The psychosocial impact of bilateral prophylactic mastectomy: prospective study using questionnaires and semistructured interviews

ObjectivesTo investigate the psychosocial impact of bilateral prophylactic mastectomy for women with increased risk of breast cancer and to identify, preoperatively, risk factors for postoperative distress.DesignProspective study using interviews and questionnaire assessments.SettingParticipants'' homes throughout the United Kingdom.Participants143 women with increased risk of developing breast cancer who were offered bilateral prophylactic mastectomy and who accepted or declined the surgery; a further 11 were offered surgery but deferred making a decision.ResultsPsychological morbidity decreased significantly over time for the 79 women who chose to have surgery (accepters): 58% (41/71) preoperatively v 41% (29/71) 6 months postoperatively (difference in percentages 17%, 95% confidence interval 2% to 32%; P=0.04) and 60% (39/65) preoperatively v 29% (19/65) 18 months postoperatively (31%, 15% to 47%; P<0.001). Psychological morbidity in the 64 women who declined surgery (decliners) did not decrease significantly: 57% (31/54) at baseline v 43% (23/54) at 6 months (14%, 0% to 29%; P=0.08) and 57% (29/52) at baseline v 41% (21/52) at 18 months (16%; −2% to 33%; P=0.11). Greater than normal proneness to anxiety was more common in the decliners than in the accepters: 78% (45/58) v 56% (41/73) (22%, 6% to 38%; P=0.006). Accepters were more likely than decliners to believe it inevitable that they would develop breast cancer (32% (24/74) v 10% (6/58) (difference in percentages 22%, 9% to 35%; P=0.003)), and decliners were more likely to believe that screening could help (92% (55/60) v 74% (55/74) (18%, 5% to 31%; P=0.007)). Level of sexual discomfort and degree of sexual pleasure did not change significantly over time in either of the two groups.ConclusionsBilateral prophylactic mastectomy may provide psychological benefits in women with a high risk of developing breast cancer.     

Retrospective audit of different antenatal screening policies for Down's syndrome in eight district general hospitals in one health region

ObjectiveTo compare the effectiveness of different screening policies for the antenatal detection of Down''s syndrome.DesignRetrospective six year survey.SettingMaternity units of eight districts.ParticipantsWomen who completed their pregnancies between 1 January 1994 and 31 December 1999 (155 501 deliveries).Results335 cases of Down''s syndrome were identified, 323 in continuing pregnancies or liveborn children. Of these, 171 were identified antenatally. Seven different screening policies were used, in three principal groups: serum screening offered to all mothers, maternal age with serum screening or nuchal translucency available to limited groups, and maternal age combined with anomaly scans. The districts that used serum screening detected 57%, those using maternal age plus serum or nuchal translucency screening 52%, and those using a maternal age of ⩾35 and anomaly scans detected 54%. The least successful district, which offered amniocentesis only to women aged over 37 years, detected only 31%. If amniocentesis had been offered from 35 years, as in all other districts, the detection rate would have risen to 54%. Across the region 15% (range 12-20%) of pregnant women were 35 years or more at delivery, and 58% (33-69%) of infants with Down''s syndrome were born to women in this age range.ConclusionsCurrent additional serum or nuchal translucency screening techniques for antenatal detection of Down''s syndrome are less advantageous than previously supposed. More pregnant women were aged over 35 than has been presumed in statistical models used in demonstration projects of serum screening and, as a result, the proportion of affected fetuses in this age group is much greater than predicted.

