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E Robinson

Publications and source records attributed to E Robinson.

At least 19 recordsLinked to original sources
PubMed2007

The value of magnetic resonance imaging in our current management of ACL and meniscal injuries.

Magnetic resonance imaging (MRI) is frequently used in the diagnosis of anterior cruciate ligament (ACL) and meniscal injuries. The aim of this retrospective study was to determine the reliability and value of MRI in our management of ACL and meniscal tears. 138 patients who had undergone a MRI to confirm or refute the clinical diagnosis of an ACL or meniscal tear were identified. Those who had subsequently undergone arthroscopy were selected. MRI findings and clinical diagnosis were compared with those at arthroscopy. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and overall accuracy of clinical diagnosis and MRI were then calculated. The overall accuracy for MRI was 91, 68 and 86% for detecting ACL, medial meniscal and lateral meniscal tears, respectively. Accuracy for clinical diagnosis was 90 and 64% for ACL and meniscal tears, respectively. In contrast to other series, our results indicate a lower accuracy of MRI in detecting pathology, especially of the ACL and medial meniscus. We noted a low sensitivity, specificity and positive predictive value but a high negative predictive value rendering MRI most useful as a negative diagnostic tool. We suggest that where symptoms and clinical findings support one of these diagnoses and arthroscopic therapeutic intervention is contemplated, that MRI scanning is not always beneficial. Our current practice of requesting scans to routinely confirm the diagnosis should be altered. Unnecessary MRI scanning increases the financial burden and delays patient treatment.

Adult↗
PubMed2006

Enzyme exposure in the British baking industry.

OBJECTIVES: Enzymes are commonly used in the baking industry, as they can improve dough quality and texture and lengthen the shelf life of the final product. There is little published information highlighting exposure to enzymes (other than fungal alpha-amylase) in the baking industry, therefore the purpose of this study was to identify antibodies and develop assays for the measurement of a variety of such enzymes in samples of airborne flour dust. METHODS: Polyclonal antibodies to bacterial amylase, glucose oxidase and amyloglucosidase were identified and developed into ELISA assays. The assays showed limited cross-reactivity with other enzymes commonly used in the baking industry. RESULTS: We measured levels of airborne enzymes in 195 personal air samples taken from a sample of 55 craft baking establishments. We were able to detect amyloglucosidase in 9% (16/184) of the samples, fungal alpha-amylase in 6% (11/171), bacterial alpha-amylase in 7% (13/195). However, we were unable to detect glucose oxidase in any of the samples. Measurements for protease enzymes were not carried out. Median levels in detectable samples of amyloglucosidase, fungal alpha-amylase and bacterial amylase were similar at 10.3, 5.3 and 5.9 ng/m(3), respectively. These figures represent the total enzyme protein (active and inactive) measured. CONCLUSIONS: There are few data in the literature regarding sensitization and exposure-response relationships to these enzymes, and indeed there is often a lack of information within the industry as to the precise enzyme content of particular baking ingredients. As a precautionary measure, all enzymes are regarded as having the potential to cause respiratory sensitization. Consequently, exposures need to be controlled to as low a level as reasonably practicable, and future investigation may highlight the importance of measuring a variety of enzyme exposures and standardizing these methodologies to inform approaches to adequate control.

Air Pollutants, Occupational↗
PubMed2005

MRI bone oedema predicts eight year tendon function at the wrist but not the requirement for orthopaedic surgery in rheumatoid arthritis.

