bluuebunny/crossref_metadata_2025 huggingface dataset:
Methicillin-Resistant Staphylococcus Aureus in a General Intensive Care Unit
Authors: Thompson D S
Published: November 2017

Methicillin-resistant Staphylococcus aureus (MRSA) has presented special problems in intensive care units (ICUs) because of the difficulties in implementing infection control measures. The prevalence and rate of acquisition of MRSA were studied over thirty months in a nine-bed ICU. Nasal and groin swabs were taken on admission and then weekly, and other cultures as clinically indicated.

Of 1361 admissions 119 were MRSA-positive on arrival. 21 cases had been identified before admission and the remainder were detected by screening; in 57 the positive result was known only after discharge. Of the 1242 admissions initially negative 68 acquired MRSA while in the ICU. The ICU had no known MRSA-positive patients on 185 (20.3%) of 914 days, the longest sequence being 17 days. Positive patients occupied 1387 (16.9%) of the 8226 available bed days. Length of stay predicted the risk of acquiring MRSA. Estimated from patients who completed each weekly screening cycle, the risk was 7.5% per week in the first week and 20.3% per week thereafter. The risk was not influenced by initial APACHE II score, the use of haemofiltration, or the number of MRSA-positive patients in the unit. The data suggest that a further 38 of those discharged between weekly screenings acquired MRSA, giving an incidence of 8.5%. MRSA was grown from blood in 17 patients, and from sputum in 53 (ICU-acquired in 18% and 47%).

This study suggests that nearly 10% of admissions to a general ICU will be MRSA-positive, of whom only half will be identified before discharge. With standard prevention the risk of previously negative patients acquiring MRSA approximates to 1% per day in the first week and 3% per day thereafter, with nearly one-fifth progressing to bacteraemia; one-half will have MRSA in sputum. Patients with longer stays constitute a high-risk minority for whom additional measures such as decontamination with oropharyngeal and enteral vancomycin should be considered.
Biochemical Recovery Time Scales in Elderly Patients with Osteomalacia
Authors: Allen S C , Raut S
Published: November 2017

Osteomalacia is not rare in the UK and climatically similar countries, particularly in elderly people and those of Asian descent. Overt clinical osteomalacia is usually treated with a loading dose of vitamin D, followed by a regular supplement. However, little is known of the time taken to reach a stable biochemical state after starting treatment. Such information would shed light on the duration of the bone remineralization phase and guide decisions on the length of follow-up. To address this we conducted a 2-year follow-up study of 42 patients (35 female, mean age 80.8 years) with biopsy proven osteomalacia treated with a standard replacement regimen and general nutritional support.

Although normocalcaemia was attained within 4 weeks the mean values continued to rise, to a mid-range plateau at 52 weeks. The phosphate and alkaline phosphatase values also took at least a year to reach a stable mean, with a slight further trend towards the mid-range for the entire 104 weeks. The mean serum albumin also rose throughout the first 52 weeks, indicating an effective response to the general nutritional support measures.

Our observations suggest that the dynamic relationship between calcium, phosphate and bone requires at least a year, and probably longer, to reach an equilibrium after treatment for osteomalacia in elderly patients. The findings emphasize the need for close medical and social follow-up in this clinical context.
Clinical Implications of ST-Segment Non-Resolution after Thrombolysis for Myocardial Infarction
Authors: Bhatia L , Clesham G J , Turner D R
Published: November 2017

Failed reperfusion after thrombolytic therapy for acute myocardial infarction is common and signifies a poor prognosis. We investigated the clinical consequences of non-resolution of the ST segment after thrombolytic therapy for acute ST-elevation myocardial infarction, in 85 consecutive patients admitted to a coronary care unit lacking rapid access to angioplasty. Failed thrombolysis was defined as <50% ST-segment resolution 180 minutes after the start of thrombolytic treatment. Outcomes were measured in terms of in-hospital adverse events, length of hospital stay, and mortality at 6 weeks and 1 year.

Thrombolysis was successful, in terms of ST-segment resolution, in 45 patients (53%). After adjustment for other factors, ST resolution was the only independent predictor of an uncomplicated recovery in hospital (odds ratio 6.8, 95% confidence interval 2.3 to 19.9; P < 0.001). At 6 weeks and 1 year, overall mortality was lower in the ST resolution group, though these differences became non-significant on multivariate analysis. In patients who survived to hospital discharge, median length of stay was greater in successfully thrombolysed patients (9 days versus 8 days) despite their lower rate of complications.