What is already known on this topic

Serum screening for Down''s syndrome has been presumed to be more effective than screening by maternal ageThere have been no controlled studies comparing serum screening with screening by maternal age, and its greater efficacy has been presumed from mathematical modelling, which assumed that only 5% of pregnant women were aged over 35 yearsThe modelling predicted that only 20-30% of cases of Down''s syndrome would arise in women aged over 35 and made no allowance for the effects of routine anomaly scanning

What this study adds

15% of pregnant women were aged over 35 years, more than double the 5-7% presumed in statistical models of screening58% of babies with Down''s syndrome were born to women aged 35 years or moreSerum screening and nuchal scanning did not achieve significantly higher antenatal detection rates of Down''s syndrome than the use of maternal age and routine anomaly scanning     

Randomised controlled trial of Helicobacter pylori testing and endoscopy for dyspepsia in primary care

ObjectiveTo determine the cost effectiveness of a strategy of near patient Helicobacter pylori testing and endoscopy for managing dyspepsia.DesignRandomised controlled trial.Setting31 UK primary care centres.Participants478 patients under 50 years old presenting with dyspepsia of longer than four weeks duration.InterventionsNear patient testing for H pylori and open access endoscopy for patients with positive results. Control patients received acid suppressing drugs or specialist referral at general practitioner''s discretion.Results40% of the study group tested positive for H pylori. 45% of study patients had endoscopy compared with 25% of controls. More peptic ulcers were diagnosed in the study group (7.4% v 2.1%, P=0.011). Paired comparison of symptom scores and quality of life showed that all patients improved over time with no difference between study and control groups. No significant differences were observed in rates of prescribing, consultation, or referral. Costs were higher in the study group (£367.85 v £253.16 per patient).ConclusionsThe test and endoscopy strategy increases endoscopy rates over usual practice in primary care. The additional cost is not offset by benefits in symptom relief or quality of life.

What is already known on this topic

Patients younger than 50 without H pylori infection are unlikely to have treatable disease detected at endoscopySuch patients can be managed by acid suppression and reassurance aloneTest and endoscopy (referral of patients testing positive for H pylori in primary care) has been recommended as a way to reduce endoscopic workload

What this paper adds

Applying a test and endoscopy strategy increased the endoscopy referral rate from 25% to 40%The strategy produced no significant differences in symptoms or quality of life compared with usual managementThe increased costs of this strategy cannot be justified     

Psychological effects of false-positive results in expanded newborn screening in China

Objectives

As more families participate expanded newborn screening for metabolic disorders in China, the overall number of false positives increases. Our goal was to assess the potential impact on parental stress, perceptions of the child''s health, and family relationships.

Methods

Parents of 49 infants with false-positive screening results for metabolic disorders in the expanded newborn screening panel were compared with parents of 42 children with normal screening results. Parents first completed structured interview using likert scales, closed and open questions. Parents also completed the parenting stress index.

Results

A total of 88 mothers and 41 fathers were interviewed. More mothers in the false-positive group reported that their children required extra parental care (21%), compared with 5% of mothers in the normal-screened group (P<0.001). 39% of mothers in the false-positive group reported that they worry about their child''s future development, compared with 10% of mothers in the normal-screened group (P<0.001). Fathers in the false-positive group did not differ from fathers in the normal-screened group in reporting worry about their child''s extra care requirements, and their child''s future development. Children with false-positive results compared with children with normal results were triple as likely to experience hospitalization (27%vs 9%, respectively; P<0.001).

Conclusions

The results showing false-positive screening results may affect parental stress and the parent-child relationship. Parental stress and anxiety can be reduced with improved education and communication to parents about false-positive results.     

Exposure to foodborne and orofecal microbes versus airborne viruses in relation to atopy and allergic asthma: epidemiological study

ObjectiveTo investigate if markers of exposure to foodborne and orofecal microbes versus airborne viruses are associated with atopy and respiratory allergies.DesignRetrospective case-control study.Participants240 atopic cases and 240 non-atopic controls from a population sample of 1659 participants, all Italian male cadets aged 17-24.SettingAir force school in Caserta, Italy.ResultsCompared with controls there was a lower prevalence of T gondii (26% v 18%, P=0.027), hepatitis A virus (30% v 16%, P=0.004), and H pylori (18% v 15%, P=0.325) in atopic participants. Adjusted odds ratios of atopy decreased with a gradient of exposure to H pylori, T gondii, and hepatitis A virus (none, odds ratio 1; one, 0.70; two or three, 0.37; P for trend=0.000045) but not with cumulative exposure to the other viruses. Conversely, total IgE concentration was not independently associated with any infection. Allergic asthma was rare (1/245, 0.4%) and allergic rhinitis infrequent (16/245, 7%) among the participants (245/1659) exposed to at least two orofecal and foodborne infections (H pylori, T gondii, hepatitis A virus).ConclusionRespiratory allergy is less frequent in people heavily exposed to orofecal and foodborne microbes. Hygiene and a westernised, semisterile diet may facilitate atopy by influencing the overall pattern of commensals and pathogens that stimulate the gut associated lymphoid tissue thus contributing to the epidemic of allergic asthma and rhinitis in developed countries.     

