Biomedical subjects

Patrick McElduff

Publications and source records attributed to Patrick McElduff.

At least 19 recordsLinked to original sources

PubMed2006

Maternal and neonatal influences on, and reproducibility of, neonatal aortic pulse wave velocity.

Aortic pulse wave velocity (aPWV), a noninvasive measure of vascular stiffness, is an independent predictor of cardiovascular disease both before and in overt vascular disease. Its characteristics in early life and its relationship to maternal factors have hardly been studied. To test the hypothesis that infant aPWV was positively related to maternal anthropometry and blood pressure (BP) at 28 weeks gestation, after adjusting for neonatal anthropometry and BP, 148 babies born in Manchester were measured 1 to 3 days after birth. A high reproducibility of aPWV, assessed in 30 babies within 3 days of birth, was found with a mean difference between occasions of -0.04 m/s (95% CI: -0.08 to 0.16 m/s). Contrary to our hypothesis, a significant inverse relation was found between neonatal aPWV (mean: 4.6 m/s) and maternal systolic BP (mean: 108.9 mm Hg; r=-0.57; 95% CI: -0.67 to -0.45) but not maternal height nor weight. Neonatal aPWV was positively correlated with birth length, birth weight, and systolic BP. In multiple regression, neonatal aPWV remained significantly inversely associated with maternal systolic BP (adjusted beta coefficient: -0.032; 95% CI: -0.040 to -0.024; P<0.001), after adjustment for maternal age, birth weight, length, and neonatal BP (all independently and positively related to aPWV) and for gestational age, maternal weight, and height (unrelated). These results suggest that infant aPWV may be a useful index of infant vascular status, is less disturbing to measure than infant BP, and is sensitive to the gestational environment marked by maternal BP.

Adult↗

PubMed2006

Adiponectin in umbilical cord blood is inversely related to low-density lipoprotein cholesterol but not ethnicity.

CONTEXT: Adiponectin is a recognized protective risk marker for cardiovascular disease in adults and is associated with an optimal lipid profile. The role of adiponectin at birth is not well understood, and its relationship with the neonatal lipid profile is unknown. Because ethnic disparities in cardiovascular risk have been attributed to low adiponectin and its associated low high-density lipoprotein cholesterol (HDL-C), investigation at birth may help determine the etiology of these risk patterns. OBJECTIVE: Our objective was to investigate the relationship between neonatal adiponectin and lipid profile at birth in two ethnic groups in cord blood. DESIGN, SETTING, AND PARTICIPANTS: Seventy-four healthy mothers and their newborns of South Asian and White European origin were studied in this cross-sectional study at St. Mary's Hospital, Manchester, United Kingdom. MAIN OUTCOME MEASURES: Serum adiponectin, total cholesterol, HDL-C, low-density lipoprotein cholesterol (LDL-C), and triglyceride levels were measured in umbilical venous blood at birth and in maternal blood collected at 28 wk gestation. RESULTS: Cord adiponectin was significantly inversely associated with cord LDL-C (r = -0.32; P = 0.005) but not HDL-C. In a multiple regression analysis, cord LDL-C remained the most significant association of cord adiponectin (beta = -0.13; P < 0.001). We did not find any significant ethnic differences in cord adiponectin or lipids with the exception of triglycerides, which were significantly lower in South Asian newborns (P < 0.05). CONCLUSION: This is the first report of an inverse relationship between cord adiponectin and LDL-C at birth. In contrast to adult studies, we found no significant association between adiponectin and HDL-C in cord blood. Our results and the strong independent association between adiponectin and HDL-C observed in adult studies suggest a role for adiponectin in lipid metabolism. Ethnic differences in adiponectin may arise after birth.

Adiponectin↗

PubMed2006

Readmission after hysterectomy and prophylactic low molecular weight heparin: retrospective case-control study.