ST-segment resolution is a useful marker of successful thrombolysis and relates to clinical outcome. If assessed routinely it might assist, along with other clinical markers, in the identification of low-risk patients who can be discharged early.
Screening for Pulmonary Embolism with a D-Dimer Assay: Do we Still Need to Assess Clinical Probability as Well?
Authors: Hammond Christopher J , Hassan Tajek B
Published: November 2017

Clinical risk stratification and D-dimer assay can be of use in excluding pulmonary embolism in patients presenting to emergency departments but many D-dimer assays exist and their accuracy varies. We used clinical risk stratification combined with a quantitative latex-agglutination D-dimer assay to screen patients before arranging further imaging if required. Retrospective analysis of a sequential series of 376 patients revealed that no patient with a D-dimer of <275 ng/mL was diagnosed with pulmonary embolism, irrespective of clinical probability. We conclude that a latex-agglutination assay could be used to exclude pulmonary embolism without the necessity for clinical risk stratification. If these findings are borne out by further work, D-dimer strategies to exclude pulmonary embolism could substantially reduce imaging workload.
Community Diabetes: An East London Perspective
Authors: Gelding Susan V , Vijayaraghavan Shanti , Davison Clare , Chowdhury Tahseen A
Published: November 2017

The rising prevalence of type 2 diabetes in the UK has necessitated a change in the delivery of diabetes care, with a shift of focus from hospital to community. The National Service Framework for Diabetes has enshrined this approach, and the new General Medical Services (GMS2) contract rewards primary healthcare professionals for developing high-quality diabetes care. New approaches cross the primary/secondary care divide and are patient focused. The evolution of diabetes care in the UK is illustrated by service developments in Newham, East London.
Curtailment of Higher Surgical Training in the UK: Likely Effects in Otology
Authors: Ray J , Hadjihannas E , Irving R M
Published: November 2017

Higher surgical training in the UK faces a cut of two years. We conducted a questionnaire survey to assess the operative experience of current higher surgical trainees in otological surgery and the likely effect of the proposed reduction from six to four years.

91 (65%) of the 142 higher surgical trainees responded with details of major otological procedures performed (independently or assisting) over one year. In the present six-year scheme a typical trainee performs 72 myringoplasties, 79 mastoidectomies, 7 skull base procedures and 28 other procedures. In the first four years, however, his or her experience is only 39 myringoplasties, 44 mastoidectomies, 4 skull base procedures and 7 others.

The large shortfall in experience that might result from shortening of the training programme would need to be met by intensification of the training or institution of accredited otology fellowships. Very similar dilemmas are faced by other surgical specialties.
Jaundice as a Presentation of Heart Failure
Authors: van Lingen R , Warshow U , Dalton H R , Hussaini S H
Published: November 2017

On rare occasions the first manifestation of heart disease is jaundice, caused by passive congestion of the liver or acute ischaemic hepatitis. We looked for this presentation retrospectively in 661 patients referred over fifty-six months to a ‘jaundice hotline’ (rapid access) service. The protocol included a full clinical history, examination and abdominal ultrasound. Those with no evidence of biliary obstruction had a non-invasive liver screen for parenchymal liver disease and those with suspected heart disease had an electrocardiogram, chest X-ray and echocardiogram.

8 patients (1.2%), bilirubin 31–79 μmol/L, mean 46 μmol/L, had a primary cardiac cause for their jaundice. All had dyspnoea, an increased cardiothoracic ratio on chest X-ray and an abnormal electrocardiogram. The jugular venous pressure was raised in the 3 in whom it was recorded. In 6 patients the jaundice was attributed to hepatic congestion and in 2 to ischaemic hepatitis. All patients had severe cardiac dysfunction.

Jaundice due to heart disease tends to be mild, and a key feature is breathlessness. The most common mechanism is hepatic venous congestion; ischaemic hepatitis is suggested by a high aminotransferase.
Unfounded Worries about Cancer in Patients Attending a Routine Otolaryngology Clinic
Authors: Ali Safina , Bingham B J G
Published: November 2017

To investigate a suspicion that many ear, nose and throat patients have unfounded concerns about cancer, we questioned 50 patients who had attended a routine clinic after screening-out of those with possibly cancer-related features. None of the 50 proved to have cancer. 15 (30%) had been worried about cancer and 7 of these were still worried despite the consultation. Unwarranted fears about cancer are best dealt with by the referring clinician, especially when the wait for an appointment will be long. Such fears also need to be recognized and addressed by the specialist.
Brain Drain from Developing Countries: How can Brain Drain be Converted into Wisdom Gain?
Authors: Dodani Sunita , LaPorte Ronald E
Published: November 2017

Brain drain is defined as the migration of health personnel in search of the better standard of living and quality of life, higher salaries, access to advanced technology and more stable political conditions in different places worldwide. This migration of health professionals for better opportunities, both within countries and across international borders, is of growing concern worldwide because of its impact on health systems in developing countries. Why do talented people leave their countries and go abroad? What are the consequences of such migrations especially on the educational sector? What policies can be adopted to stem such movements from developing countries to developed countries?

This article seeks to raise questions, identify key issues and provide solutions which would enable immigrant health professionals to share their knowledge, skills and innovative capacities and thereby enhancing the economic development of their countries.
Research Governance: Where did it Come From, What Does it Mean?
Authors: Shaw Sara , Boynton Petra M , Greenhalgh Trisha
Published: November 2017

For a variety of historical and social reasons, research has become increasingly formalized and regulated. This change has potential benefits (reduction in fraud and misconduct, protection of vulnerable groups, financial probity) but also disadvantages (increased paperwork, time delays, constraints on research freedom).

The terms ‘research’ and ‘governance’ mean different things in different contexts. Even with explicit guidance, ambiguities must be resolved by human judgement. Variation in the nature and outcome of approval decisions is therefore a fact of life.