Randomised controlled trial of midwife led debriefing to reduce maternal depression after operative childbirth

ObjectiveTo assess the effectiveness of a midwife led debriefing session during the postpartum hospital stay in reducing the prevalence of maternal depression at six months postpartum among women giving birth by caesarean section, forceps, or vacuum extraction.DesignRandomised controlled trial.SettingLarge maternity teaching hospital in Melbourne, Australia.Participants1041 women who had given birth by caesarean section (n= 624) or with the use of forceps (n= 353) or vacuum extraction (n= 64).Results917 (88%) of the women recruited responded to the outcome questionnaire. More women allocated to debriefing scored as depressed six months after birth than women allocated to usual postpartum care (81 (17%) v 65 (14%)), although this difference was not significant (odds ratio=1.24, 95% confidence interval 0.87 to 1.77). They were also more likely to report that depression had been a problem for them since the birth, but the difference was not significant (123 (28%) v 94 (22%); odds ratio=1.37, 1.00 to 1.86). Women allocated to debriefing had poorer health status on seven of the eight SF-36 subscales, although the difference was significant only for role functioning (emotional): mean scores 73.32 v 78.98, t= −2.31, 95% confidence interval −10.48 to −0.84).ConclusionsMidwife led debriefing after operative birth is ineffective in reducing maternal morbidity at six months postpartum. The possibility that debriefing contributed to emotional health problems for some women cannot be excluded.     

Is it possible to exclude a diagnosis of myocardial damage within six hours of admission to an emergency department? Diagnostic cohort study

ObjectiveTo assess the clinical efficacy and accuracy of an emergency department based six hour rule-out protocol for myocardial damage.DesignDiagnostic cohort study.SettingEmergency department of an inner city university hospital.Participants383 consecutive patients aged over 25 years with chest pain of less than 12 hours'' duration who were at low to moderate risk of acute myocardial infarction.InterventionSerial measurements of creatine kinase MB mass and continuous ST segment monitoring for six hours with 12 leads.ResultsOutcome of the gold standard test was available for 292 patients. On the diagnostic test for the protocol, 53 patients had positive results and 239 patients had negative results. There were 18 false positive results and one false negative result. Sensitivity was 97.2% (95% confidence interval 95.0% to 99.0%), specificity 93.0% (90.0% to 96.0%), the negative predictive value 99.6%, and the positive predictive value 66.0%. The positive likelihood ratio was 13.9 and the negative likelihood ratio 0.03.ConclusionsThe six hour rule-out protocol for myocardial infarction is accurate and efficacious. It can be used in patients presenting to emergency departments with chest pain indicating a low to moderate risk of myocardial infarction.

What is already known on this topic

Many patients with chest pain in emergency departments indicating a low to moderate risk of myocardial infarction are admitted to rule out myocardial damageSome 6% of those discharged have undiagnosed myocardial damage

What this study adds

An emergency department based chest pain assessment unit protocol to rule out myocardial damage is sensitive enough to allow safe discharge of patients at low to moderate risk of myocardial infarction within six hoursSuch units can also reduce the number of patients admitted unnecessarily     

Computer assisted self interviewing in a sexual health clinic as part of routine clinical care; impact on service and patient and clinician views

Background

Computer assisted self interviewing (CASI) has been used at the Melbourne Sexual Health Centre (MSHC) since 2008 for obtaining sexual history and identifying patients'' risk factors for sexually transmitted infections (STIs). We aimed to evaluate the impact of CASI operating at MSHC.