OBJECTIVE: To determine whether use of tinzaparin, a low molecular weight heparin introduced for prophylactic management of deep vein thrombosis, increases the risk of serious postoperative bleeding leading to a higher than expected 28 day readmission rate after discharge for hysterectomy. DESIGN: Retrospective case-control study using computerised hospital inpatient data and review of case notes. SETTING: District general hospital. SUBJECTS: 2108 patients undergoing hysterectomy between August 1997 and March 2003 MAIN OUTCOME MEASURES: Readmission and reoperation associated with bleeding. RESULTS: 54 cases of serious postoperative bleeding were identified, 46 of which were readmissions. These 54 cases were compared with 179 controls. Regression analysis indicated a positive relation between prophylaxis with tinzaparin and serious postoperative bleeding. There was a significant twofold increase in odds (odds ratio 2.02, 95% confidence interval 1.02 to 4.05) after adjustment for type of operation, age, and type of pain relief. CONCLUSIONS: In the prophylactic treatment of thromboembolic disease after hysterectomy, compared with calci-heparin, tinzaperin is associated with a twofold increase in risk of serious postoperative bleeding.

Adult↗

PubMed2005

Comparative levels and time trends in blood pressure, total cholesterol, body mass index and smoking among Caucasian and South-Asian participants of a UK primary-care based cardiovascular risk factor screening programme.

BACKGROUND: Individuals of South-Asian origin have a comparatively higher cardiovascular disease burden, but there is uncertainty about whether this is due to differences in risk factor levels and trends. We therefore studied comparative levels and time trends in blood pressure (BP), total cholesterol, body mass index (BMI) and current smoking among UK Caucasian and South-Asian individuals. METHODS: Repeatable cross-sectional survey of men and women aged 35-60 attending for first screening as part of a primary-care based cardiovascular risk factor screening programme 1989 and 1999. RESULTS: Of 34,122 men and 37,294 women participants, 499 men (1.5%)and 381 women (1%) were of South-Asian origin. South-Asian men had lower systolic [(-4.91 mmHg (95% Confidence Iterval (CI): -3.58 to -6.23)] and diastolic BP [-2.87 mmHg (-2.02 to -3.72)], with no significant differences in cholesterol and BMI. South-Asian women had lower systolic BP [-1.77 mmHg, 95% (-0.21 to -3.33)], diastolic BP [-1.87 mmHg (-0.92 to -2.82)], cholesterol [-0.24 mmol/l (-0.08 to -0.39)]; and higher BMI [+0.78 kg/m2 (0.25 to 1.3)]. South-Asian men and women had significantly lower prevalence of self-reported current smoking (29.0% and 1.8% respectively). With the exception of self-reported current smoking, between ethnic group risk factor trends were not converging. CONCLUSION: With the exception of women's BMI, South-Asian individuals had either lower or similar levels of the examined cardiovascular risk factor levels, compared with Caucasian individuals. Although time trends in smoking were converging, other risk factors trends were similar between the two ethnic groups. Overall the findings do not support the hypothesis that the relatively high cardiovascular disease burden in UK South-Asians is due to higher levels exposure to the examined risk factors. Other hypotheses, such as higher frequency of diabetes and increased genetic predisposition, require further exploration.

Adult↗

PubMed2005

The role of the early therapeutic alliance in predicting drug treatment dropout.

BACKGROUND: To investigate the role of the therapeutic alliance in predicting length of retention in residential drug treatment. METHODS: The study recruited 187 clients starting residential rehabilitation treatment for drug misuse in three UK services. Counsellor and client information was assessed at intake, and the average total scores of client and counsellor ratings on the WAI-S (obtained during weeks 1-3) were use as the alliance measure. Length of retention and treatment completion (stay beyond 90 days) were used as measures of retention. RESULTS: Clients with weak counsellor rated alliances dropped out of treatment significantly sooner than clients with strong counsellor rated therapeutic alliances, whether or not the model adjusted for individual counsellor effects and potential confounders including psychological well-being, treatment motivation and readiness, coping strategies, and attachment style. The client rated alliance did not predict length of retention. Apart from the alliance, pre-treatment crack use, secure attachment style and better coping strategies were associated with shorter retention, whereas greater confidence in treatment, older client age and better education predicted treatment completion. Counsellors with greater experience of delivering drug counselling retained clients longer. CONCLUSIONS: The findings of this study stress the importance of treatment professionals attending to the therapeutic alliance in drug treatment, as counsellors' alliance ratings were found to be amongst the strongest predictors of dropout. Using alliance measures as clinical tools may help treatment practitioners to become aware of the risk of disengagement early on. Prospective studies are needed to evaluate whether strategies of reallocating clients with poor alliances to different counsellors lead to improvements in retention.

