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PURPOSE: Two questions were addressed: (1) How much physical activity do patients with diabetes perform? (2) What are the perceived factors that prevent patients from doing more physical activity? RESEARCH DESIGN AND METHODS: Interview based questionnaires were distributed to consecutive patients attending the Diabetes Clinic, Ninewells Hospital, Dundee over a period of five months. Exclusion criteria were age below 20 years and inadequate understanding of English; 428 questionnaires were given out with 406 completed. RESULTS: Physical activity was undertaken by 34% of patients with diabetes and only 9% of these patients exercised sufficiently to achieve a large change in heart rate or breathing. The main reasons for inactivity included perceived difficulty taking part in exercise, feelings of tiredness, and being distracted by something good on television. Lack of time and lack of local facilities also contributed. CONCLUSIONS: Few patients with diabetes participate in physical activity, and in those who do the level of intensity is low. There are many modifiable factors distracting patients from exercise.

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Compliance with asthma medication is recognised to be a problem. Acquisition of medication is the first step towards compliance. Factors predicting poor collection of prophylactic medication were investigated. A case/control study was conducted. Cases were children who had had at least two consultations for poorly controlled asthma in 1 yr and collected prescriptions of prophylactic medication irregularly. Controls were children whose prescriptions were collected as instructed. Levels of knowledge about asthma and asthma medication were high in both groups. Parents of cases were more likely to perceive their child's asthma to be moderate or severe and more likely to report that their child's asthma was not well controlled. They reported more night-time symptoms, exercise symptoms and school absence. Parents of cases were less likely to report that administering inhalers was part of the evening routine. They were less likely to perceive their child's prophylactic medication to be very effective and more reluctant to administer prophylactic medication. Some parents may decide to undertreat their children, although lack of organised routine may contribute to poor compliance. Parents need guidance on interpreting symptoms and support in establishing routines for the administration of medication.

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Assessment tools are a vital component of chronic disease management. The Royal College of Physicians has developed a patient-focused outcome measure for the treatment of asthma, the 'Three Key Questions'. However, in a study investigating the goals of people with asthma, several issues related to the tool emerged. Forty-seven adults of a range of ages and asthma severity but with no significant co-morbidity were interviewed. It emerged that the outcome measure may be subject to recall bias. Also, symptom reports may be conflated if daytime symptoms also occur with activity. 'Interference with activity' is a subjective term the interpretation of which varies considerably. Changes in the level of activity undertaken may be reported rather than changes in symptom severity. The 'Three Key Questions' are not fully patient-centred because they assess the presence of symptoms rather than their importance to the individual. The use of the 'Three Key Questions' as an outcome measure may not allow valid comparisons to be made between settings.

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To identify a range of attitudes and beliefs which influence the timing of introduction to solid food, five focus group discussions were undertaken within a maternity hospital setting. These sessions explored early feeding behaviour, stimuli to changing feeding habits and subsequent responses in 22 primiparous and seven multiparous mothers (mean age 27.0+/-4.8 years) with babies aged 8-18 weeks (mean age 13.0+/-4.2 weeks). One-third of the participants had introduced solid food to their infants (mean age of introduction 11.6 weeks, range 2-16 weeks). Mothers believed that the introduction of solids was baby led and initiated by some physical characteristic or behavioural action of the infant. All mothers were aware of current recommendations to avoid the introduction of solid food until 4 months. Few knew why this should be and concepts of long-term ill health were difficult to conceptualize. The conflict between rigid feeding guidelines and flexible advice from supportive health professionals created confusion over the importance of good weaning practices. The current findings highlight issues relevant to the introduction of solid food, and provide a foundation for further research which can identify the relative importance of these factors and provide a rationale for the design of contemporary intervention strategies.