Methodology/Principal Findings

The proportion of patients who decline to answer questions using CASI was determined. We then compared consultation times and STI-testing rates during comparable CASI and non-CASI operating periods. Patients and staff completed anonymous questionnaires about their experience with CASI. 14,190 patients completed CASI during the audit period. Men were more likely than women to decline questions about the number of partners they had of the opposite sex (4.4% v 3.6%, p = 0.05) and same sex (8.9% v 0%, p<0.001). One third (34%) of HIV-positive men declined the number of partners they had and 11–17% declined questions about condom use. Women were more likely than men to decline to answer questions about condom use (2.9% v 2.3%, p = 0.05). There was no difference in the mean consultation times during CASI and non-CASI operating periods (p≥0.17). Only the proportion of women tested for chlamydia differed between the CASI and non-CASI period (84% v 88% respectively, p<0.01). 267 patients completed the survey about CASI. Most (72% men and 69% women) were comfortable using the computer and reported that all their answers were accurate (76% men and 71% women). Half preferred CASI but 18% would have preferred a clinician to have asked the questions. 39 clinicians completed the staff survey. Clinicians felt that for some STI risk factors (range 11%–44%), face-to-face questioning was more accurate than CASI. Only 5% were unsatisfied with CASI.

Conclusions

We have demonstrated that CASI is acceptable to both patients and clinicians in a sexual health setting and does not adversely affect various measures of clinical output.     

Prevalence of dysfunctional breathing in patients treated for asthma in primary care: cross sectional survey

ObjectivesTo estimate the prevalence of dysfunctional breathing in adults with asthma treated in the community.DesignPostal questionnaire survey using Nijmegen questionnaire.SettingOne general practice with 7033 patients.ParticipantsAll adult patients aged 17-65 with diagnosed asthma who were receiving treatment.Results227/307 patients returned completed questionnaires; 219 (71.3%) questionnaires were suitable for analysis. 63 participants scored ⩾23. Those scoring ⩾23 were more likely to be female than male (46/132 (35%) v 17/87 (20%), P=0.016) and were younger (mean (SD) age 44.8 (14.7) v 49.0 (13.8, (P=0.05). Patients at different treatment steps of the British Thoracic Society asthma guidelines were affected equally.ConclusionsAbout a third of women and a fifth of men had scores suggestive of dysfunctional breathing. Although further studies are needed to confirm the validity of this screening tool and these findings, these prevalences suggest scope for therapeutic intervention and may explain the anecdotal success of the Buteyko method of treating asthma.

What is already known on this topic

Abnormal breathing patterns may cause characteristic symptoms and impair quality of lifeEffective interventions exist for dysfunctional breathingDysfunctional breathing has been described in patients attending hospital respiratory clinics

What this study adds

29% of adults treated for asthma in primary care had symptoms suggestive of dysfunctional breathingAffected patients were more likely to be female and younger, but no differences were found with severity of asthmaSome patients with asthma may benefit from breathing therapy     

Images of the good doctor in Western medicine: The doctor-patient relationship

ObjectiveTo determine whether the management of head injuries differs between patients aged ⩾65 years and those <65.DesignProspective observational national study over four years.Setting25 Scottish hospitals that admit trauma patients.Participants527 trauma patients with extradural or acute subdural haematomas.ResultsPatients aged ⩾65 years had lower survival rates than patients <65 years. Rates were 15/18 (83%) v 165/167 (99%) for extradural haematoma (P=0.007) and 61/93 (66%) v 229/249 (92%) for acute subdural haematoma (P<0.001). Older patients were less likely to be transferred to specialist neurosurgical care (10 (56%) v 142 (85%) for extradural haematoma (P=0.005) and 56 (60%) v 192 (77%) for subdural haematoma (P=0.004)). There was no significant difference between age groups in the incidence of neurosurgical interventions in patients who were transferred. Logistic regression analysis showed that age had a significant independent effect on transfer and on survival. Older patients had higher rates of coexisting medical conditions than younger patients, but when severity of injury, initial physiological status at presentation, or previous health were controlled for in a log linear analysis, transfer rates were still lower in older patients than in younger patients (P<0.001).ConclusionsCompared with those aged under 65 years, people aged 65 and over have a worse prognosis after head injury complicated by intracranial haematoma. The decision to transfer such patients to neurosurgical care seems to be biased against older patients.

