Acute cooling of the feet and the onset of common cold symptoms

Background. There is a common folklore that chilling of thebody surface causes the development of common cold symptoms,but previous clinical research has failed to demonstrate anyeffect of cold exposure on susceptibility to infection withcommon cold viruses. Objective. This study will test the hypothesis that acute coolingof the feet causes the onset of common cold symptoms. Methods. 180 healthy subjects were randomized to receive eithera foot chill or control procedure. All subjects were asked toscore common cold symptoms, before and immediately after theprocedures, and twice a day for 4/5 days. Results. 13/90 subjects who were chilled reported they weresuffering from a cold in the 4/5 days after the procedure comparedto 5/90 control subjects (P = 0.047). There was no evidencethat chilling caused any acute change in symptom scores (P =0.62). Mean total symptom score for days 1–4 followingchilling was 5.16 (±5.63 s.d. n = 87) compared to a scoreof 2.89 (±3.39 s.d. n = 88) in the control group (P =0.013). The subjects who reported that they developed a cold(n = 18) reported that they suffered from significantly morecolds each year (P = 0.007) compared to those subjects who didnot develop a cold (n = 162). Conclusion. Acute chilling of the feet causes the onset of commoncold symptoms in around 10% of subjects who are chilled. Furtherstudies are needed to determine the relationship of symptomgeneration to any respiratory infection. Keywords. Cold exposure, common cold, infection, nose.     

A clustered randomized trial of the effects of feedback using academic detailing compared to postal bulletin on prescribing of preventative cardiovascular therapy

Background. Interventions to promote prescribing of preventivetherapies in patients with cardiovascular disease (CVD) or diabeteshave reported variable success. Objective. (i) To evaluate the effect of prescribing feedbackon GP practice using academic detailing compared to postal bulletinon prescribing of CVD preventive therapies in patients withCVD or diabetes at 3 and 6 months post intervention and (ii)to evaluate the intervention from a GP's perspective. Methods. Volunteer GP practices (n = 98) were randomized toreceive individualized prescribing feedback via academic detailing(postal bulletin plus outreach visit) (n = 48) or postal bulletin(n = 50). The proportion of CVD or diabetic patients on statinsand antiplatelet agents/warfarin pre- and post-interventionwas calculated for each GP practice. Multivariate regressionwith a random effects model was used to compare differencesbetween the groups adjusting for GP clustering and confoundingfactors. ß-Coefficients and 95% confidence intervals(CIs) are presented. Results. There was a 3% increase in statin prescribing in CVDpatients at 6 months post-intervention for both randomized groups,but there was no statistical difference between the groups (ß= 0.004; 95% CI = –0.01 to 0.02). Statin and antiplatelet/warfarinprescribing also increased in the diabetic population; therewas no significant differences between the groups. GPs participatingin the project expressed a high level of satisfaction with bothinterventions. Conclusion. Prescribing of preventive therapies increased inboth randomized groups over the study period. But academic detailingdid not have an additional effect on changing prescribing overthe postal bulletin alone. Keywords. Academic detailing, feedback, prescribing, primary care.     

Can we measure the ankle-brachial index using only a stethoscope? A pilot study

Background. Ankle-brachial index (ABI) is an excellent methodfor the diagnosis of peripheral arterial disease (PAD) whenit is performed with Doppler. However, this device is not alwaysavailable for primary care physicians. The ABI measured withstethoscope is an easy alternative approach, but have not beenproved to be useful. Objective. To assess the accuracy of the ABI measured usinga stethoscope comparatively to that of the current eligiblemethod for the diagnosis of PAD, the Doppler ABI, and describethe characteristics of this new approach. Methods. We conducted a diagnostic study of ABI measured witha stethoscope and a Doppler probe and compared the results.Eighty-eight patients were accessed by both methods. Results. Mean stethoscope ABI, 1.01 ± 0.15, and meanDoppler ABI, 1.03 ± 0.20, (P = 0.047) displayed a goodcorrelation. Measurements of stethoscope ABI diagnostic accuracyin recognizing a Doppler ABI are described. The comparison ofthis data with the current gold standard method results gavea sensitivity of 71.4% [95% confidence interval (CI), 41.9–91.6]and specificity of 91.0% (95% CI, 81.5–96.6), with predictivepositive value of 62.5% (95% CI, 38.6–81.5) and negativepredictive value of 93.8% (95% CI, 85.2–97.6). The studyaccuracy was 87.7%. The area under the ROC curve was 0.895 (95%CI, 0.804–0.986, P < 0.0001). Conclusions. According to our study, the stethoscope ABI isa useful method to detect PAD and it may be suitable for itsscreening in the primary care setting. Keywords. Ankle-brachial index, peripheral arterial disease, stethoscope.     