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Using bioinformatics approaches, 34 potential multidrug resistance (MDR) transporter sequences representing 4 different transporter families were identified in the unannotated Enterococcus faecalis database (TIGR). A functional genomics campaign generating single-gene insertional disruptions revealed several genes whose absence confers significant hypersensitivities to known antimicrobials. We constructed specific strains, disrupted in a variety of previously unpublished, putative MDR transporter genes, as tools to improve the success of whole-cell antimicrobial screening and discovery. Each of the potential transporters was inactivated at the gene level and then phenotypically characterized, both with single disruption mutants and with 2-gene mutants built upon a delta norA deleted strain background.

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OBJECTIVE: To assess mothers' perception of information given to them about bottle feeding. DESIGN: Survey, as part of a longitudinal study of professional support given to infant feeding mothers. Data were analysed from postal questionnaires completed at 34 weeks gestation and one month postnatally. SUBJECTS: Every woman over 16 years expecting her first baby in an uncomplicated pregnancy, in two Scottish regions, was sent an antenatal questionnaire over an eight month period during 1998. This report considers respondents over 23 years of age, of whom there were 365 (51% response rate). Of these, 296 (81%) completed the subsequent questionnaire at one month postnatally. RESULTS: Fewer than 50% of women reported being given information about sterilising equipment, making feeds and offering the right quantities, before the birth of their baby. Of women considering bottle feeding only 42% had been given any information on sterilising equipment before their baby's birth. Of women who had begun to breastfeed but were giving bottle feeds at one month postnatally, fewer than 40% had been given information on bottle feeding antenatally, and less than 56% postnatally. CONCLUSION: In a study of 365 mothers of 23 years and over most women reported having little or no information about bottle feeding. Women who intended to bottle feed reported receiving more information than those intending to breastfeed. Those giving bottle feeds at one month reported that they received more information than those exclusively breastfeeding, but low levels of information giving were recalled overall.

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OBJECTIVE: To review the literature on the benefits and disadvantages of clinical and medical audit, and to assess the main facilitators and barriers to conducting the audit process. DESIGN: A comprehensive literature review was undertaken through a thorough review of Medline and CINAHL databases using the keywords of "audit", "audit of audits", and "evaluation of audits" and a handsearch of the indexes of relevant journals for key papers. RESULTS: Findings from 93 publications were reviewed. These ranged from single case studies of individual audit projects through retrospective reviews of departmental audit programmes to studies of interface projects between primary and secondary care. The studies reviewed incorporated the experiences of a wide variety of clinicians, from medical consultants to professionals allied to medicine and from those involved in unidisciplinary and multidisciplinary ventures. Perceived benefits of audit included improved communication among colleagues and other professional groups, improved patient care, increased professional satisfaction, and better administration. Some disadvantages of audit were perceived as diminished clinical ownership, fear of litigation, hierarchical and territorial suspicions, and professional isolation. The main barriers to clinical audit can be classified under five main headings. These are lack of resources, lack of expertise or advice in project design and analysis, problems between groups and group members, lack of an overall plan for audit, and organisational impediments. Key facilitating factors to audit were also identified: they included modern medical records systems, effective training, dedicated staff, protected time, structured programmes, and a shared dialogue between purchasers and providers. CONCLUSIONS: Clinical audit can be a valuable assistance to any programme which aims to improve the quality of health care and its delivery. Yet without a coherent strategy aimed at nurturing effective audits, valuable opportunities will be lost. Paying careful attention to the professional attitudes highlighted in this review may help audit to deliver on some of its promise.