The type of approval needed for a research study depends on the official remit of the approval body, the question to be addressed; the methods to be used; the context in which the work will take place; the level of analysis and interpretation; and the plans for how the findings will be presented and used.
Venous Thromboprophylaxis in Uk Medical Inpatients
Authors: Rashid S T , Thursz M R , Razvi N A , Voller R , Orchard T , Rashid S T , Shlebak A A
Published: November 2017

We prospectively assessed the implementation of venous thromboembolism (VTE) prophylaxis guidelines and the impact of grand round presentation of the data in changing clinical practice. Two NHS teaching hospitals were studied for 24 months from January 2003. Patients were risk stratified according to the THRIFT (thromboembolic risk factor) consensus group guidelines and compared with the recommendations of the THRIFT and ACCP (American College of Chest Physicians) consensus groups. Six months following presentation of the initial results, a further analysis was made to assess changes in clinical practice.

1128 patients were assessed of whom 1062 satisfied the inclusion criteria for thromboprophylaxis. 89% of all patients were stratified as having high or moderate risk of developing VTE. Of these only 28% were prescribed some form of thromboprophylaxis–-4% received the THRIFT-recommended and 22% received the ACCP-recommended thromboprophylaxis. The vast majority (72%) received no thromboprophylaxis at all. Reassessment, following data presentation at grand rounds, showed a significant increase to 31% in patients receiving THRIFT (P<0.0001) and ACCP (P=0.002) recommended thromboprophylaxis. However, the proportion of patients receiving no form of prophylaxis barely changed (72% to 69%: P=0.59).

We found a gross underutilization of thromboprophylaxis in hospitalized medical patients. A simple grand-round presentation of the data and recommended guidelines to clinicians significantly increased the proportion of patients receiving recommended thromboprophylaxis but did not increase the overall proportion of patients receiving it. We therefore conclude that a single presentation of guidelines is not enough to achieve the desired levels. Such presentations may only serve to make DVT (deep venous thromboembolism) aware clinicians prescribe prophylaxis more accurately.
Pyosalpinx in a Man
Authors: Baig M K , Padmanabhan J , Liston T
Published: November 2017

True hermaphroditism is a rare condition, usually diagnosed soon after birth.1 In an adult, the male external genitalia may look normal.
Treatment with Octreotide to Suppress Corticotropin Secretion by a Carcinoid Tumour
Authors: Tirovola Eugenia B , Malpas James S
Published: November 2017

Ectopic secretion of corticotropin (ACTH) by a tumour is most likely to respond to somatostatin analogues if hypercortisolaemia has not yet developed.
A Surrealistic Mega-Analysis of Redisorganization Theories
Authors: Oxman Andrew D , Sackett David L , Chalmers Iain , Prescott Trine E
Published: November 2017

Background

We are sick and tired of being redisorganized.

Objective

To systematically review the empirical evidence for organizational theories and repeated reorganizations.

Methods

We did not find anything worth reading, other than Dilbert, so we fantasized. Unfortunately, our fantasies may well resemble many people's realities. We are sorry about this, but it is not our fault.

Results

We discovered many reasons for repeated reorganizations, the most common being ‘no good reason’. We estimated that trillions of dollars are being spent on strategic and organizational planning activities each year, thus providing lots of good reasons for hundreds of thousands of people, including us, to get into the business. New leaders who are intoxicated with the prospect of change further fuel perpetual cycles of redisorganization. We identified eight indicators of successful redisorganizations, including large consultancy fees paid to friends and relatives.

Conclusions

We propose the establishment of ethics committees to review all future redisorganization proposals in order to put a stop to uncontrolled, unplanned experimentation inflicted on providers and users of the health services.
Research Governance: Regulating Risk and Reducing Harm?
Authors: Shaw Sara , Barrett Geraldine
Published: November 2017

Risk assessment can be thought of as the lens through which we anticipate the consequences of research and the impact of the actions of researchers. The way in which risk of harm is managed in research is strongly influenced by the surrounding social and political environment, leading to differences in national and local styles of regulation and review.

Different research studies carry different risks, so systems for review and approval must adapt to the question being asked and the nature of the study. Researchers can never wholly guarantee safety in any research but participants and researchers must be offered reasonable protection within any study, with appropriate arrangements in place should something go wrong.
Do shock absorbing insoles in recruits undertaking high levels of physical activity reduce lower limb injury? A randomized controlled trial
Authors: Withnall Richard , Eastaugh Joanne , Freemantle Nick
Published: November 2017

Objectives

To assess the benefits, if any, of the use of shock absorbing insoles in reducing lower limb injury among Air Force recruits, and to assess the differences, if any, in the efficacy of two commonly available shock absorbing insoles.

Design

Randomized controlled trial. Setting: RAF Halton, UK. Site of all basic training for RAF personnel. Participants: 1205 recruits participating in basic training between 17 September 2003 and 7 April 2004. Interventions: Participants were randomized to receive either standard issue Saran non-shock absorbing insoles, or shock absorbing Sorbothane or Poron insoles, on a 1:1:1 basis.

Main Outcome Measures

The primary outcome measure was withdrawal from training for lower limb injury. The two primary comparisons were shock absorbing insole versus non-shock absorbing insole, and Sorbothane versus Poron (comparison of different shock absorbing insoles). Secondary outcomes were medical withdrawals for reasons other than those qualifying for the primary outcome measure.