UK research staff perspectives on improving recruitment and retention to primary care research; nominal group exercise

Background. Primary care studies often encounter recruitmentdifficulties, but there is little evidence to inform solutions.As part of a National Institute for Health Research School forPrimary Care Research and UK Clinical Research Network programme,we elicited research staff perspectives on factors facilitatingor obstructing recruitment. Objective. To identify factors that experienced research staffconsider important in successful recruitment and retention andtheir confidence in achieving them. Methods. An iterative series of three workshops was held. Thethird used a modified nominal group technique to categorizewhether factors related to the ‘context’ in whichthe research took place, the ‘content’ of the studyor the recruitment ‘process’ and to prioritize themby their importance to success. Results. Eighteen research staff participated in the prioritizationworkshop. They prioritized positive attitudes of primary carestaff towards research and trust of researchers by potentialparticipants as major contextual factors affecting recruitment.Studies needed to be considered safe and relevant by staff andfit with practice systems. They proposed that researchers strengthenrelationships with staff and participants and minimize workloadfor primary care teams. Although confident in many recruitmentprocesses, respondents remained uncertain how to achieve culturalchange so that research became part of normal practice activityand how best to motivate patients to participate. Conclusions. Research workers taking part identified factorswhich might be important in recruitment, several of which theyexpressed little confidence in addressing. Understanding howto improve recruitment is crucial if current efforts to strengthenprimary care research are to bear fruit. Keywords. Attitude of health personnel, health services research, patient selection, primary health care, randomized-controlled trials.     

Prevalence of distress and symptom severity from the lower urinary tract in men: a population-based study with the DAN-PSS questionnaire

Background. Lower urinary tract symptoms (LUTS) are a commonand costly public health issue. The prevalence varies greatlyin published reports. The distress caused by each symptom isimportant to assess the primary care required before therapeuticdecisions or a referral to an urologist are made. Objectives. LUTS are highly prevalent in men, but less is knownregarding the distress caused by each symptom. The aim of thisstudy was to examine symptom severity and different levels ofdistress using the Danish Prostatic Symptom Score (DAN-PSS)questionnaire in men affected by symptoms from the lower urinarytract. Methods. The study included all men aged 41–81 years (n= 504) that, 12 months earlier in a population-based survey,had reported stress incontinence, urgency or post-micturitiondribbling in a postal questionnaire. The DAN-PSS questionnairewas used to measure severity and distress from LUTS. Results. In total, 311 (80%) of the 387 responders who reportedat least one symptom experienced some level of distress. Themost distressing symptom overall was urinary incontinence. Nineof 10 men with storage symptoms (stress, urge and ‘other’urinary incontinence) reported distress even if the symptomoccurred only seldom. Moreover, two-thirds of the men with themost frequent symptom, post-micturition dribbling, characterizedtheir symptom as moderate or severe; the most distressing voidingsymptom was weak stream. In general, LUTS were well tolerated. Conclusion. Urge incontinence was the most distressing LUTSeven when occurring only seldom. The DAN-PSS questionnaire maybe a potentially useful tool for health professionals to identifypatients with pronounced distress from LUTS to offer therapeuticand nursing care on the relevant level. Keywords. DAN-PSS, distress, LUTS, population-based, postal questionnaire.     

The real ethical problem

In this issue, we publish a study of medication errors [1] andan accompanying editorial [2] that raises several ethical concernsabout the study and also about the decision to publish the article.As the editor, I wish to explain my position. When do we need ethical oversight? I have argued previously that we need more ethical oversightof quality improvement projects, whether     

Which agents cause reactive airways dysfunction syndrome (RADS)? A systematic review

Aim To identify those agents reported as being associated withreactive airways dysfunction syndrome (RADS). Methods A systematic review was undertaken. Abstracts were screenedand those selected reviewed against pre-determined diagnosticcriteria for RADS. Results Significant information gaps were identified for allmeasures of interest. In some articles, even the causative agentwas not reported. The most commonly reported agents were chlorine(nine subjects), toluene di-isocyanate (TDI) (n = 6) and oxidesof nitrogen (n = 5). Most exposures occurred in the workplace(n = 51) and affected men (60%). Dyspnoea (71%) and cough (65%)were the commonest symptoms. Median symptom duration was 13months (interquartile range = 6.5–43.5) for RADS. Conclusions Although the most commonly reported agent associatedwith RADS was chlorine, the main finding of a general lack ofadequate information on exposure, investigation and outcomesuggests that to better explore RADS a more structured approachto gathering information is required. A minimum data set forreporting RADS cases is proposed.     