Adaptation, Psychological↗

PubMed2005

The unrecognized prevalence of chronic kidney disease in diabetes.

BACKGROUND: Diabetes mellitus and chronic kidney disease (CKD) are common and exhibit synergistic associations with premature mortality. Current diabetes guidelines in the UK recommend annual urinary albumin and serum creatinine determinations to screen for diabetic kidney disease. The aim of this study was to estimate the burden of CKD in patients with diabetes and examine the ability of serum creatinine and albuminuria to detect clinically meaningful CKD compared with estimated glomerular filtration rate (eGFR). METHODS: All adults known to have diabetes in primary and secondary care in Salford, UK, alive with independent renal function on 1 January 2004 were included in this observational study (n=7596). Demographic and laboratory parameters were obtained from the Electronic Patient Record. eGFR was determined using the 4-variable modification of diet in renal disease (MDRD) formula. Clinically meaningful CKD was defined as an eGFR <60 ml/min/1.73 m(2). RESULTS: Creatinine and albuminuria were measured in the preceding 2 years in 82.3 and 55.2% of subjects, respectively. In patients with CKD, normoalbuminuria was present in 48.8%, and serum creatinine was normal ( or=120 micromol/l) had a sensitivity and specificity of 45.3 and 100%, respectively, to identify CKD. The combination of abnormal creatinine and albuminuria had an improved performance but still failed to detect a large number with CKD (sensitivity 82.4%, specificity 75.4%). Serum creatinine failed to identify CKD more often in females (OR 8.22, CI 6.56-10.29). CONCLUSIONS: Undiagnosed CKD is common in diabetes. Current screening strategies, based on creatinine or albuminuria, fail to identify a considerable number of subjects with CKD. Incorporating eGFR into screening for CKD would identify individuals earlier in the natural history of the disease and enable early effective treatment to delay progression of CKD.

Adult↗

PubMed2005

Neonatal thyrotropin as measured in a congenital hypothyroidism screening program: influence of the mode of delivery.

CONTEXT: Many developed countries are reexperiencing iodine deficiency. One World Health Organization index of iodine deficiency in populations is the percentage of neonates with TSH levels greater than 5 mIU/liter 72 h after delivery. Measured TSH levels vary with methodology and are influenced by external factors including iodine exposure at time of delivery. OBJECTIVE: We wished to determine whether babies delivered by cesarean section have higher levels of TSH than babies delivered vaginally because this factor could influence determination of iodine deficiency. DESIGN AND SETTING: This was a cohort study of mothers delivering at a teaching hospital in 2002-2003 and their babies. PATIENTS AND METHODS: Women delivering a live infant were eligible for the study. Demographic data, mode of delivery, and subsequent routine newborn screening TSH levels were recorded. RESULTS: Of 2031 infants, 31.2% were delivered by cesarean section; 1864 babies were born after 37 wk, with blood samples collected by d 5 (>91% on d 3). Significant predictors of TSH concentration were the day TSH was measured and type of delivery. The distribution curve of TSH values was right shifted in infants born by cesarean section. The percentage of neonates born by cesarean with at TSH value greater than 5 was 7.1%. The figure for those born vaginally was 4.3%. CONCLUSIONS: Babies delivered by cesarean section are significantly more likely to have TSH levels greater than 5 mIU/liter on d 3 than those delivered vaginally. With the rise in the rate of births by cesarean, this could be an important factor in assessing population iodine deficiency using neonatal TSH levels.

Cesarean Section↗

PubMed2005

High C-reactive protein and low paraoxonase1 in diabetes as risk factors for coronary heart disease.

