Bookmarkers beware: Bookmarks to pages other than the home page may not work after we change our server in April Editor's Choice | This Week in BMJ | Press releases BMJ No 7130 Volume 316 Papers - Abstracts Saturday 14 February 1998 Childhood energy intake and adult mortality from cancer: the Boyd Orr cohort study Cross sectional longitudinal study of spot morning urine protein:creatinine ratio, 24 hour urine protein excretion rate, glomerular filtration rate, and end stage renal failure in chronic renal disease in patients without diabetes Guidelines on anticoagulant treatment in atrial fibrillation in Great Britain: variation in content and implications for treatment Winter mortality and cold stress in Yekaterinburg, Russia: interview survey Relation of out of hours activity by general practice and accident and emergency services with deprivation in Nottingham: longitudinal survey The use of out of hours health services: a cross sectional survey Childhood energy intake and adult mortality from cancer: the Boyd Orr cohort study Stephen Frankel, David J Gunnell, Tim J Peters, Maria Maynard, George Davey Smith Abstract Objective: To examine the relation between energy intake in childhood and adult mortality from cancer. Study design: Cohort study. Setting: 16 rural and urban centres in England and Scotland. Subjects: 3,834 people who took part in Lord Boyd Orr's Carnegie survey of family diet and health in prewar Britain between 1937 and 1939 who were followed up with the NHS central register. Standardised methods were used to measure household dietary intake during a one week period. Main outcome measures: Cancer mortality. Results: Significant associations between childhood energy intake and cancer mortality were seen when the confounding effects of social variables were taken into account in proportional hazards models (relative hazard for all cancer mortality 1.15 (95% confidence interval 1.06 to 1.24), P=0.001, for every MJ increase in adult equivalent daily intake in fully adjusted models). This effect was essentially limited to cancers not related to smoking (relative hazard 1.20; 1.07 to 1.34; P=0.001), with similar effects seen in men and women. Conclusion: This positive association between childhood energy intake and later cancer is consistent with animal evidence linking energy restriction with reduced incidence of cancer and the association between height and human cancer, implying that higher levels of energy intake in childhood increase the risk of later development of cancer. This evidence for long term effects of early diet confirm the importance of optimal nutrition in childhood and suggest that the unfavourable trends seen in the incidence of some cancers may have their origins in early life. Department of Social Medicine, University of Bristol, Bristol BS8 2PR Stephen Frankel, professor of epidemiology and public health medicine David J Gunnell, senior lecturer in epidemiology and public health medicine Tim J Peters, reader in medical statistics Maria Maynard, research student George Davey Smith, professor of clinical epidemiology Correspondence to: Professor Frankel email: stephen.frankel@bristol.ac.uk Cross sectional longitudinal study of spot morning urine protein:creatinine ratio, 24 hour urine protein excretion rate, glomerular filtration rate, and end stage renal failure in chronic renal disease in patients without diabetes Piero Ruggenenti, Flavio Gaspari, Annalisa Perna, Giuseppe Remuzzi Abstract Objective: To evaluate whether the protein:creatinine ratio in spot morning urine samples is a reliable indicator of 24 hour urinary protein excretion and predicts the rate of decline of glomerular filtration rate and progression to end stage renal failure in non-diabetic patients with chronic nephropathy. Design: Cross sectional correlation between the ratio and urinary protein excretion rate. Univariate and multivariate analysis of baseline predictors, including the ratio and 24 hour urinary protein, of decline in glomerular filtration rate and end stage renal failure in the long term. Setting: Research centre in Italy. Subjects: 177 non-diabetic outpatients with chronic renal disease screened for participation in the ramipril efficacy in nephropathy study. Main outcome measures: Rate of decline in filtration rate evaluated by repeated measurements of unlabelled iohexol plasma clearance and rate of progression to renal failure. Results: Protein:creatinine ratio was significantly correlated with absolute and log transformed 24 hour urinary protein values (P=0.0001 and P<0.0001, respectively.) Ratios also had high predictive value for rate of decline of the glomerular filtration rate (univariate P=0.0003, multivariate P=0.004) and end stage renal failure (P=0.002 and P=0.04). Baseline protein:creatinine ratios and rate of decline of the glomerular filtration rate were also significantly correlated (P<0.0005). In the lowest third of the protein:creatinine ratio (<1.7) there was 3% renal failure compared with 21.2% in the highest third (g2.7) (P<0.05). Conclusions: Protein:creatinine ratio in spot morning urine samples is a precise indicator of proteinuria and a reliable predictor of progression of disease in non-diabetic patients with chronic nephropathies and represents a simple and inexpensive procedure in establishing severity of renal disease and prognosis. Mario