Reversal of ethanol-induced hepatic steatosis and lipid peroxidation by taurine: a study in rats

We read with interest the study reported by Kerai et al. inthe July–August (1999) issue of Alcohol and Alcoholism.The authors concluded that hepatic steatosis and lipid peroxidationcaused by chronic alcohol consumption in rats can be reversedby administration of taurine. Furthermore, . . . [Full Text of this Article]FOOTNOTESREFERENCES     

C-reactive protein and community-acquired pneumonia in ambulatory care: systematic review of diagnostic accuracy studies

Background. There is uncertainty regarding the diagnostic valueof C-reactive protein (CRP) in patients presenting with symptomssuggestive of community-acquired pneumonia (CAP) in communityor ambulatory settings. Objective. We assessed the diagnostic value of CRP in primarycare and accident and emergency departments in terms of rulingin or ruling out CAP. Methods. Diagnostic accuracy systematic review, we searchedPubMed from January 1966 to September 2008 and EMBASE from January1980 to September 2008 using a diagnostic accuracy search filter.We included cross-sectional or cohort studies that assess thediagnostic utility of CRP at different cut-points against areference standard of chest X-ray. We calculated pooled positiveand negative likelihood ratios (LRs) and assessed heterogeneityusing the I² index. Results. Eight studies incorporating 2194 patients were included.The median prevalence of CAP was 14.6% (range 5%–89%).At a CRP cut-point of 20 mg/l, the pooled positive LR+ was 2.1[95% confidence interval (CI) 1.8–2.4] and the poolednegative LR– was 0.33 (95% CI 0.25–0.43). At thetwo other CRP cut-points (50, >100 mg/l), the results wereheterogeneous, so the pooled results should be interpreted withcaution. Conclusions. CRP may be of value in ruling out a diagnosis ofCAP in situations where the probability of CAP >10%, typicallyaccident and emergency departments. In primary care, additionaldiagnostic testing with CRP is unlikely to alter the probabilityof CAP sufficiently to change subsequent management decisionssuch as antibiotic prescribing or referral to hospital. Keywords. Ambulatory care, C-reactive protein, diagnosis, pneumonia.     

A factor analysis of the important people inventory

Aims:For well over a decade, the Important People Inventory(IP, Clifford and Longabaugh, 1991; Clifford et al., 1992) hasbeen used to collect a wide range of valuable information regardingnetwork support for alcohol use. However, because of psychometriclimitations and varied adaptations of the IP, the followingstudy performed factor analyses to develop a more structurallyconsistent model of the scaleas compared to the existing model.MethodsA first principal components analysis (Varimax rotation) wasrun on the indices of the IP using data from a national investigationof residents within a recovery community (N = 897).Next, a second principal components analysis was run using datacollected from participants recruited from inpatient treatmentsettings (N = 150).Results Results indicated a nine-index,three-factor model, which explained about two thirds of thecommon variance. These three factors included: Support for Drinkingfrom Network Members (3 items), Drinking Behaviours of NetworkMembers (3 items), and General Social Support (3 items).ConclusionsResultsof both studies suggest that the IP fits a multi-component structure.It is recommended that Drinking Behaviours of Network Membersbe examined for predictive validity and that General SocialSupport be removed from the scale or have additional items added.     

Secondary depression in weaned alcoholics: implications of Lesch's typology of chronic alcoholism

Schuckit (1983) described two types of alcohol-related depression:(1) the common type, in which secondary depression disappearswithout treatment within the first few weeks of abstinence;(2) a less frequent type, primary depression, requiring specifictreatment. It is difficult to anticipate whether an alcoholicpatient needs antidepressive treatment or whether depressionwill remit spontaneously. A potential guide to differentiatedepressed alcoholic patients who might need specific treatmentfor depression could be the typology of Lesch et al. (1990).Based on . . . [Full Text of this Article]ConclusionFOOTNOTESREFERENCES     

Addendum

Since this article was written a report in The Lancet (T. W.Hoskins et al. (1973) 1, 116) has also shown that an injectablevaccine using the A/Hong Kong strain gave substantial protectionagainst the A/England/42/72 variant.     