What is already known on this topic

Older patients with acute intracranial haematomas have significantly higher mortality and poorer functional outcome than younger patients with similar injuriesIntracranial haematomas are larger and more common in older patients with head injury than in younger patientsEarly diagnosis and surgical intervention for operable lesions is a crucial factor in determining patients'' outcomes

What this study adds

Older patients with acute intracranial haematomas were less likely to be transferred for specialist neurosurgical care than younger patients with similar severities of injuries, extracranial injuries, and physiological status at presentationSignificant differences in transfer rates related to age were still seen after pre-existing medical conditions were controlled for     

Nicotine nasal spray with nicotine patch for smoking cessation: randomised trial with six year follow up

ObjectiveTo evaluate the efficacy of using a nicotine patch for 5 months with a nicotine nasal spray for 1 year.DesignPlacebo controlled, double blind trial.SettingReykjavik health centre.Subjects237 smokers aged 22-66 years living in or around Reykjavik.InterventionsNicotine patch for 5 months with nicotine nasal spray for 1 year (n=118) or nicotine patch with placebo spray (n=119). Treatment with patches included 15 mg of nicotine for 3 months, 10 mg for the fourth month, and 5 mg for the fifth month, whereas nicotine in the nasal spray was available for up to 1 year. Both groups received supportive treatment.ResultsThe log rank test for 6 years (χ²=8.5, P=0.004) shows a significant association between abstinence from smoking and type of treatment. Sustained abstinence rates for the patch and nasal spray group and patch only group were 51% v 35% after 6 weeks (P=0.011 (χ²), 95% confidence interval 1.17% to 3.32%), 37% v 25% after 3 months (P=0.045, 1.01% to 3.08%), 31% v 16% after 6 months (P=0.005, 1.27% to 4.50%), 27% v 11% after 12 months (P=0.001, 1.50% to 6.14%), and 16% v 9% after 6 years (P=0.077, 0.93% to 4.72%).ConclusionsShort and long term abstinence rates show that the combination of using a nicotine patch for 5 months with a nicotine nasal spray for 1 year is a more effective method of stopping smoking than using a patch only. The low percentage of participants using the nasal spray at 1 year, and the few relapses during the second year, suggest that it is not cost effective to use a nasal spray for longer than 7 months after stopping a patch.

Key messages

• Combined methods of nicotine replacement therapy have a potential advantage over one method because of high levels of substitution
• Nicotine patches release nicotine slowly, but nicotine nasal spray delivers nicotine more rapidly, enabling the smoker to respond quickly to any smoking urges
• Treatment with a patch and nicotine nasal spray was significantly more effective than patch and placebo from day 15 after stopping smoking
• Using a patch for 5 months with a nicotine nasal spray for 1 year provides a more effective means of stopping smoking than using a patch only
• It is not cost effective to use a nicotine nasal spray for longer than 7 months after stopping a patch

     

Mental health problems of homeless children and families: longitudinal study

Objective: To establish the mental health needs of homeless children and families before and after rehousing. Design: Cross sectional, longitudinal study. Setting: City of Birmingham. Subjects: 58 rehoused families with 103 children aged 2-16 years and 21 comparison families of low socioeconomic status in stable housing, with 54 children. Main outcome measures: Children’s mental health problems and level of communication; mothers’ mental health problems and social support one year after rehousing. Results: Mental health problems remained significantly higher in rehoused mothers and their children than in the comparison group (mothers 26% v 5%, P=0.04; children 39% v 11%, P=0.0003). Homeless mothers continued to have significantly less social support at follow up. Mothers with a history of abuse and poor social integration were more likely to have children with persistent mental health problems. Conclusions: Homeless families have a high level of complex needs that cannot be met by conventional health services and arrangements. Local strategies for rapid rehousing into permanent accommodation, effective social support and health care for parents and children, and protection from violence and intimidation should be developed and implemented.