Negri Institute for Pharmacological Research, Clinical Research Centre for Rare Diseases, Via Gavazzeni 11, 24125 Bergamo, Italy Piero Ruggenenti, doctor Flavio Gaspari, chemist Annalisa Perna, statistical scientist Giuseppe Remuzzi, director Correspondence to: Dr Ruggenenti email: ruggenenti@irfmn.mnegri.it Guidelines on anticoagulant treatment in atrial fibrillation in Great Britain: variation in content and implications for treatment Richard Thomson, Helen McElroy, Mark Sudlow Abstract Objective: To describe the content of guidelines on the use of anticoagulant treatment in patients with atrial fibrillation and the impact of variations in guidelines on treatment. Design: Postal survey of guidelines, semistructured interview with lead developers of guidelines, and application of guidelines to patient sample. Subjects: 15 lead developers of the 20 guidelines identified in the postal survey were interviewed. 100 patients over 65 with atrial fibrillation to whom the guidelines were applied. Main outcome measures: the methods of dissemination, implementation, review, and evaluation; proportion of patients recommended for anticoagulant treatment by each guideline; and level of agreement between guidelines. Results: There was considerable variation in whether anticoagulant treatment was recommended for subjects (range 13% to 100%, |gk=0.12). Guidelines varied greatly in advice on treatment by age, the use of echocardiography, and the target value or range of the international normalised ratio (8 of the 20 guidelines included values unlikely to be effective). Development was unsystematic; evidence based approaches were rarely used. 9 of the 15 lead developers had developed the guidelines themselves, and the 6 guidelines developed by groups relied on informal consensus. Methods to support effective dissemination, implementation, and evaluation were limited. Conclusion: The widespread non-systematic production of guidelines has led to considerable variation with implications for the quality of care and clinical decision making. There is a need for a central, well funded programme of guideline development to ensure that valid guidelines are produced and disseminated. Department of Epidemiology and Public Health, School of Health Sciences, Medical School, University of Newcastle upon Tyne, Newcastle upon Tyne NE2 4HH Richard Thomson, senior lecturer in public health medicine Helen McElroy, research associate Departments of Epidemiology and Public Health and of Medicine, Medical School, University of Newcastle upon Tyne Mark Sudlow, MRC special training fellow in health services research Correspondence to: Dr Thomson email: Richard.Thomson@newcastle.ac.uk Winter mortality and cold stress in Yekaterinburg, Russia: interview survey G C Donaldson, V E Tchernjavskii, S P Ermakov, K Bucher, W R Keatinge Abstract Objectives: To evaluate how mortality and protective measures against exposure to cold change as temperatures fall between October and March in a region of Russia with a mean winter temperature below -6°C. Design: Interview to assess factors associated with cold stress both indoors and outdoors, to measure temperatures in living room, and to survey unheated rooms. Setting: Sverdlovsk Oblast (district), Yekaterinburg, Russia. Subjects: Residents aged 50-59 and 65-74 living within approximately 140 km of Yekaterinburg in Sverdlovsk Oblast. Survey of sample of 1000 residents equally distributed by sex and age groups. Main outcome measures: Regression analysis was used to relate data on indoor heating and temperatures, the amount of clothing worn, the amount of physical activity, and shivering while outside, to outdoor temperature; results were compared with mortality patterns for ischaemic heart disease, cerebrovascular disease, respiratory disease, and mortality from all causes. Results: As mean daily temperatures fell to 0°C the amount of clothing worn outdoors increased, physical activity while outdoors became more continuous, and only 11 (6.6%) of the 167 people surveyed who went outdoors at temperatures above 0°C reported shivering. The mean temperature in living rooms in the evening remained above 21.9°C. Mortality from ischaemic heart disease, cerebrovascular disease, respiratory disease, and all causes did not change. As the temperature fell below 0°C the number of items of clothing worn plateaued at 16.0 and the number of layers at 3.7. With regression analysis, shivering outdoors was found to increase progressively to 34.6% (P<0.001) of excursions at -25°C, and mortality (after declining slightly) rose progressively (all cause mortality rose by 1.15% for each 1°C drop in temperature from 0°C to -29.6°C, 95% confidence interval 0.97% to 1.32%). 