BACKGROUND: Paraoxonase1 (PON1) is an anti-inflammatory enzyme located on HDL, which protects against the development of atherosclerosis. C-reactive protein (CRP) is a marker of the inflammatory response in CHD. We hypothesised that low PON1 and high CRP found in CHD may be important markers of CHD and the CRP:PON1 ratio may be an index of the risk of developing atherosclerosis. We have, therefore, compared the levels of PON1 and CRP between control subjects, those with no diabetes and CHD, type 1 diabetes and type 2 diabetes. METHODS AND RESULTS: PON1 activity was different between the populations in the order: controls > type 1 diabetes > type 2 diabetes > CHD with no diabetes (P<0.001). CRP concentration also differed between the populations in the order: controls < type 1 diabetes < type 2 diabetes < CHD with no diabetes (P<0.001). The CRP:PON1 ratio followed the same trend as the CRP concentration (P<0.001). Both CRP and the CRP:PON1 ratio were associated with the presence of CHD. In the control population only, PON1 was a determinant of CRP concentration. Amongst the diabetics, people with CHD had higher levels of CRP (P<0.001) and in comparing the control group with the CHD group, the CHD group had a higher level of CRP (P<0.001). CONCLUSIONS: Higher levels of CRP seem to be generally associated with low levels of PON1 activity, providing a mechanistic link between inflammation and the development of atherosclerosis. However, the relationship between PON1, CRP and atherosclerosis, and the usefulness of the PON1:CRP ratio as a risk factor for CHD requires further evaluation.

Adult↗

PubMed2005

Effects of dydrogesterone and norethisterone, in combination with oestradiol, on lipoproteins and inflammatory markers in postmenopausal women.

OBJECTIVE: The lack of cardiovascular benefit from postmenopausal hormone replacement therapy (HRT) in randomised controlled trials is not readily explained. The androgenic properties of progestogens could be crucial in understanding the results of these studies, all of which employed medroxyprogesterone. We have previously reported that medroxyprogesterone has some androgenic effects intermediate between those of the more androgenic norethisterone and the less androgenic desogestrel. To examine the androgenicity of progestogens further, we compared the effects of dydrogesterone (DGT) that is even less androgenic than desogestrel, and norethisterone (NET), on lipoproteins and inflammatory markers while maintaining the same oestrogen dose. METHOD: In a crossover trial, 25 non-hysterectomised postmenopausal women were randomised to two preparations of HRT each for three 28-day treatment cycles. Both HRT regimens comprised oestradiol (1mg). One also included DGT (10mg) and the other NET (1mg). Oestradiol was taken continuously and the progestogens sequentially. Measurements were made at baseline and on the last day of the oestradiol phase and the last day of the progestogen phase in the third treatment cycle of each regimen. RESULTS: NET was more effective than DGT in significantly reducing lipoprotein (a) (p < 0.05). NET was, however, associated with significantly lower levels of high-density lipoprotein (HDL) cholesterol (p = 0.001) and triglycerides (p < 0.05). NET was less effective in opposing the oestrogen-related increase in C-reactive protein (CRP). Interleukin-6 levels did not change with either progestogen. CONCLUSION: The effect of androgenic progestogens on cardiovascular risk factors may not be as deleterious as previously assumed, especially if the lower HDL levels result from more efficient reverse cholesterol transport. The hormone related rise in C-reactive protein, without a corresponding increase in interleukin-6, may not represent a systemic inflammatory response.

Biomarkers↗

PubMed2005

A method for meta-analysis of molecular association studies.

Although population-based molecular association studies are becoming increasingly popular, methodology for the meta-analysis of these studies has been neglected, particularly with regard to two issues: testing Hardy-Weinberg equilibrium (HWE), and pooling results in a manner that reflects a biological model of gene effect. We propose a process for pooling results from population-based molecular association studies which consists of the following steps: (1) checking HWE using chi-square goodness of fit; we suggest performing sensitivity analysis with and without studies that are in HWE. (2) Heterogeneity is then checked, and if present, possible causes are explored. (3) If no heterogeneity is present, regression analysis is used to pool data and to determine the gene effect. (4) If there is a significant gene effect, pairwise group differences are analysed and these data are allowed to 'dictate' the best genetic model. (5) Data may then be pooled using this model. This method is easily performed using standard software, and has the advantage of not assuming an a priori genetic model.