OBJECTIVE: To investigate the role of early magnetic resonance imaging (MRI) of the wrist in predicting functional outcome in rheumatoid arthritis. METHODS: MRI scans of the dominant wrist were scored for synovitis, tendon inflammation, bone oedema, and erosion at first presentation (n = 42), at 1 year (n = 42), and at 6 years (n = 31). At 8 years, clinical reassessment (n = 28) was undertaken. Tendon function was graded 0-3 for movement, tendon sheath swelling, and pain on resistance at nine flexor and extensor tendons of the hand. Hand function was also assessed using the Sollerman grip test. The requirement for joint or tendon surgery by 8 years was determined by telephone survey in 39 of the original 42 patients. RESULTS: At 8 years, tendon function was highly correlated with hand function (Sollerman score, R = -0.51, p = 0.005) and global function (health assessment questionnaire score, R = 0.53, p = 0.004). Using a model incorporating baseline and 1 year MRI scores, the MRI bone oedema score was strongly predictive of tendon function at 8 years (chi(2)(2) = 15.3, p = 0.0005), as was the MRI bone erosion score (chi(2)(2) = 9.23, p = 0.01). Hand function was also predicted by the baseline MRI erosion score (p = 0.02). MRI variables did not predict the requirement for surgery, but patients who had surgery were more likely to show progression of MRI bone erosion scores between baseline and 1 year (p = 0.008). CONCLUSIONS: Extensive MRI bone oedema and erosions at the wrist in early rheumatoid arthritis predict tendon dysfunction and impaired hand function in the medium term but not the requirement for joint or tendon surgery.

Adult↗
PubMed2005

Maternal stress, social support and preschool children's intelligence.

BACKGROUND: Despite some research suggesting maternal stress may be associated with cognitive impairment in preschool children, there has been little direct investigation of the association between maternal stress, social support and children's intelligence. AIM: To determine whether maternal stress and social support during pregnancy and during the child's early years of life are associated with the intelligence test performance of preschool children. STUDY DESIGN: Five hundred and fifty European mothers and children enrolled in the Auckland Birthweight Collaborative Study at birth were interviewed when the child was 3 1/2 years of age. SUBJECTS: All children were full term gestation and approximately half the sample were small for gestational age at birth (SGA = birthweight < or = 10th percentile). OUTCOME MEASURE: The cognitive ability of children aged 3 1/2 years was assessed using the Stanford Binet Intelligence Scale 4th Edition. RESULTS: In the total sample, maternal stress and lack of social support during pregnancy were significantly associated with lower intelligence test scores of children. In the group of SGA children, maternal stress post pregnancy was significantly associated with lower intelligence test scores in children. There is evidence that for some children the presence of good social support for mothers may reduce the negative effects of maternal stress on children's cognitive development. CONCLUSION: Maternal stress and lack of social support appear to be associated with lower intelligence test scores of preschool children. Social support may attenuate some of the negative effects of maternal stress on intelligence in children born small for gestational age.

Child Development↗
PubMed2005

Risk factors for atopic dermatitis in New Zealand children at 3.5 years of age.

BACKGROUND: The prevalence of atopic dermatitis (AD) is increasing in Western societies. The hygiene hypothesis proposes that this is due to reduced exposure to environmental allergens and infections during early life. OBJECTIVES: To examine factors associated with a diagnosis of AD at 3.5 years of age, especially those factors implicated by the hygiene hypothesis. METHODS: The Auckland Birthweight Collaborative study is a case-control study of risk factors for small for gestational age babies. Cases were born at term with birthweight < or = 10th centile; controls were appropriate for gestational age, with birthweight > 10th centile. The infants were assessed at birth, 1 year and 3.5 years of age. Data were collected by parental interview and examination of the child. AD was defined as the presence of an itchy rash in the past 12 months with three or more of the following: history of flexural involvement; history of generally dry skin; history of atopic disease in parents or siblings; and visible flexural dermatitis as per photographic protocol. Statistical analyses took into account the disproportionate sampling of the study population. RESULTS: Analysis was restricted to European subjects. Eight hundred and seventy-one children were enrolled at birth, 744 (85.4%) participated at 1 year, and 550 (63.2%) at 3.5 years. AD was diagnosed in 87 (15.8%) children seen at 3.5 years. The prevalence of AD did not differ by birthweight. AD at 3.5 years was associated with raised serum IgE > 200 kU L(-1), and wheezing, asthma, rash or eczema at 1 year. In multivariate analysis, adjusted for parental atopy and breastfeeding, AD at 3.5 years was associated with atopic disease in the parents: maternal atopy only, adjusted odds ratio (OR) 3.83, 95% confidence interval (CI) 1.20-12.23; paternal atopy only, adjusted OR 3.59, 95% CI 1.09-11.75; both parents atopic, adjusted OR 6.12, 95% CI 2.02-18.50. There was a higher risk of AD with longer duration of breastfeeding: < 6 months, adjusted OR 6.13, 95% CI 1.45-25.86; > or = 6 months, adjusted OR 9.70, 95% CI 2.47-38.15 compared with never breastfed. These findings remained significant after adjusting for environmental factors and a personal history of atopy. AD at 3.5 years was associated with owning a cat at 3.5 years (adjusted OR 0.45, 95% CI 0.21-0.97) but not with owning a dog at 3.5 years, pets at 1 year, nor with older siblings. Furthermore, AD at 3.5 years was not associated with gender, socioeconomic status, maternal smoking, parity, damp, mould, immunizations, body mass index or antibiotic use in first year of life. CONCLUSIONS: A personal and a parental history of atopic disease are risk factors for AD at 3.5 years. Duration of breastfeeding was associated with an increased risk of AD. No association was found with those factors implicated by the hygiene hypothesis. This study suggests that breastfeeding should not be recommended for the prevention of AD.