94.2% of bedrooms were directly heated, and evening temperatures in the living room averaged 19.8°C even when outside temperatures reached -25°C. Conclusions: Outdoor cold stress and mortality in Yekaterinburg increased only when the mean daily temperature dropped below 0°C. At temperatures down to 0°C cold stress and excess mortality were prevented by increasing the number of items of clothing worn and the amount of physical activity outdoors in combination with maintaining warmth in houses. Department of Physiology, Basic Medical Sciences, Queen Mary and Westfield College, University of London, London E1 4NS G C Donaldson, senior research associate W R Keatinge, emeritus professor of physiology Russian Ministry of Health, 11 Dobrolubova Street, Moscow 127254, Russia V E Tchernjavskii, deputy director, public health institute S P Ermakov, principal researcher Dezemat Biosynoptik der Zentralen Medizin-Meteorologischen Forschungsstelle des Deutschen Wetterdienstes, Stefan Maier Strasse 4, 7800 Freiburg 1, Germany K Bucher, head Correspondence to: Professor Keatinge email: w.r.keatinge@qmw.ac.uk Relation of out of hours activity by general practice and accident and emergency services with deprivation in Nottingham: longitudinal survey Robin Carlisle, Lindsay M Groom, Anthony J Avery, Daphne Boot, Stephen Earwicker See Paper (abstract only), p 524Paper (abstract only), p 524 Abstract Objectives: To investigate the relation between out of hours activity of general practice and accident and emergency services with deprivation and distance from accident and emergency department. Design: Six month longitudinal study. Setting: Six general practices and the sole accident and emergency department in Nottingham. Subjects: 4,745 out of hours contacts generated by 45,182 patients from 23 electoral wards registered with six practices. Main outcome measures: Rates of out of hours contacts for general practice and accident and emergency services calculated by electoral ward; Jarman and Townsend deprivation scores and distance from accident and emergency department of electoral wards. Subjects: 4745 out of hours contacts generated by 45 182 patients from 23 electoral wards registered with six practices. Main outcome measures: Rates of out of hours contacts for general practice and accident and emergency services calculated by electoral ward; Jarman and Townsend deprivation scores and distance from accident and emergency department ranged from 0.8 to 9 km, and Jarman deprivation scores ranged from -23.4 to 51.8. Out of hours contacts varied by ward from 110 to 350 events/1000 patients/year, and 58% of this variation was explained by the Jarman score. General practice and accident and emergency rates were positively correlated (Pearson coefficient 0.50, P=0.015). Proximity to accident and emergency department was not significantly associated with increased activity when deprivation was included in regression analysis. One practice had substantially higher out of hours activity (B coefficient 124 (95% confidence interval 67 to 181)) even when deprivation was included in regression analysis. Conclusions: A disproportionate amount of out of hours workload fell on deprived inner city practices. High general practice and high accident and emergency activity occurred in the same areas rather than one service substituting for the other. Division of General Practice, University of Nottingham, University Hospital, Nottingham NG7 2UH Robin Carlisle, lecturer Lindsay M Groom, research unit coordinator Anthony J Avery, senior lecturer Daphne Boot, research associate Stapleford Health Centre, Nottingham NG9 7AT Stephen Earwicker, general practitioner Correspondence to: Dr R Carlisle, Roundwood Surgery, Wood Street, Mansfield, Nottinghamshire NG18 1QQ The use of out of hours health services: a cross sectional survey Catherine Brogan, Diane Pickard, Alastair Gray, Steve Fairman, Alison Hill Abstract Objectives: To determine the use and costs of the principal out of hours health services in Buckinghamshire. Design: Prospective cross sectional survey and cost description of patient contacts with out of hours services. Subjects: General practices, accident and emergency departments, ambulance services, and community nursing services. Main outcome measure: Contacts with patients and cost of out of hours services. Results: 438 patient contacts/1000 population/year were recorded at an annual incremental cost of between £4.6m and £7.2m (depending on the costing of general practitioner services), for a population of 660,000. Of these contacts, 21,649 (45%) were with general practitioners. Night time contacts with all services diminished sharply after 10 pm. General practitioners considered that 40% of contacts were unnecessary or could have waited until morning. Over 70% of contacts were for upper respiratory tract infections, earache, gastroenteritis, and other minor ailments. Nursing care was predominantly for elderly people, and 33% of nursing contacts were to supervise medication. Accident and emergency care was predominately for young adults, especially men, and 41% of attendances were for medical conditions. Conclusions: New models such as multidisciplinary primary care centres with telephone advice lines and triaging are required to ensure high quality, cost effective care that is responsive to the needs of both consumers and professionals. Anglia and Oxford Regional Office NHS Executive, Linford Wood, Milton Keynes MK14 6QP Catherine Brogan, Consultant in public health medicine Buckinghamshire Health Authority, Verney House, Aylesbury HP19 3ET Diane Pickard, research and development specialist nurse Steve Fairman, information manager Alison Hill, director of public health Health Economics Research Centre, University of Oxford, Institute of Health Sciences, Oxford OX3 7LF Alastair Gray, director Correspondence to: Dr Brogan Home | Current contents | Past issues | Classified ads | Career Focus | Feedback Collections | About this site | About the BMJ | BMA | Medline