Bone Density↗

PubMed2005

Mid-term Body Mass Index increase among obese and non-obese individuals in middle life and deprivation status: a cohort study.

BACKGROUND: In the UK, obesity is associated with a clear socioeconomic gradient, with individuals of lower socioeconomic status being more likely to be obese. Several previous studies, using individual measures of soecioeconomic status, have shown a more rapid increase in Body Mass Index (BMI) over time among adults of lower socioeconomic status. We conducted a study to further examine whether ecologically defined deprivation status influences within-individual BMI change during middle life, as the answer to this question can help determine optimal preventive strategies both for obesity per se, and its' associated socioeconomic disparities. METHODS: Anonymised records of participants to the Stockport population-based cardiovascular disease risk factor screening programme were analysed. Individuals aged 35-55 who had a first screening episode between 1989 and 1993, and a subsequent screening episode were included in the study. Deprivation status was defined using quintiles of the Townsend score. Mean annual BMI change by deprivation group was calculated using linear regression. Subsequently, deprivation group was included in the model as an ordinal variable, to test for trend. The modelling was repeated separately for individuals who were obese (BMI < 30) and non-obese at the time of first screening. In supplementary analysis, regression models were also adjusted for baseline BMI. RESULTS: Of 21,976 women and 19,158 men initially screened, final analysis included just over half of all individuals [11,158 (50.8%) women and 9,831 (51.3%) men], due to the combined effect of loss to follow-up and incomplete BMI ascertainment. In both sexes BMI increased by 0.19 kg/m2 annually (95% Confidence Intervals 0.15-0.24 for women and 0.16-0.23 for men). All deprivation groups had similar mean annual change, and there was no evidence of a significant deprivation trend (p = 0.801, women and 0.892, men). Restricting the analysis to individuals who were non-obese at baseline did not alter the results in relation to the lack of a deprivation effect. When restricting the analysis to individuals who were obese at baseline however, the findings were suggestive of an association of BMI increase with higher deprivation group, which was further supported by a significant association when adjusting for baseline BMI. CONCLUSION: In the study setting, the BMI of non-obese individuals aged 35-55 was increasing over time independently of deprivation status; among obese individuals a positive association with higher deprivation was found. The findings support that socioeconomic differences in mean BMI and obesity status are principally attained prior to 35 years of age. Efforts to tackle inequalities in mean BMI and obesity status should principally concentrate in earlier life periods, although there may still be scope for focusing inequality reduction efforts on obese individuals even in middle life.

Adult↗

PubMed2005

Cord blood lipoproteins and prenatal influences.

PURPOSE OF REVIEW: Blood lipoprotein profiles in early life are known to be related to and predictive of those in adulthood, but little is known about their determinants. Genetic and environmental influences affect cord blood lipoproteins, but how this occurs and the relative contribution of these influences to the overall profile in healthy newborns remains uncertain. RECENT FINDINGS: This review discusses findings from a range of earlier and more recent studies, and summarizes the key influences on cord blood lipoproteins. In particular, we review the potential contribution of maternal blood total cholesterol levels during pregnancy and the increased maternal transmission in newborns of mothers with diabetes. SUMMARY: In cord blood, cholesterol levels are lower than in adults and the relative proportion present in HDL as opposed to LDL is much higher. The currently available evidence suggests that several factors influence the composition of cord blood lipoproteins. Although inheritance of major monogenic disorders can affect cord lipids in general, the genetic contribution appears to be minimal, although effects of the proprotein convertase subtilisin/kexine type 9 gene (PCSK9) need fuller exploration in this regard in certain ethnic groups. Evidence is summarized that maternal lipoprotein levels, particularly those due to diet or induced by pregnancy, influence cord lipid levels. Placental insufficiency and other conditions affecting fetal growth and the mode of delivery may also influence cord lipoprotein concentrations. How maternal glucose tolerance during pregnancy affects cord blood lipoproteins remains unclear. In view of increasing evidence that cardiovascular risk may have prenatal antecedents, this would seem to be an important area for further investigation.

Cholesterol↗

PubMed2005

Predicting the early therapeutic alliance in the treatment of drug misuse.