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Hormone replacement therapy (HRT) is effective in alleviating vasomotor symptoms but the effect on psychological symptoms is less clear. This study aimed to compare the psychological effects of two regimens of HRT in perimenopausal women in a randomized, initially double-blind, controlled trial. Thirty-eight women reporting climacteric symptoms were randomly allocated into either oral conjugated equine estrogen 0.625 mg daily plus progestogen (norgestrel) 150 micrograms for the last 12 days of each 28 day cycle, or tibolone 2.5 mg/day for 28 days. They were assessed using standardized psychological assessments. There were no significant differences in changes from baseline between the two types of therapy. For both groups combined there were significant improvements compared with baseline in vasomotor symptoms in the first month, plus anxiety, sleep, memory and somatic dysfunction by the second and third months, but not in scores of depression. Log linear analysis of weekly scores showed that depression scores were significantly related to improvement in vasomotor scores independent of type of therapy and time on HRT. Memory problems were related to vasomotor symptoms independent of depression. No difference between the two types of therapy was found, nor any direct effect of HRT on anxiety or depression. The results support the domino theory, suggesting that psychological improvement follows alleviation of vasomotor symptoms.

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The Blatt-Kupperman menopausal index has been used widely in studies of climacteric symptoms, but it now needs to be reassessed. The original index was derived from clinical experience in New York in the 1950s. The index was a combination of self report and physician ratings; it omitted measures of vaginal dryness and loss of libido; no demographic data of the sample were given; weighting was used without statistical justification; terms were ill defined; categories included overlapping scores, and most importantly scores were summed without being based on independent factors. Modern psychometrics has led to the publication of reliable and valid scales. These should be used in climacteric research in preference to the Blatt-Kupperman index.

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OBJECTIVE: To evaluate whether xamoterol, a partial agonist, would improve exercise time more than metoprolol in patients with mild to moderate heart failure after a myocardial infarction. DESIGN: Single-centre double blind randomised parallel group comparison of metoprolol 50-100 mg and xamoterol 100-200 mg twice daily. PATIENTS: 210 patients aged 40-80 years (173 men) with clinical evidence of heart failure early after a myocardial infarction. 106 were given metoprolol and 104 xamoterol. MAIN OUTCOME MEASURES: Exercise test results and performance at three months; the exercise test, quality of life, and clinical assessments at baseline (5-7 days after the infarction) and after 3, 6, and 12 months. RESULTS: Exercise time increased at three months by 22% in the metoprolol group and 29% in the xamoterol group, but with no significant difference between the groups. Patients taking xamoterol showed overall non-significantly higher mean values of exercise time achieved with higher heart rates at rest and exercise. Improvements in quality of life, clinical signs of heart failure, and New York Heart Association functional class were seen in both treatment groups over one year, with minor benefits of xamoterol on breathlessness, peripheral oedema, and functional class. Eighteen patients taking metoprolol and 22 taking xamoterol withdrew from the study during one year, with a low mortality, reinfarction rate, and progress of heart failure in both treatment groups. Mean dose from baseline to 3 months was 135 mg metoprolol and 347 mg xamoterol. CONCLUSION: beta 1 Receptor antagonists with or without partial agonist activity are safe to use in mild to moderate heart failure after a myocardial infarction. Exercise tolerance, quality of life, and clinical signs and functional class of heart failure improve, and few patients show deterioration in their condition. Exercise tolerance is no better with xamoterol than metoprolol.

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Tibolone (Livial) has advantages over other forms of hormone replacement therapy (HRT); it is easy to use and does not induce withdrawal bleeding in postmenopausal women. The evidence for the effect of tibolone on climacteric symptoms is reviewed and shows that tibolone is effective in reducing vasomotor symptoms and vaginal dryness. Tibolone's effect on a range of other symptoms such as headache and insomnia is unclear. There are reports that tibolone improves mood and libido but much of this research is methodologically flawed. Methodologically sound research is required to investigate tibolone's effect on mood and libido; such a study is in progress.

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1. Anxiety may be a factor influencing attendance for cervical screening. 2. Anxiety may be caused by stress and embarrassment of the test procedure and/or misunderstanding its purpose. 3. Women who were given the routine procedure were compared with a study group who were given an extra 10 minutes discussion by nurses. 4. The study group rated the explanation as being clearer, and after receiving the result they reported significantly less anxiety than those in the routine group.