Allergens↗
PubMed2005

A randomized controlled trial of an asthma clinical pathway for children in general practice.

AIMS: To evaluate the effect of the implementation of an asthma clinical pathway on asthma in children in general practice. METHODS: A randomized, controlled trial involving 270 general practitioners. One group of general practitioners implemented the asthma clinical pathway for children (intervention group) and the control group continued with their usual asthma medical care management. The main outcome measures were admissions to hospital for asthma and attendance at the Children's Emergency Department. Compliance with the guidelines was assessed by examining asthma drug prescriptions. RESULTS: Admissions to hospital for asthma dropped 40% in the intervention group, by 33% in the control group and by 22% in general practitioners not participating in the trial. The differences between the intervention and control and between the intervention and non-participating general practitioners were not statistically significant. The decrease in attendance at the Children's Emergency Department decreased by 25%, 30% and 19%, respectively, but this was not statistically significant. There was a significant decrease in prescriptions for oral relievers, dry powder relievers in the under 6s, mast cell stabilizers and methylxanthines in both control and intervention groups. However, only for oral relievers was there a significant difference between the intervention group and control, with the decrease larger in the intervention group (p < 0.001). CONCLUSIONS: Admissions to hospital for asthma decreased, as did attendance at the Children's Emergency Department. Prescriptions for asthma medication changed in the direction anticipated with compliance with the asthma clinical pathway. However, we found no evidence within the study that implementation of the asthma clinical pathway by general practitioners resulted in lower morbidity than those general practitioners who did not implement the pathway. Possible explanations are that these general practitioners were already providing care according to the recommendations of the pathway, or that there was contamination of the control group by the intervention, or that the guidelines, although based on currently accepted recommendations, are ineffective.

Adolescent↗
PubMed2005

Breastfeeding and intelligence of preschool children.

AIM: To investigate whether breastfeeding during infancy is a determinant of intelligence at 3.5 y. METHODS: Five hundred and fifty European children enrolled at birth in the Auckland Birthweight Collaborative Study were assessed at 3.5 y of age. Approximately half were small for gestational age (SGA < or =10th percentile) at birth and half were appropriate for gestational age (AGA >10th percentile). Duration of breastfeeding was recorded at maternal interview, and the intelligence of children was assessed using the Stanford Binet Intelligence Scale. Regression analysis was used to calculate estimates of difference in intelligence scores between breastfeeding groups for the total sample and the group of SGA children. Analyses of the total sample were weighted to account for the disproportionate sampling of SGA children. RESULTS: Breastfeeding was not significantly related to intelligence scores in the total sample despite a trend for longer periods of breastfeeding to be associated with higher intelligence scores. However, in the SGA group, breastfeeding was significantly related to IQ at 3.5 y. Small for gestational age children who were breastfed for longer than 12 mo had adjusted scores 6.0 points higher than those who were not breastfed (p=0.06). CONCLUSION: Breastfeeding may be particularly important for the cognitive development of preschool children born small for gestational age.

Breast Feeding↗
PubMed2005

Comparison of forced-air warming and radiant heating during transurethral prostatic resection under spinal anaesthesia.

