member/year (PFY), with a mean impact factor of 2.69 (4.63). Eighteen per cent of the faculty did not have any publication in the six year study period, and only 20% had two or more publications per year. There was a significantly higher publication rate among newly recruited faculty members (0.93 (1.40) PFY for those appointed before 1990, 1.45 (1.24) PFY for those appointed during 1990–1995, and 1.67 (1.43) for those appointed after 1995, p = 0.007), and among those who are younger in age (p<0.01). Collaboration with international investigators resulted in more original publications than work done only at AUB (65% v 35%, p<0.001), and a higher journal impact factor for the publications (3.20 (3.85) v 1.71 (2.36), p<0.05).

Conclusions

This is one of the first studies that analyse the research productivity of the medical faculty in a university setting in a developing country. It shows a wide variation in the research productivity of the faculty members that seems to be related to individual as well as institutional characteristics. Further analysis is needed to define and characterise these factors.     

Secular trends in the medical discharge summary in an acute medical hospital

Background

Although recent research has reported an evolution in the level of medical care, little is known about secular trends in the medical discharge summary.

Methods

The audit evaluated the evolution of discharge summary abstract over a decade in an acute medicine hospital among three successive periods of 1994, 2000, and 2005.

Results

Of the 140 random samples of discharge summaries, significant between‐cohort difference existed in the logarithm transformed length of discharge summary; the median length of discharge summary increased from 11 lines in 1994 to 26 lines in 2005 (p<0.001 corrected for multiple comparison). The closest univariate associations of discharge summary length were positively with the year of hospitalisation, length of stay, length of wordings about discharge plan and duplication of previous discharge summary, and negatively with clinical or planned admission (all p<0.01). In a multiple linear regression analysis, the year of patient admission correlated significantly with the length of discharge summary (p<0.001).

Conclusions

Over the 10 year study period, significant secular trends were seen in the discharge summary length and discharge plan documentation. The causes and implications for these trends deserve further investigation.     

Effect of an acute medical admission unit on key quality indicators assessed by funnel plots

Objective

To determine the effect of the introduction of an acute medical admissions unit (AMAU) on key quality efficiency and outcome indicator comparisons between medical teams as assessed by funnel plots.

Methods

A retrospective analysis was performed of data relating to emergency medical patients admitted to St James'' Hospital, Dublin between 1 January 2002 and 31 December 2004, using data on discharges from hospital recorded in the hospital in‐patient enquiry system. The base year was 2002 during which patients were admitted to a variety of wards under the care of a named consultant physician. In 2003, two centrally located wards were reconfigured to function as an AMAU, and all emergency patients were admitted directly to this unit. The quality indicators examined between teams were length of stay (LOS) <30 days, LOS >30 days, and readmission rates.

Results

The impact of the AMAU reduced overall hospital LOS from 7 days in 2002 to 5 days in 2003/04 (p<0.0001). There was no change in readmission rates between teams over the 3 year period, with all teams displaying expected variability within control (95%) limits. Overall, the performance in LOS, both short term and long term, was significantly improved (p<0.0001), and was less varied between medical teams between 2002 and 2003/04.

Conclusions

Introduction of the AMAU improved performance among medical teams in LOS, both short term and long term, with no change in readmissions. Funnel plots are a powerful graphical technique for presenting quality performance indicator variation between teams over time.     

Is rheumatoid arthritis a disease that starts in the intestine? A pilot study comparing an elemental diet with oral prednisolone

Objectives

This pilot study aimed to determine if an elemental diet could be used to treat patients with active rheumatoid arthritis and to compare its effect to that of oral prednisolone.

Methods

Thirty patients with active rheumatoid arthritis were randomly allocated to 2 weeks of treatment with an elemental diet (n = 21) or oral prednisolone 15 mg/day (n = 9). Assessments of duration of early morning stiffness (EMS), pain on a 10 cm visual analog scale (VAS), the Ritchie articular index (RAI), swollen joint score, the Stanford Health Assessment Questionnaire, global patient and physician assessment, body weight, erythrocyte sedimentation rate (ESR), C‐reactive protein (CRP) and haemoglobin, were made at 0, 2, 4 and 6 weeks.

Results

All clinical parameters improved in both groups (p<0.05) except the swollen joint score in the elemental diet group. An improvement of greater than 20% in EMS, VAS and RAI occurred in 72% of the elemental diet group and 78% of the prednisolone group. ESR, CRP and haemoglobin improved in the steroid group only (p<0.05).