Results

When comparing the non-shock absorbing insole to the shock absorbing insoles 72/401 participants (18.0%) allocated to Saran insoles were removed from training because of a qualifying lower limb injury, compared with 149/ 804 (18.5%) allocated to the shock absorbing insole (Sorbothane or Poron), odds ratio 1.04 (95% CI 0.75 to 1.44; P=0.87). When comparing the two shock absorbing insole 73/ 421 participants (17.3%) randomized to Sorbothane were removed from training because of a qualifying lower limb injury, compared with 76/383 for Poron (19.8%), odds ratio 0.85 (95% CI 0.58 to 1.23; P=0.37).

Conclusions

Similar rates of lower limb injuries were observed for all insoles (shock absorbing and non-shock absorbing) in the trial. The trial provides no support for a change in policy to the use of shock absorbing insoles for military recruits.
Association of Population and Practice Factors with pOtentially Avoidable Admission Rates for Chronic Diseases in London: Cross Sectional Analysis
Authors: Saxena Sonia , George Julie , Barber Julie , Fitzpatrick Justine , Majeed Azeem
Published: November 2017

Objectives:

To examine the association between underlying ill health, material deprivation and primary care supply factors and hospital admission rates for potentially avoidable admissions in primary care trusts in London.

Design:

Cross sectional analysis at primary care trusts level using routine data from multiple sources.

Setting:

All 31 primary care trusts in London with a total resident population of 7 million patients.

Main outcome measures:

Age-standardized hospital admission rates for asthma, diabetes, heart failure, hypertension and chronic obstructive pulmonary disease.

Results:

Admission rates varied widely for the conditions examined across the 31 primary care trusts. In 2001, age adjusted admission rates for asthma varied from 76 to 189 per 100 000 and for diabetes from 38 to 183 per 100 000. There was a significant association between higher admission rates and measures of underlying ill health and material deprivation but not quantitative measures of primary care service provision. Provision of specialist chronic disease services in primary care for diabetes but not for asthma were significantly associated with reduced admission rates. There was no association of prescribing levels in primary care trusts with admission rates for any of the conditions examined.

Conclusions:

Although hospital admission for some chronic diseases is potentially avoidable and rates of hospital admission for these conditions are possible indicators of the quality of care, they should be interpreted in conjunction with measures of population composition and deprivation. Failure to do this may result in primary care trusts and general practitioners being criticized for aspects of health care utilization that are not under their direct control.
The Doctor's PDA and Smartphone Handbook: Medical References
Authors: Al-Ubaydli Mohammad , Paton Chris
Published: November 2017

This is the fourth in a series of extracts from a forthcoming book by M Al-Ubaydli and C Paton. The website [ www.rsmpress.co.uk/bkpda.htm ] includes video tutorials to accompany this text.
Risk of Cardiovascular Events and Celecoxib: a Systematic Review and Meta-Analysis
Authors: Caldwell Brent , Aldington Sarah , Weatherall Mark , Shirtcliffe Philippa , Beasley Richard
Published: November 2017

Objectives

To examine whether the increased risk of cardiovascular events with rofecoxib represents a class effect of cyclooxygenase-2 (COX-2) specific inhibitors.

Design

Systematic review and meta-analysis of randomized double-blind clinical trials of celecoxib of at least 6 weeks’ duration and presented data on serious cardiovascular thromboembolic events. Data sources included six bibliographic databases, the relevant files of the United States Food and Drug Administration, and pharmaceutical company websites.

Main outcome measures

Pooled fixed effects estimates of the odds ratios for risk of cardiovascular events with celecoxib compared with comparator treatment were calculated using the inverse variance weight method. The main outcome measure was myocardial infarction.

Results

Four placebo-controlled trials with 4422 patients were included in the primary meta-analysis comparing celecoxib with placebo. The odds ratio of myocardial infarction with celecoxib compared to placebo was 2.26 (95% confidence interval 1.0 to 5.1). For composite cardiovascular events [odd ratio 1.38 (95% CI 0.91 to 2.10)], cardiovascular deaths [OR 1.06 (95% CI 0.38 to 2.95)] and stroke [OR 1.0 (95% CI 0.51 to 1.84)] there was no significant increase in risk with celecoxib. The secondary meta-analysis which included a total of six studies (with placebo, diclofenac, ibuprofen, and paracetamol as comparators) of 12 780 patients, showed similar findings with a significant increased risk with celecoxib for myocardial infarction [OR 1.88 (95% CI 1.15 to 3.08)] but not other outcome measures.

Conclusion

The available data indicate an increased risk of myocardial infarction with celecoxib therapy, consistent with a class effect for COX-2 specific inhibitors.
Open Access Publishing and Author-Pays Business Models: A Survey of Authors’ Knowledge and Perceptions
Authors: Schroter Sara , Tite Leanne
Published: November 2017

Objectives

We aimed to assess journal authors’ current knowledge and perceptions of open access and author-pays publishing.

Design

An electronic survey.

Setting

Authors of research papers submitted to BMJ, Archives of Disease in Childhood, and Journal of Medical Genetics in 2004.