Translation problems of the Spanish version of the Readiness to Change Questionnaire

The Readiness to Change Questionnaire instrument by Rollnicket al. (1992) has become a standard in assessing stages of changeamong substance users. It has found such widespread acceptancethat recently it has been translated into Spanish by Rodriguez-Martoset al. (2000). . . . [Full Text of this Article]FOOTNOTESREFERENCES     

Occupational Mortality in the Armed Services

This article intends to show that the Services mortality experiencehas been somewhat misrepresented in recent publications, andthe reasons for this. I have also pointed out some areas wherewe are well aware that our experience is below average, andhave highlighted accidental deaths mainly due to road trafficaccidents and deaths in soldiers from ischaemic heart disease,as areas of concern. Accepted        1 October 1981 Requests for reprints should be addressed to: Col. P. J. Blackburn, Ministry of Defence (AMO 5), First Avenue House, High Holborn, London. ^*Paper presented at the Joint Services and Faculty of OccupationalMedicine Conference held at the Institute of Naval Medicine,Alverstoke, 29-30 January 1981.     

Doctors, their mental health and capacity for work

Background Information about doctors’ mental ill-healthis limited. This study looks at doctors’ careers followingmental illness and the strategies that helped them return towork. Aim To examine the effect of mental ill-health on doctors’careers. Methods Questionnaire survey of members of the Doctors SupportNetwork (DSN). The DSN is a peer support group for doctors whohave experienced, or are experiencing, mental ill-health. Results One hundred and sixteen doctors (35% response rate)returned completed questionnaires (n = 116, 63% female, 37%male). Prior to their ill-health, 80% worked full time, 15%part-time, 2% were not working and 3% were medical students.Following illness, 33% worked full time (P < 0.05), 36% part-time(P < 0.05) and 29% were not working (P < 0.01). Flexibleworking practices were the most helpful reported strategy forenabling a doctor to return to work. Conclusions Following mental ill-health, a doctor’s capacityto work full time is reduced. Most doctors return to full-timeor part-time work. With improved support, more doctors may beable to return to work.     

Is daily single dosage of diazepam as effective as chlordiazepoxide in divided doses in alcohol withdrawal--a pilot study

We report on a pilot double-blind study on the effectivenessof divided doses of chlordiazepoxide and a single daily doseof diazepam in the treatment of the alcohol-withdrawal syndrome.While a variety of drugs (chlormethiazole, propranolol and clonidine)have been used for treatment of alcohol-withdrawal symptoms,benzodiazepines remain the drugs of choice for alcohol detoxification(Mayo-Smith, 1997). Diazepam and chlordiazepoxide are both . . . [Full Text of this Article]APPENDIXFOOTNOTESREFERENCES     

Writing a research article: advice to beginners.

Writing research papers does not come naturally to most of us.The typical research paper is a highly codified rhetorical form[1,2]. Knowledge of the rules—some explicit, others implied—goesa long way toward writing a paper that will get accepted ina peer-reviewed journal. Primacy of the research question A good research paper addresses a specific research question.The research question—or study objective or main researchhypothesis—is the central organizing principle of thepaper. Whatever relates to the research question belongs inthe paper; the rest doesn’t. This is perhaps obvious whenthe paper reports on a well planned research project. However,in     

Empowering women to obtain high quality care: evidence from an evaluation of Mexico's conditional cash transfer programme

Objectives To evaluate the impact of Mexico's conditional cashtransfer programme on the quality of health care received bypoor women. Quality is measured by maternal reports of prenatalcare procedures received that correspond with clinical guidelines. Methods The data describe retrospective reports of care receivedfrom 892 women in poor rural communities in seven Mexican states.The women were participating in an effectiveness study and randomlyassigned to incorporation into the programme in 1998 or 1999.Eligible women accepted cash transfers conditional on obtaininghealth care and nutritional supplements, and participated inhealth education sessions. Results Oportunidades beneficiaries received 12.2% more prenatalprocedures compared with non-beneficiaries (adjusted mean 78.9,95% Confidence Interval (CI): 77.5–80.3; P < 0.001). Conclusion The Oportunidades conditional cash transfer programmeis associated with better quality of prenatal care for low-income,rural women in Mexico. This result is probably a manifestationof the programme's empowerment goal, by encouraging beneficiariesto be informed and active health consumers.