Forced-air warming is commonly used to warm patients intraoperatively, but may not achieve normothermia during a short procedure. Comparative trials of a new radiant warming device in general anaesthesia (Suntouch, Fisher and Paykel, Auckland, New Zealand) have had conflicting results. We conducted a randomized controlled trial to compare the efficacy and thermal comfort of the Suntouch radiant warmer and forced-air warming in patients at high risk of hypothermia during neuraxial blockade. With ethics committee approval, 60 patients having transurethral resection of the prostate under spinal were randomized to either radiant warming or forced-air warming. All intravenous and irrigation fluids were warmed but pre-warming was not used. The final intraoperative rectal temperatures for the radiant warming and forced-air warming groups were 36.1 degrees C and 36.4 degrees C respectively (P= 0.03). A large proportion of patients in both groups (46% and 33% respectively, P=0.3) were hypothermic (<36 degrees C) on arrival in the post-anaesthesia care unit. No other patient variables were significantly different. Neither warming device reliably prevented hypothermia, although forced-air warming was slightly superior.

Aged↗
PubMed2004

Exposure to flour dust in UK bakeries: current use of control measures.

OBJECTIVES: In May 2001, a maximum exposure limit (MEL) for flour dust was set in the UK at 10 mg/m(3) [8 h time-weighted average (TWA)] with a short-term exposure limit (STEL) of 30 mg/m(3) (15 min reference period). The purpose of this study was to produce a benchmarking baseline of current control measures and exposure levels, in addition to assessing the provision of training and the knowledge of the UK regulations amongst the bakeries. METHODS: A total of 208 long-term personal inhalable dust samples (8 h TWA) were collected from workers in 55 bakeries (covering a wide range of industry types and sizes) between October 2002 and December 2003 in England, Wales and Scotland. Standardized occupational hygiene reports were produced for each establishment to provide information about the site (such as the size of the bakery) and the control measures employed (including ventilation, good working practices, knowledge of UK regulations and the extent of training provided). RESULTS: Median inhalable dust exposure (8 h TWA) for the bakery workers was 3.7 mg/m(3) (75th percentile at 7.7 mg/m(3)) and 17% of the dust results exceeded the MEL. Although information about the MEL has been available in the trade press and through recognised trade associations, only 27% of the bakeries were aware of the MEL and STEL. Mixed model regression analysis suggested that determinants of higher exposure included the job category (particularly weighing/sieving or mixing), medium to large bakery size (50 or more employees) and bakeries being located in Scotland. However, having an appointed safety representative was associated with lower exposure. CONCLUSIONS: The conclusions derived here are based upon the use of a statistical model, but clearly, if bakeries and individuals employ good working practices, with correct use of local exhaust ventilation, they should be able to comply with the MEL.

Dust↗
PubMed2004

The metabolic consequences of prematurity.

An association between low birth weight, commonly a reflection of an adverse in utero environment, and the subsequent development of diseases such as type 2 diabetes and hypertension in later life is now generally accepted - as is an association between an adverse perinatal environment and a permanent reduction in insulin sensitivity. This and other metabolic abnormalities have been demonstrated from childhood through to adulthood in subjects who were born full-term but small for gestational age (SGA). Less is known about children born prematurely into an adverse neonatal environment. We present data demonstrating that premature infants also have metabolic abnormalities similar to those observed in full-term, SGA children, and that these occur irrespective of whether the premature infants are SGA or appropriate for gestational age (AGA).

Child↗
PubMed2004

In vitro predictions of skin absorption of caffeine, testosterone, and benzoic acid: a multi-centre comparison study.