Main outcome measures

Familiarity with and perceptions of open access and author-pays publishing. Results: 468/1113 (42%) responded. Prior to definitions being provided, 47% (222/468) and 38% (176/468) reported they were familiar with the terms ‘open access’ and ‘authorpays’ publishing, respectively. Some who did not at first recognize the terms, did claim to recognize them when they were defined. Only 10% (49/468) had submitted to an author-pays journal. Compared with non-open access subscription-based journals, 35% agreed that open access author-pays journals have a greater capacity to publish more content making it easier to get published, 27% thought they had lower impact factors, 31% thought they had faster and more timely publicaitons, and 46% agreed that people will think anyone can pay to get published. 55% (256/468) thought they would not continue to submit to their respective journal if it became open access and charged, largely because of the reputaiton of the journals. Half (54%, 255/468) said open access has ‘no impact’ or was ‘low priority’ in their submission decisions. Two-thirds (66%, 308/468) said they would prefer to submit to a non-open access subscription-based journal than an open access author-pays journal. Over half thought they would have to make a contribution or pay the full cost of an author charge (56%, 262/468).

Conclusions

The survey yielded useful information about respondents’ knowledge and perceptions of these publishing models. Authors have limited familiarity with the concept of open-access publishing and surrounding issues. Currently, open access policies have little impact on authors’ decision of where to submit papers.
A Systematic Review of Systematic Reviews of Spinal Manipulation
Authors: Ernst E , Canter P H
Published: November 2017

Objectives

To systematically collate and evaluate the evidence from recent systematic reviews of clinical trials of spinal manipulation.

Design

Literature searches were carried out in four electronic databases for all systematic reviews of the effectiveness of spinal manipulation in any indication, published between 2000 and May 2005. Reviews were defined as systematic if they included an explicit and repeatable inclusion and exclusion criteria for studies.

Results

Sixteen papers were included relating to the following conditions: back pain (n=3), neck pain (n=2), lower back pain and neck pain (n=1), headache (n=3), non-spinal pain (n=1), primary and secondary dysmenorrhoea (n=1), infantile colic (n=1), asthma (n=1), allergy (n=1), cervicogenic dizziness (n=1), and any medical problem (n=1). The conclusions of these reviews were largely negative, except for back pain where spinal manipulation was considered superior to sham manipulation but not better than conventional treatments.

Conclusions

Collectively these data do not demonstrate that spinal manipulation is an effective intervention for any condition. Given the possibility of adverse effects, this review does not suggest that spinal manipulation is a recommendable treatment.
Self-Image in Obesity: Clinical and Public Health Implications
Authors: Krentz Andrew J
Published: November 2017

‘I know that I am more than my personality, my body, and my body image’. Oprah Winfrey
A Pandemic on the Horizon
Authors: Donaldson Liam
Published: November 2017

A pandemic of human influenza is on the horizon: the question is not whether it will arrive but when. Knowing that a pandemic is coming provides an opportunity to plan ahead to mitigate against its impact. However, there are inevitably many uncertainties and managing these, under a constant media spotlight, is an additional and novel challenge.
Research Misconduct: The Poisoning of the Well
Authors: Smith Richard
Published: November 2017

Richard Smith was editor of the BMJ and chief executive of the BMJ Publishing Group for 13 years. In his last year at the journal he retreated to a 15th century palazzo in Venice to write a book. This is a much shortened chapter from the author's book provisionally entitled The Trouble With Medical Journals that the RSM Press will publish in the autumn [ www.rsmpress.co.uk ], and this is the fourth in a series of extracts that will be published in the JRSM.
Trends in National and State-Level Obesity in the USA after Correction for Self-Report Bias: Analysis of Health Surveys
Authors: Ezzati Majid , Martin Hilarie , Skjold Suzanne , Hoorn Stephen Vander , Murray Christopher J L
Published: November 2017

Objectives

To quantify population-level bias in self-reported weight and height as a function of age, sex, and the mode of self-report, and to estimate unbiased trends in national and state level obesity in the USA.

Design

Statistical analysis of repeated cross-sectional health examination surveys (the National Health and Nutrition Examination Survey [NHANES]) and health surveys (the Behavioral Risk Factor Surveillance System [BRFSS]) in the USA.

Setting

The 50 states of the USA and the District of Columbia.

Results

In the USA, on average, women underreported their weight, but men did not. Young and middle-aged (565 years) adult men over-reported their height more than women of the same age. In older age groups, over-reporting of height was similar in men and women. Population-level bias in self-reported weight was larger in telephone interviews (BRFSS) than in-person interviews (NHANES). Except in older adults, height was over-reported more often in telephone interviews than in-person interviews. Using corrected weight and height in the year 2000, Mississippi (31%) and Texas (30%) had the highest prevalence of obesity for men; Texas (37%), Louisiana (37%), Mississippi (37%), District of Columbia (37%), Alabama (37%), and South Carolina (36%) for women.