Key messages

• Homeless children and their mothers have a high level of mental health problems
• Homeless families experience many risk factors, such as domestic violence, abuse, and family and social disruption
• In two fifths of children and a quarter of mothers, mental health problems persisted after rehousing
• In contrast with a comparison group of families of low socioeconomic status, a substantial proportion of homeless families remained residentially and socially unstable

     

Endpiece: The noble profession

ObjectivesTo assess whether bacterial vaginosis or chlamydial infection before 10 weeks'' gestation is associated with miscarriage before 16 weeks.DesignProspective cohort study.Setting32 general practices and five family planning clinics in south London.Participants1216 pregnant women, mean age 31, presenting before 10 weeks'' gestation.Results121 of 1214 women (10.0%, 95% confidence interval 8.3% to 11.7%) miscarried before 16 weeks. 174 of 1201 women (14.5%, 12.5% to 16.5%) had bacterial vaginosis. Compared with women who were negative for bacterial vaginosis those who were positive had a relative risk of miscarriage before 16 weeks'' gestation of 1.2 (0.7 to 1.9). Bacterial vaginosis was, however, associated with miscarriage in the second trimester at 13-15 weeks (3.5, 1.2 to 10.3). Only 29 women (2.4%, 1.5% to 3.3%) had chlamydial infection, of whom one miscarried (0.32, 0.04 to 2.30).ConclusionBacterial vaginosis is not strongly predictive of early miscarriage but may be a predictor after 13 weeks'' gestation. The prevalence of Chlamydia was too low to assess the risk, but it is unlikely to be a major risk factor in pregnant women.

What is already known on this topic

Miscarriages are common and associated with considerable morbidity and costsBacterial vaginosis is associated with miscarriage after 16 weeks'' gestation and preterm birth but the role of chlamydial infection is uncertain

What this study adds

Bacterial vaginosis is not a strong predictor of miscarriage before 16 weeks'' gestation but may be associated with miscarriage at 13-15 weeks'' gestationThe prevalence of chlamydial infection was too low for it to be a major risk factor for miscarriage in this population of healthy pregnant womenNon-invasive screening for bacterial vaginosis and chlamydial infection by using self administered vaginal swabs is feasible in pregnant women in the community     

Longevity of screenwriters who win an academy award: longitudinal study

ObjectiveTo determine whether the link between high success and longevity extends to academy award winning screenwriters.DesignRetrospective cohort analysis.ParticipantsAll screenwriters ever nominated for an academy award.ResultsA total of 850 writers were nominated; the median duration of follow up from birth was 68 years; and 428 writers died. On average, winners were more successful than nominees, as indicated by a 14% longer career (27.7 v 24.2, P=0.004), 34% more total films (23.2 v 17.3, P<0.001), 58% more four star films (4.8 v 3.1, P<0.001), and 62% more nominations (2.1 v 1.3, P<0.001). However, life expectancy was 3.6 years shorter for winners than for nominees (74.1 v 77.7 years, P=0.004), equivalent to a 37% relative increase in death rates (95% confidence interval 10 to 70). After adjustment for year of birth, sex, and other factors, a 35% relative increase in death rates was found (7% to 70%). Additional wins were associated with a 22% relative increase in death rates (3% to 44%). Additional nominations and additional other films in a career otherwise caused no significant increase in death rates.ConclusionThe link between occupational achievement and longevity is reversed in screenwriters who win academy awards. Doubt is cast on simple biological theories for the survival gradients found for other members of society.