AIMS: To predict the early therapeutic alliance from a range of potentially relevant factors, including clients' social relationships, motivation and psychological resources, and counsellors' professional experience and ex-user status. DESIGN: The study recruited 187 clients starting residential rehabilitation treatment for drug misuse in three UK services. Counsellor and client information was assessed at intake, and client and counsellor ratings of the alliance were obtained during weeks 1, 2 and 3. MEASUREMENTS: The intake assessment battery included scales on psychological wellbeing, treatment motivation, coping strategies and attachment style. Client and counsellor versions of the Working Alliance Inventory (WAI-S) were used for weekly alliance measurement. Hierarchical linear models were used to examine the relationship between alliance and predictor variables. FINDINGS: Clients who had better motivation, coping strategies, social support and a secure attachment style were more likely to develop good alliances. Findings with regard to counsellor characteristics were not clear cut: clients rated their relationships with ex-user counsellors, experienced counsellors and male counsellors as better, but more experienced counsellors rated their alliances as worse. CONCLUSIONS: The findings offer important leads as to what interventions might improve the therapeutic alliance. Further work will need to establish whether the therapeutic alliance and ultimately treatment outcomes can be enhanced by working on improving clients' motivation and psychosocial resources.

Adolescent↗

PubMed2005

Cold periods and coronary events: an analysis of populations worldwide.

STUDY OBJECTIVE: To investigate the association between cold periods and coronary events, and the extent to which climate, sex, age, and previous cardiac history increase risk during cold weather. DESIGN: A hierarchical analyses of populations from the World Health Organisation's MONICA project. SETTING: Twenty four populations from the WHO's MONICA project, a 21 country register made between 1980 and 1995. PATIENTS: People aged 35-64 years who had a coronary event. MAIN RESULTS: Daily rates of coronary events were correlated with the average temperature over the current and previous three days. In cold periods, coronary event rates increased more in populations living in warm climates than in populations living in cold climates, where the increases were slight. The increase was greater in women than in men, especially in warm climates. On average, the odds for women having an event in the cold periods were 1.07 higher than the odds for men (95% posterior interval: 1.03 to 1.11). The effects of cold periods were similar in those with and without a history of a previous myocardial infarction. CONCLUSIONS: Rates of coronary events increased during comparatively cold periods, especially in warm climates. The smaller increases in colder climates suggest that some events in warmer climates are preventable. It is suggested that people living in warm climates, particularly women, should keep warm on cold days.

Adult↗

PubMed2005

Polymorphisms in IGF-binding protein 1 are associated with impaired renal function in type 2 diabetes.

The dysregulation of the IGF system has been implicated in the pathogenesis of obesity, diabetes, and diabetes complications such as nephropathy, but little is known about the genomics of the IGF system in health and disease. We genotyped 13 single nucleotide polymorphisms (SNPs) in IGFBP1 gene in 732 representative type 2 diabetic patients from the Salford Diabetes Register. Of the 13 SNPs, 8 were polymorphic and 7 of those had minor allele frequencies >0.1, one of which was in the gene promoter and one of which was nonsynonymous in exon 4. The minor alleles of these SNPs and two others were associated with a reduced prevalence of diabetic nephropathy. Haplotype analysis revealed that 97% of the genetic variation for IGFBP1 in the population sample could be accounted for using two of the "reno-protective" SNPs, with other SNPs adding little extra information. One of these two SNPs was the nonsynonymous mutation in exon 4, lying close to the integrin-binding RGD motif, which is thought to affect tissue delivery of IGF-I by IGF-binding protein 1 (IGFBP-1), possibly suggesting a "reno-protective" effect via altered IGFBP-1 binding. In conclusion, we have described the first genomic markers to be associated with diabetic microvascular complications within the human IGFBP1 gene.

Base Sequence↗

PubMed2004

Assessing the impact of heart failure specialist services on patient populations.