Conclusions

Population-level bias in self-reported weight and height is larger in telephone interviews than in-person interviews. Telephone interviews are a low-cost method for regular, nationally- and sub-nationally representative monitoring of obesity. It is possible to obtain corrected estimates of trends and geographical distributions of obesity from telephone interviews by using systematic analysis which measure weight and height from an independent sample of the same population.
Quantitative Evidence for Judgments on the Efficacy of Inoculation for the Prevention of Smallpox: England and New England in the 1700s
Authors: Huth Edward
Published: November 2017

Additional material for this article is available from the James Lind Library website [ www.jameslindlibrary.org ] where this paper was previously published.
Learning from Death: A Hospital Mortality Reduction Programme
Authors: Wright John , Dugdale Bob , Hammond Ian , Jarman Brian , Neary Maria , Newton Duncan , Patterson Chris , Russon Lynne , Stanley Philip , Stephens Rose , Warren Erica
Published: November 2017

Problem

There are wide variations in hospital mortality. Much of this variation remains unexplained and may reflect quality of care.

Setting

A large acute hospital in an urban district in the North of England.

Design

Before and after evaluation of a hospital mortality reduction programme.

Strategies for change

Audit of hospital deaths to inform an evidence-based approach to identify processes of care to target for the hospital strategy. Establishment of a hospital mortality reduction group with senior leadership and support to ensure the alignment of the hospital departments to achieve a common goal. Robust measurement and regular feedback of hospital deaths using statistical process control charts and summaries of death certificates and routine hospital data. Whole system working across a health community to provide appropriate end of life care. Training and awareness in processes of high quality care such as clinical observation, medication safety and infection control.

Effects

Hospital standardized mortality ratios fell significantly in the 3 years following the start of the programme from 94.6 (95% confidence interval 89.4, 99.9) in 2001 to 77.5 (95% CI 73.1, 82.1) in 2005. This translates as 905 fewer hospital deaths than expected during the period 2002–2005.

Lessons learnt

Improving the safety of hospital care and reducing hospital deaths provides a clear and well supported goal from clinicians, managers and patients. Good leadership, good information, a quality improvement strategy based on good local evidence and a community-wide approach may be effective in improving the quality of processes of care sufficiently to reduce hospital mortality.
Doctors Charged with Manslaughter in the Course of Medical Practice, 1795–2005: A Literature Review
Authors: Ferner R E , McDowell Sarah E
Published: November 2017

Objectives

To quantify the number of doctors charged with manslaughter in the course of legitimate medical practice and to classify cases, as mistakes, slips (or lapses), and violations, using a recognized classification of human error system.

Design

We searched newspaper databases, Medline, Embase, and the Wellcome library catalogue to identify relevant cases from 1795 to December 2005.

Setting

Medical practice in the United Kingdom.

Main Outcome Measure

Number of doctors charged with manslaughter in the course of medical practice.

Results

We identified 85 doctors charged with manslaughter since 1795. The number of doctors charged was relatively high in the mid-19th century and the inter-war years, and has dramatically increased since 1990. Sixty of the doctors were acquitted, 22 were convicted, and three pleaded guilty. Most doctors were charged as a consequence of mistakes (37) or slips (17), and a minority because of alleged violations (16).

Conclusions

The number of doctors prosecuted for manslaughter has risen steeply since 1990, but the proportion of doctors convicted remains low. Prosecution for deliberately violating rules is understandable, but accounts for only a minority of these cases. Unconscious errors–-mistakes and slips (or lapses)–-are an inescapable consequence of human actions and prosecution of individuals is unlikely to improve patient safety. That requires improvement to the complex systems of health care.
Two Controlled Trials of Supplementary Feeding of British School Children in the 1920s
Authors: Pollock Jon
Published: November 2017

Additional material for this article is available from the James Lind Library website [ www.jameslindlibrary.org ] where this paper was previously published.
Exercise-Associated Hyponatraemia after a Marathon: Case Series
Authors: Goudie A M , Tunstall-Pedoe D S , Kerins M , Terris J
Published: November 2017

Objectives

To review the presentation, treatment and response of those runners from the London Marathon who presented to St Thomas’ Hospital with exercise induced hyponatraemia.

Design

Observational case series.

Setting

St Thomas’ Hospital, a tertiary hospital situated near the finish line of the 2003 London Marathon.

Participants

All runners who presented to St Thomas’ Hospital on the day of the 2003 London Marathon with altered mental state whose serum sodium concentration was less than 135 mmol/L.

Main outcome measures

Presenting symptoms, volume and type of fluids administered and response to treatment (biochemical and clinical).

Results

Fourteen patients were diagnosed with exercise associated hyponatraemia with serum sodium concentrations ranging from 116 to 133 mmol/L. Eleven presented with confusion. There were long delays between the finish time and presentation time for some runners. Anecdotal descriptions suggested some runners finished the race with normal mental state then became confused. There was no correlation between running time and serum sodium level. All patients received 0.9% saline and six received 1.8% saline. Despite this, some patients demonstrated falls in serum sodium concentrations. Thirteen to fourteen patients were symptomatically well the following morning, with the remaining patient significantly improved.

Conclusion

Presentation of exercise associated hyponatraemia may be delayed. Optimal treatment is controversial, but the use of isotonic saline may not result in rises of serum sodium and we would suggest the early use of hypertonic fluids in symptomatic patients.
Walking, Cycling and Transport Safety: An Analysis of Child Road Deaths
Authors: Sonkin Beth , Edwards Phil , Roberts Ian , Green Judith
Published: November 2017

Objective

To examine trends in road death rates for child pedestrians, cyclists and car occupants.