What is already known on this topic

High achievement has been associated with decreased all cause mortality for people in many different occupationsSuch an association is compatible with behavioural and biological theories for the role of social determinants

What this study adds

Screenwriters nominated for an academy award show a paradoxical survival pattern, where greater success is associated with a large decrease in life expectancyThe paradox is not easily explained by talent, prestige, financial earnings, material conditions, reverse causality, measurement error, or simple demographicsIt might reflect the unusual lifestyles of writers, where success is not linked to exemplary conduct or control; this underscores the importance of behaviour     

The uptake and accuracy of oral kits for HIV self-testing in high HIV prevalence setting: a cross-sectional feasibility study in Blantyre, Malawi

Background

Although HIV testing and counseling (HTC) uptake has increased dramatically in Africa, facility-based services are unlikely to ever meet ongoing need to the full. A major constraint in scaling up community and home-based HTC services is the unacceptability of receiving HTC from a provider known personally to prospective clients. We investigated the potential of supervised oral HIV self-testing from this perspective.

Methods and Findings

Adult members of 60 households and 72 members of community peer groups in urban Blantyre, Malawi, were selected using population-weighted random cluster sampling. Participants were offered self-testing plus confirmatory HTC (parallel testing with two rapid finger-prick blood tests), standard HTC alone, or no testing. 283 (95.6%) of 298 selected adults participated, including 136 (48.0%) men. 175 (61.8%) had previously tested (19 known HIV positive), although only 64 (21.5%) within the last year. HIV prevalence was 18.5%. Among 260 (91.9%) who opted to self-test after brief demonstration and illustrated instructions, accuracy was 99.2% (two false negatives). Although 98.5% rated the test “not hard at all to do,” 10.0% made minor procedural errors, and 10.0% required extra help. Most participants indicated willingness to accept self-test kits, but not HTC, from a neighbor (acceptability 94.5% versus 46.8%, p = 0.001).

Conclusions

Oral supervised self-testing was highly acceptable and accurate, although minor errors and need for supervisory support were common. This novel option has potential for high uptake at local community level if it can be supervised and safely linked to counseling and care. Please see later in the article for the Editors'' Summary     

The blind nasotracheal aspiration method is not a useful tool for pathogen detection of pneumonia in children

Background

Acute lower respiratory infection (ALRI) is a major cause of hospitalization for children in China, while the etiological diagnosis of ALRI remains a challenge. This study was performed to evaluate the utility of the blind Nasotracheal aspiration (NTA) in the pathogen detection in ALRI through an evaluation of the test''s specificity.

Methodology/Principal Findings

A hospital-based study of children ≤3 years was carried out from March 2006 through March 2007 in Suzhou University Affiliated Children''s Hospital, including 379 cases with ALRI from the respiratory wards, and 394 controls receiving elective surgery. Nasopharyngeal swabs (NPS) and NTA specimens were taken on admission. S. pneumoniae was isolated from 10.3% of NTA samples from ALRI children, H. influenzae from 15.3%, and M. catarrhalis from 4.7%. The false positive rate—the strains from NTA in control group children—was 8.4% (95% CI: 5.8%–11.4%) for S. pneumoniae, 27.2% (95% CI: 22.7–31.5%) for H. influenzae, and 22.1% (95% CI: 18.0%–26.2%) for M. catarrhalis. The agreement between NPS and NTA in the control group was over 70%.

Conclusion/Significance

The blind NTA test is not a useful test for etiologic diagnosis of ALRI.     

The health of children in refuges for women victims of domestic violence: cross sectional descriptive survey

ObjectivesTo describe the health and developmental status of children living in refuges for women victims of domestic violence and to investigate their access to primary healthcare services.DesignCross sectional survey.SettingWomen''s refuges in Cardiff.Participants148 resident children aged under 16 years and their mothers.Results148/257 (58%) children living in refuges between April 1999 and January 2000 were assessed. Child health system data were incorrect (general practitioner and/or address) or unavailable for 85/148 (57%) children. Uptake of all assessments and immunisations was low. 13/68 (19%) children aged <5 years had delayed or questionable development on the Denver test, and 49/101 (49%) children aged 3-15 years had a Rutter score of >10 (indicating probable mental health problems). Concerns were expressed by mothers of 113/148 (76%) children. After leaving the refuge, 22 children were untraceable and 36 returned home to the perpetrator from whom the families had fled.ConclusionsThe children had a high level of need, as well as poor access to services. Time spent in a refuge provides a window of opportunity to review health and developmental status. Specialist health visitors could facilitate and provide support, liaison, and follow up.