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The attitudes of women of reproductive age in Scotland, Romania and Slovenia to the idea of a contraceptive pill which is taken only once each month or only when menses are delayed was investigated. In all three centres, the great majority of women felt positive towards the idea of a once-a-month pill which inhibited ovulation and greater than 50% found a pill which inhibited or interfered with implantation an acceptable idea. Only 24% of women in Scotland were attracted to the idea of a pill which was taken only if menstruation was delayed by 1 or 2 days, that is a pill which would cause an abortion, while in contrast 58% of women in Slovenia and 80% in Romania thought that such a method of controlling fertility would be acceptable. Attitudes were not related to age, social class or marital status but were influenced by religious belief and in Scotland by a history of abortion. In countries where the availability of contraception is limited and abortion is common, women would seem to welcome another method of fertility regulation--even one which disrupts the very early stages of pregnancy.

PIP: In 1990-91, 400 women attending clinics at the Family Planning Centre Dean Terrace, Edinburgh, Scotland; 400 women attending a gynecology clinic in Tirgu-Mures, Romania; and 100 women attending a family planning clinic in Ljubljana, Slovenia, completed a questionnaire as part of a study to determine attitudes about taking a once-a-month contraceptive (OC) or using an OC to induce menstruation (missed-period OC). The highest abortion rate was in Ljubljana (55%)even though the rate in Romania was more than 2 times as high as the rate in Yugoslavia. Ljubljana had the most Roman Catholics (54%), but the lowest percentage espousing strong religious beliefs (2%). Women with weak religious beliefs were more positive about a once-a-month OC than those with strong religious beliefs in Scotland and Romania (p .005). This same relationship existed about the missed-period OC among only Scottish women. Most women in all 3 centers liked the idea of a once-a-month OC (71.8% in Edinburgh, 81.3% in Tirgu-Mures, and 94% in Ljubljana). Women in Edinburgh were less likely to accept a missed-period OC than women from the other centers (24.2% vs. 80% and 58%, respectively). The women from all 3 centers found ovulation inhibition to be the most acceptable mode of action (77.3-90.4% vs. 54.2-68% for prevention of implantation and 15.7-33.4% for implantation suppression). Overall, most women found any method which acts after implantation unacceptable. Scottish women who did not use an IUD or postcoital emergency contraception in the past tended to have a negative attitude about a once-a-month OC (p .01) and a missed-period OC (p .001). Women who had a induced abortion tended to have a positive attitude about a missed-period OC (p .01 in Edinburgh and p .05 in Ljubljana). Abortion history did not influence attitudes towards either OC in Romania. Childless women in Edinburgh were more likely to be positive about the once-a-month OC than women with children (p .05).

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Sexual and marital relationships change throughout marriage and the transition to parenthood can be seen as a psychosocial crisis. Recent studies do not support the finding of Masters and Johnson (1966) that there is a mid-trimester rise in sexual responsiveness. Sexual behaviour decreases towards the end of pregnancy and a number of studies have found that in the majority of mothers there is only a slow return to pre-pregnancy levels in the first postnatal year. Some of the factors influencing the rate of return are discussed. Breast-feeding is important because of the hormonal changes it produces and it has been said to stimulate sexual feelings in both mother and baby. There is some evidence that breast-feeding has an adverse effect on sexuality in the first postnatal year. It is not clear whether this could be related to differences in hormone levels or differences in feeding behaviour. Fatigue and contraception have largely been ignored in studies of factors influencing postnatal sexual behaviour. Women who went on to breast-feed were found to be very similar on antenatal measures of sexual behaviour to those who went on to bottle-feed. The method of feeding is the major influence on the hormonal status, and the experience of painful intercourse reported by breast-feeding mothers may be related to low oestrogen levels. Breast-feeding persistence is influenced by both social and psychological factors and its effect on sexual behaviour is discussed.