BACKGROUND: The assessment of the impact of healthcare interventions may help commissioners of healthcare services to make optimal decisions. This can be particularly the case if the impact assessment relates to specific patient populations and uses timely local data. We examined the potential impact on readmissions and mortality of specialist heart failure services capable of delivering treatments such as b-blockers and Nurse-Led Educational Intervention (N-LEI). METHODS: Statistical modelling of prevented or postponed events among previously hospitalised patients, using estimates of: treatment uptake and contraindications (based on local audit data); treatment effectiveness and intolerance (based on literature); and annual number of hospitalization per patient and annual risk of death (based on routine data). RESULTS: Optimal treatment uptake among eligible but untreated patients would over one year prevent or postpone 11% of all expected readmissions and 18% of all expected deaths for spironolactone, 13% of all expected readmisisons and 22% of all expected deaths for b-blockers (carvedilol) and 20% of all expected readmissions and an uncertain number of deaths for N-LEI. Optimal combined treatment uptake for all three interventions during one year among all eligible but untreated patients would prevent or postpone 37% of all expected readmissions and a minimum of 36% of all expected deaths. CONCLUSION: In a population of previously hospitalised patients with low previous uptake of b-blockers and no uptake of N-LEI, optimal combined uptake of interventions through specialist heart failure services can potentially help prevent or postpone approximately four times as many readmissions and a minimum of twice as many deaths compared with simply optimising uptake of spironolactone (not necessarily requiring specialist services). Examination of the impact of different heart failure interventions can inform rational planning of relevant healthcare services.

Adrenergic beta-Antagonists↗

PubMed2004

Does dietary calcium have a protective effect on bone fractures in women? A meta-analysis of observational studies.

It is generally accepted that supplemental Ca and/or vitamin D is effective in reducing the incidence of bone fractures; this is supported by numerous randomised controlled trials and meta-analyses. However, a question that has received much less attention is whether dietary Ca, i.e. Ca in physiological doses in normal food intake, also affects bone fracture risk. The present study aims to review the effect of dietary Ca on bone fractures at the hip, spine and radius in women >35 years old, and to compare these results with previous meta-analyses. MEDLINE (1966-1999) and reference lists in papers were searched for observational dietary Ca studies. Data were extracted in duplicate and separately. Heterogeneity and publication bias were tested. Observational studies failed to show any association between dietary Ca intake and risk of hip fracture (risk ratio 1.01, 95 % CI 0.96, 1.07 for each increment of 300 mg dietary Ca intake/d). There is a suggestion that either extremely low Ca intake may increase fracture risk, or that East Asian women may respond differently to increasing Ca intake.

Adult↗

PubMed2004

GPs' and physicians' interpretation of risks, benefits and diagnostic test results.

BACKGROUND: Understanding pre-test probability and baseline risks helps to interpret the results of diagnostic tests and the benefits of treatment, but how good is the understanding of these concepts? OBJECTIVES: Our aim was to assess the ability of GPs and consultant physicians to make accurate estimates and understand the application of pre-test probability and baseline risk for two common clinical conditions. METHODS: A two-stage questionnaire survey based on case scenarios of patients with angina and congestive heart failure was carried out of 202 physicians, randomly selected from the members of the Royal College of Physicians in the NW of England, 205 GPs randomly chosen from the practice list of the NW Health Authorities and 128 MRCGP examiners attending an examiners meeting. A total of 115, 106 and 81 members of these groups, respectively, responded to the first stage, and 44, 46 and 64 to the second. The main outcome measures were the stated likelihood of true ischaemic heart disease (IHD) being present and the predicted 1-year mortality; the impact of changing prevalence and baseline risk on these results; and interpretation of different methods of risk presentation. RESULTS: Estimates of pre-test probability of IHD being present ranged from 5 to 100% and of baseline risk of 1-year mortality from 0 to 86%. More GP examiners and consultant physicians understood the impact of increasing age on the test result than did the random sample of GPs. A majority of each group correctly said that increasing age would reduce the number needed to treat (NNT). Presentation of benefit as relative risk reduction was a greater stimulus to starting treatment than the NNT or measures of population impact. CONCLUSION: Clinicians should collect data to allow a better knowledge of the likelihood of disease and of baseline risk in their patient populations. Methods to increase the understanding of the influence of pre-test probability on diagnostic test results and of how to quantify and demonstrate the impact of the benefit of interventions should be explored.

Clinical Competence↗