What is already known on this topic

A pilot study showed poor uptake of immunisations and surveillance among children who live in refuges for women victims of domestic violenceQualitative studies suggest that these children are at risk of psychological ill health

What this study adds

Baseline health and demographic data show that children in refuges have a high level of unmet health need, particularly in relation to mental health difficultiesTheir families have poor access to health services     

Randomised controlled trial of homoeopathy versus placebo in perennial allergic rhinitis with overview of four trial series

ObjectiveTo test the hypothesis that homoeopathy is a placebo by examining its effect in patients with allergic rhinitis and so contest the evidence from three previous trials in this series.DesignRandomised, double blind, placebo controlled, parallel group, multicentre study.SettingFour general practices and a hospital ear, nose, and throat outpatient department.Participants51 patients with perennial allergic rhinitis.InterventionRandom assignment to an oral 30c homoeopathic preparation of principal inhalant allergen or to placebo.ResultsFifty patients completed the study. The homoeopathy group had a significant objective improvement in nasal airflow compared with the placebo group (mean difference 19.8 l/min, 95% confidence interval 10.4 to 29.1, P=0.0001). Both groups reported improvement in symptoms, with patients taking homoeopathy reporting more improvement in all but one of the centres, which had more patients with aggravations. On average no significant difference between the groups was seen on visual analogue scale scores. Initial aggravations of rhinitis symptoms were more common with homoeopathy than placebo (7 (30%) v 2 (7%), P=0.04). Addition of these results to those of three previous trials (n=253) showed a mean symptom reduction on visual analogue scores of 28% (10.9 mm) for homoeopathy compared with 3% (1.1 mm) for placebo (95% confidence interval 4.2 to 15.4, P=0.0007).ConclusionThe objective results reinforce earlier evidence that homoeopathic dilutions differ from placebo.     

Evaluation of immunoassays for the diagnosis of Schistosoma japonicum infection using archived sera

Background

With a national program initiated recently to reduce transmission of Schistosoma japonicum in the People''s Republic of China (P.R. China), there is an urgent need for accessible, quality-assured diagnostics for case detection, surveillance, and program monitoring of chemotherapy efficacy and other control interventions in areas of low endemicity. We compared the performance of nine immunodiagnostic tests developed in P.R. China for detection of antibodies against S. japonicum and established their priority for further assessment in field settings.

Methodology/Principal Findings

Using the Kato-Katz technique as the reference standard, 240 well-characterized archived serum specimens (100 positive and 140 negative) were evaluated in nine immunological tests developed in P.R. China. The enzyme-linked immunoelectrotransfer blot assay (EITB), which uses an adult worm extract of S. japonicum, supplied by the Center of Disease Control and Prevention, USA, was also evaluated. The sensitivity and specificity of each test were determined and the reproducibility of each test was assessed by evaluating operator-to-operator and run-to-run variation. In addition the simplicity of use for the end-user was evaluated. All tests showed good sensitivities ranging from 92.0% (95% confidence interval (CI): 86.7–97.3%) to 98.0% (95% CI: 95.3–100.0%). The test specificities varied from 70.0% (95% CI: 62.4–77.6%) to 97.1% (95% CI: 94.4–99.9%). All tests showed excellent reproducibility with a discordant rate in the range of 0–10.0% for operator-to-operator variation and run-to-run variation. All tests, except one magnetic particle-based enzyme-linked immunosorbent assay, were found to be easy to use, especially the dot immunogold filtration assays.

Conclusions/Significance

Most evaluated tests had acceptable performance characteristics and could make an impact on the schistosomiasis control programs in P.R. China. Three tests with the highest sensitivity, specificity and greatest ease of use, were selected for further evaluation in field settings.