PIP: The birth of the 1st child constitutes a psychosocial crisis for most couples, and significant marital and sexual changes occur during the childbearing years. Most women report a decline in sexual activity and interest as their pregnancy progresses, although an association with prepregnancy sexual behavior is apparent. Prospective studies of sexual behavior in the 1st postnatal year reveal resumption of intercourse by the 6th-8th week after delivery and a slow return to prenatal levels of sexual frequency. Pain and tenderness in the episiotomy scar, fear of another pregnancy, changes in body image, and fatigue all have been cited by women for the avoidance or dislike of sexual intercourse in the postpartum period. There is some evidence that breastfeeding, too, has an adverse effect on sexuality in the 1st year postpartum. Lactating women experience raised levels of prolactin and prolonged hypo-estrogenization. In addition, lactating women with diminished sexual desire have been found to have significantly lower levels of androstenedione and testosterone than their counterparts whose sexual interest was not severely reduced. Unclear is whether the generally negative association between prolonged breastfeeding and resumption of prepregnancy levels of sexual activity reflects hormonal changes linked to lactation or psychosocial characteristics that determine whether a women breastfeeds or bottlefeeds. Marriage counselors have observed that sexual problems often have their origins in the year after the birth of the 1st child. Thus, more research on the association between infant feeding and sexual behavior, mood, and morbidity is needed so clinicians can try to avert the development of marital conflicts.

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91 women were assessed early in pregnancy and again 3 and 6 months postpartum. Women who persisted in breastfeeding were less neurotic on the EPI but did not differ from artificial feeders in psychiatric history or sexuality before pregnancy. Breast feeders showed greater impairment of sexuality and slightly more depression at 3 months postpartum. These differences had largely disappeared at 6 months. Possible reasons for these negative effects of breast feeding are discussed and are likely to be multifactorial.

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Of 25 primiparous women, investigated prospectively for six months post-partum, 19 persisted with breast feeding and six changed to artificial during the first six weeks. Sexual activity, mood, and feeding patterns were recorded in weekly diaries. Hormones were measured from weekly urine samples (oestrogen and pregnanediol) and fortnightly blood samples (prolactin, testosterone, androstenedione, and sex hormone binding globulin). In breast-feeding women, testosterone and androstenedione levels were significantly lower in those who reported severe reduction in sexual interest. Changes in sexuality or mood were not related to levels of prolactin or oestrogen, or to the return of follicular activity, which was delayed in persistent breast feeders. The relationships of mood, sexuality, and hormones are discussed.

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Hormonal factors have been suggested as a cause of post-natal depression, but suckling frequency which is the major influence on hormone levels post-partum has not been considered in previous studies. Eighty-nine women who had taken part in a prospective study of post-natal depression were asked about their feeding patterns 18 months after childbirth. Half the mothers who were breast feeding introduced solids or artificial milk feeds before 12 weeks and were likely to have lowered prolactin levels and increased ovarian follicular activity. Mothers who totally breastfed their babies for at least 12 weeks or who were on the pill, had a higher incidence of post-natal depression than those who were not on the pill or who partially breastfed. Among the 62 women who attempted breast feeding those most likely to have normal levels of endogenous hormones were those least likely to have depressive symptoms.

PIP: Hormonal factors have been suggested as a cause of postnatal depression, but suckling frequency which is the major influence on hormone levels postpartum has not been considered in previous studies. 89 women who had taken part in a prospective study of postnatal depression were asked about their feeding patterns 18 months after childbirth. 1/2 of the mothers who were breastfeeding introduced solids or artificial milk feeds before 12 weeks and were likely to have lowered prolactin levels and increased ovarian follicular activity. Mothers who totally breastfed their babies for at least 12 weeks or who were on the pill had a higher incidence of postnatal depression than those who were not on the pill or who partially breastfed. Among the 62 women who attempted to breastfeed, those most likely to have normal levels of endogenous hormones were those least likely to have depressive symptoms.

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