Design

Analysis of road traffic injury death rates per 100 000 children and death rates per 10 million passenger miles travelled.

Setting

England and Wales between 1985 and 2003.

Participants

Children aged 0–14 years.

Interventions

None.

Main outcome measures

Death rates per 100 000 children and per 10 million child passenger miles for pedestrians, cyclists and car occupants.

Results

Death rates per head of population have declined for child pedestrians, cyclists and car occupants but pedestrian death rates remain higher (0.55 deaths/100 000 children; 95% confidence interval [CI] 0.42 to 0.72 deaths) than those for car occupants (0.34 deaths; 95% CI 0.23 to 0.48 deaths) and cyclists (0.16 deaths; 95% CI 0.09 to 0.27 deaths). Since 1985, the average distance children travelled as a car occupant has increased by 70%; the average distance walked has declined by 19%; and the average distance cycled has declined by 58%. Taking into account distance travelled, there are about 50 times more child cyclist deaths (0.55 deaths/10 million passenger miles; 0.32 to 0.89) and nearly 30 times more child pedestrian deaths (0.27 deaths; 0.20 to 0.35) than there are deaths to child car occupants (0.01 deaths; 0.007 to 0.014). In 2003, children from families without access to a vehicle walked twice the distance walked by children in families with access to two or more vehicles.

Conclusions

More needs to be done to reduce the traffic injury death rates for child pedestrians and cyclists. This might encourage more walking and cycling and also has the potential to reduce social class gradients in injury mortality.
Identifying Patients at High Risk of Emergency Hospital Admissions: A Logistic Regression Analysis
Authors: Bottle Alex , Aylin Paul , Majeed Azeem
Published: November 2017

Objective

To use routine data to identify patients at high risk of future emergency hospital admissions.

Design

Descriptive analysis of inpatient hospital episode statistics. Predictive model developed using multiple logistic regression.

Setting

National Health Service hospital trusts in England.

Participants

All patients with an emergency admission to an NHS hospital between 1 April 2000 and 31 March 2001.

Main outcome measures

‘High-impact users’ were defined as patients who had at least one emergency inpatient admission and who then went on to have at least two further emergency hospital admissions in the 12 months following the start date of that index admission.

Results

2 895 234 patients were admitted as emergencies in 2000/2001, of whom 147 725 (5.1%) did not survive their first spell. Of the 2 747 509 surviving patients, 269 686 (9.8%) subsequently had at least two or more emergency admissions within 365 days of the index date of admission. A further 236 779 (8.6%) died during this period. Risk factors for becoming a high-impact user included the number of emergencies in the 36 months before index spell, comorbidity, age, an admission for an ambulatory care sensitive condition, ethnicity, area-level socio-economic data, local admission rates, the number of episodes in the index spell, sex and the source of admission. The predictive model based on all emergency admissions produced a receiver operating characteristic curve score of 0.72.

Conclusions

Routine hospital episode statistics can be used to identify patients who are at high risk of suffering future multiple emergency hospital admissions. The potential cost savings in preventing a proportion of these subsequent admissions need to be compared with the costs of case management of these patients.
Diabetes management in the USA and England: comparative analysis of national surveys
Authors: Mainous Arch G , Diaz Vanessa A , Saxena Sonia , Baker Richard , Everett Charles J , Koopman Richelle J , Majeed Azeem
Published: November 2017

Objectives

To compare diabetes management in adults between England and the United States, particularly focusing on the impact of a universal access health insurance system.

Design

Analysis of the nationally-representative surveys Health Survey of England, 2003 (unweighted n=14 057) and the National Health and Nutrition Examination Survey, 2001–2002 (unweighted n=5411).

Setting and Participants

Adults 20–64 years of age; individuals >65.

Main Outcome Measures

Glycaemic, lipid and blood pressure control and medication use among individuals with previously diagnosed diabetes.

Results

Among those aged 20–64 the prevalence of diagnosed diabetes was lower in England (2.7%) than in the USA (5.0%). The proportion with diabetes receiving treatment was similar for the two countries. However, the mean HbA1c in England was 7.6%: in the USA it was 7.5% for those with insurance and 8.6% for those without insurance. The proportion of individuals on ACE inhibitors in England was 39%: in USA it was 39% for those with insurance, and 14% for those without.

Conclusions

Individuals in a healthcare system providing universal access have better managed diabetes than those in a market based system once one accounts for insurance.
Comparison of reports of randomized controlled trials and systematic reviews in surgical journals: literature review
Authors: Panesar Sukhmeet Singh , Thakrar Ricky , Athanasiou Thanos , Sheikh Aziz
Published: November 2017

Objectives

Randomized controlled trials and systematic reviews of such trials are the gold standard for assessing the effectiveness of interventions. There have been concerns about the anecdotal evidence underpinning many of the interventions used and introduced into surgical care. The American College of Surgeons has prioritized the need for more trials and systematic reviews of trials. To investigate the assertion that the methodological quality of studies conducted in surgery is in general poor and to assess the possible impact of new policy developments in the US, we sought to compare the number and proportion of published randomized controlled trials and systematic reviews in the leading two US and UK general surgical journals. Two reviewers systematically and independently hand searched all issues of these journals over a 12-month period to identify randomised controlled trials and systematic reviews.