Conclusions

An elemental diet for 2 weeks resulted in a clinical improvement in patients with active rheumatoid arthritis, and was as effective as a course of oral prednisolone 15 mg daily in improving subjective clinical parameters. This study supports the concept that rheumatoid arthritis may be a reaction to a food antigen(s) and that the disease process starts within the intestine.     

Dietary habits of young people attending secondary schools serving a multiethnic, inner-city community in the UK

Background

Childhood obesity is an escalating health concern with important implications, including increased risk of type 2 diabetes and cardiovascular disease. Although South Asians in the UK have an increased risk of developing these conditions, detailed studies on their lifestyles including the dietary habits of young people are scarce.

Methods

As part of an action research project, a food intake questionnaire was used to survey the dietary habits of 11–15‐year olds attending five inner‐city schools serving a predominantly South Asian population. Food choices were considered in the overall sample and in South Asians compared with white Europeans.

Results

3418 (72% of registered pupils) responses were obtained. A subset of 3018 pupils could be categorised as either South Asian (86%) or white European (14%). Around one fifth of pupils started the school day without eating anything. Responses indicated high consumption of “negative” foods such as sweets, including Asian sweets (63%), but lower rates for “positive” foods such as vegetables (34%). In the full sample, 26% said they had consumed more than one can of sugar‐sweetened fizzy drink and 17% reported eating more than one packet of full‐fat crisps on the previous day. Poor dietary habits were indicated in both South Asian and white European pupils.

Conclusions

Our large‐scale survey confirmed poor dietary habits in secondary school pupils from a multiethnic community. Urgent efforts are needed to find ways of encouraging healthy lifestyles, particularly in populations with a high risk of developing cardiovascular disease and type 2 diabetes.     

Paracetamol availability and recent changes in paracetamol poisoning: is the 1998 legislation limiting availability of paracetamol being followed?

Objective

To determine the degree of adherence to legislation introduced in 1998 restricting the availability of over the counter paracetamol.

Design

A prospective observational study.

Setting

An emergency department in an inner city London teaching hospital. Pharmacy and non‐pharmacy outlets in south London.

Main outcome measures

(1) The source of paracetamol ingested by 107 patients presenting with an acute paracetamol overdose (2001–2003) and (2) the ability to purchase paracetamol from pharmacy and non‐pharmacy outlets in a manner contravening paracetamol pack size legislation (2004).

Results

Potentially toxic amounts of paracetamol in excess of pack size restrictions were purchased in 70% (17 of 24) of outlets. Forty six per cent of patients who had ingested a potentially toxic dose of paracetamol obtained the tablets in a manner contravening the 1998 legislation.

Conclusion

Legislation limiting the availability of over the counter paracetamol is not being adhered to in south London. A significant number of patients ingesting a potentially toxic dose of paracetamol report purchasing the tablets in a manner contravening the legislation. Studies that attempt to assess the impact of the legislation need to be interpreted in the context of these results. Measures to enforce current legislation may help to reduce the severity of paracetamol poisoning in the UK.     

Comparison of a basic and an advanced pharmacotherapy-related clinical decision support system in a hospital care setting in the Netherlands

Objective

To compare the clinical relevance of medication alerts in a basic and in an advanced clinical decision support system (CDSS).

Design

A prospective observational study.

Materials and methods

We collected 4023 medication orders in a hospital for independent evaluation in two pharmacotherapy-related decision support systems. Only the more advanced system considered patient characteristics and laboratory test results in its algorithms. Two pharmacists assessed the clinical relevance of the medication alerts produced. The alert was considered relevant if the pharmacist would undertake action (eg, contact the physician or the nurse). The primary analysis concerned the positive predictive value (PPV) for clinically relevant medication alerts in both systems.

Results

The PPV was significantly higher in the advanced system (5.8% vs 17.0%; p<0.05). Significant differences were found in the alert categories: drug–(drug) interaction (9.9% vs 14.8%; p<0.05), drug–age interaction (2.9% vs 73.3%; p<0.05), and dosing guidance (5.6% vs 16.9%; p<0.05). Including laboratory values and other patient characteristics resulted in a significantly higher PPV for the advanced CDSS compared to the basic medication alerts (12.2% vs 23.3%; p<0.05).

Conclusion

The advanced CDSS produced a higher proportion of clinically relevant medication alerts, but the number of irrelevant alerts remained high. To improve the PPV of the advanced CDSS, the algorithms should be optimized by identifying additional risk modifiers and more data should be made electronically available to improve the performance of the algorithms. Our study illustrates and corroborates the need for cyclic testing of technical improvements in information technology in circumstances representative of daily clinical practice.