Design

Systematic searching and independent abstraction of data from all volumes of the top two general surgical journals published in the USA and the UK in 2004.

Setting

519 original reports in UK journals and 616 original reports in USA journals.

Main Outcome Measures

Number and proportion of randomized controlled trials and systematic reviews.

Results

Overall, the proportion of randomized controlled trials in all four journals was 5.6% (95% confidence interval [CI] 4.4–7.0) and 5.2% (95% CI 4.1–6.7) for systematic reviews. For journals published in the UK 29/519 (5.6%) of the publications were reports of randomized controlled trials, and for the USA journals this figure was 34/616 (5.5%); odds ratio [OR]=0.99, 95%CI 0.6–1.6; P=0.96. Systematic reviews were significantly more commonly reported in the UK journals: UK 37/519 (7.1%) versus USA 22/616 (3.6%); OR=0.48, 95%CI 0.3–0.8; P<0.01.

Conclusions

The concerns expressed almost a decade ago remain valid: there are still very few reports of randomized controlled trials and systematic reviews published in leading USA and UK surgical journals, with relatively little difference between these countries in the proportion of reported studies employing these designs. The American College of Surgeons initiative has yet to make an impact.
The 1944 patulin trial of the British Medical Research Council
Authors: Clarke Mike
Published: November 2017

Additional material for this article is available from the James Lind Library website [ http://www.jameslindlibrary.org ] where this paper was previously published.
The Global Fund at Five: What Next for Universal Access for HIV/AIDS, TB and Malaria?
Authors: Sidibe Michel , Ramiah Ilavenil , Buse Kent
Published: November 2017

This is the second in a series of articles on leadership in international health.
The MRC Randomized Trial of Streptomycin and its Legacy: A View from the Clinical front Line
Authors: Crofton J
Published: November 2017

Additional material for this article is available from the James Lind Library website ( http://www.jameslindlibrary.org ), where this paper was previously published.
The World Bank's New Health Sector Strategy: Building on Key Assets
Authors: Levine Ruth , Buse Kent
Published: November 2017

This is the third in a series of articles on leadership in international health. The series was coordinated by Kent Buse.
Mumps Orchitis
Authors: Masarani M , Wazait H , Dinneen M
Published: November 2017

Although the incidence of mumps orchitis has dramatically declined since the introduction of the childhood vaccination programme, a sharp increase in reported cases of both mumps and mumps orchitis has been seen recently in the UK. There are great concerns about mumps outbreaks and the associated risk of infertility; it remains an important clinical condition. Immunization is the best policy to avoid this viral disease.
Association of Age, Sex and Deprivation with Quality Indicators for Diabetes: Population-Based Cross Sectional Survey in Primary Care
Authors: Gray Jeremy , Millett Christopher , O'Sullivan Caoimhe , Omar Rumana Z , Majeed Azeem
Published: November 2017

Objectives

To determine the quality of diabetes management in primary care after the publication of the National Service Framework and examine the impact of age, gender and deprivation on the achievement of established quality indicators.

Design

Population-based cross sectional survey using electronic general practice records carried out between June–October 2003.

Setting

Thirty-four practices in Wandsworth, South-West London, UK.

Participants

6035 adult patients (≥18 years) with diabetes from a total registered population of 201 572 patients.

Interventions

None.

Main Outcome Measures

Success rates for the diabetes quality indicators within the General Medical Services contract for general practitioners.

Results

We identified large variations in diabetes management between general practitioner practices with poorer recording of quality care in younger patients (18–44 years). In addition, younger patients had a worse cholesterol and glycaemia profile, although hypertension was more common in older patients. Gender and deprivation did not appear to be important determinants of the quality of care received.

Conclusions

There are large variations in diabetes management between general practitioner practices, with care seemingly worse for younger adults. Longitudinal studies are required to determine whether current UK quality improvement initiatives have been successful in attenuating existing variations in care and treatment outcomes.
The First Randomized Trial of Aspirin for Heart Attack and the Advent of Systematic Overviews of Trials
Authors: Elwood Peter
Published: November 2017

Additional material for this article is available from the James Lind Library website [ http://www.jameslindlibrary.org ], where this paper was previously published.
The Big Idea: Iron-Dependent Inflammation in Venous Disease and Proposed Parallels in Multiple Sclerosis
Authors: Zamboni Paolo
Published: November 2017

This article is based on a lecture presented at the Tripartite Meeting, EVF-AVF-UKVF, Royal Society of Medicine, London, 1 July 2006.
Scientific Journals are ‘Faith Based’: Is there Science behind Peer Review?
Authors: Linkov Faina , Lovalekar Mita , LaPorte Ronald
Published: November 2017

‘The strongest arguments prove nothing so long as the conclusions are not verified by experience. Experimental science is the queen of sciences and the goal of all speculation.’

(R Bacon)
‘They would say that, wouldn't they?’ A Reader's Guide to Author and Sponsor Biases in Clinical Research
Authors: Bastian Hilda
Published: November 2017

‘This study was funded by (Company A). Professor XYZ has received honoraria and travel support for lectures and advisory boards, as well as research grants, from (Company A) and (Company B).’