To obtain better insight into the robustness of in vitro percutaneous absorption methodology, the intra- and inter-laboratory variation in this type of study was investigated in 10 European laboratories. To this purpose, the in vitro absorption of three compounds through human skin (9 laboratories) and rat skin (1 laboratory) was determined. The test materials were benzoic acid, caffeine, and testosterone, representing a range of different physico-chemical properties. All laboratories performed their studies according to a detailed protocol in which all experimental details were described and each laboratory performed at least three independent experiments for each test chemical. All laboratories assigned the absorption of benzoic acid through human skin, the highest ranking of the three compounds (overall mean flux of 16.54+/-11.87 microg/cm(2)/h). The absorption of caffeine and testosterone through human skin was similar, having overall mean maximum absorption rates of 2.24+/-1.43 microg/cm(2)/h and 1.63+/-1.94 microg/cm(2)/h, respectively. In 7 out of 9 laboratories, the maximum absorption rates of caffeine were ranked higher than testosterone. No differences were observed between the mean absorption through human skin and the one rat study for benzoic acid and testosterone. For caffeine the maximum absorption rate and the total penetration through rat skin were clearly higher than the mean value for human skin. When evaluating all data, it appeared that no consistent relation existed between the diffusion cell type and the absorption of the test compounds. Skin thickness only slightly influenced the absorption of benzoic acid and caffeine. In contrast, the maximum absorption rate of testosterone was clearly higher in the laboratories using thin, dermatomed skin membranes. Testosterone is the most lipophilic compound and showed also a higher presence in the skin membrane after 24 h than the two other compounds. The results of this study indicate that the in vitro methodology for assessing skin absorption is relatively robust. A major effort was made to standardize the study performance, but, unlike in a formal validation study, not all variables were controlled. The variation observed may be largely attributed to human variability in dermal absorption and the skin source. For the most lipophilic compound, testosterone, skin thickness proved to be a critical variable.

Adolescent↗
PubMed2004

Maternal nutritional risk factors for small for gestational age babies in a developed country: a case-control study.

AIMS: To assess the effect of maternal diet during pregnancy on the risk of delivering a baby who is small for gestational age (SGA). METHODS: Case-control study of 844 cases (SGA) and 870 controls (appropriate size for gestational age (AGA)). Only term (37+ completed weeks of gestation) infants were included. Retrospective food frequency questionnaires were completed at birth on the diet at the time of conception and in the last month of pregnancy. RESULTS: At the time of conception, mothers of AGA infants ate significantly more servings of carbohydrate rich food and fruit, and were more likely to have taken folate and vitamin supplements than mothers of SGA infants. There was some evidence that mothers of AGA infants also ate more servings of dairy products, meat, and fish (0.05 < p < 0.1). However, after adjustment for maternal ethnicity, smoking, height, weight, hypertension, and occupation, fish intake (p = 0.04), carbohydrate-rich foods (p = 0.04), and folate supplementation (p = 0.02) were associated with a reduced risk of SGA. In the last month of pregnancy, only iron supplementation was associated with a reduced risk of SGA (p = 0.05) after adjustment for potential confounders. CONCLUSIONS: This study suggests that small variations in maternal diets within the normal range during pregnancy in developed countries are associated with differences in birth weight.

Case-Control Studies↗
PubMed2004

A randomised placebo controlled trial of delipidated, deglycolipidated Mycobacterium vaccae as immunotherapy for psoriatic arthritis.

OBJECTIVES: To test the hypothesis that PVAC, delipidated, deglycolipidated heat killed Mycobacterium vaccae, is an effective and safe treatment for psoriatic arthritis (PsA). This treatment has shown promising results in psoriasis. METHODS: 36 patients with PsA in two centres were studied in this double blind, placebo controlled, randomised trial. Patients were randomised to receive two intradermal injections of 50 micro g PVAC or placebo and were followed up for 24 weeks. The primary end point was the Psoriatic Arthritis Response Criteria (PsARC), a composite measure based on changes in joint tenderness and swelling scores and physician and patient global assessments. RESULTS: The PsARC response at either 12 or 24 weeks was achieved by 9/18 (50%) placebo and 9/18 (50%) PVAC patients (p = 1.0). No significant differences in the Psoriasis Activity and Severity Index (PASI), patient or physician global assessments, CRP, or Health Assessment Questionnaire score over time were found between the two groups. However, changes in the pain visual analogue scale over time did differ between the two groups (p = 0.006): at 24 weeks the mean score in the PVAC group had declined by 19.2 mm and in the placebo group had increased by 4.8 mm. PVAC was well tolerated with no increased incidence of adverse events compared with placebo. CONCLUSIONS: PVAC was not shown to be as effective as immunotherapy for PsA. The striking response to placebo in this study reinforces the importance of adequately controlling therapeutic trials in PsA.

Adult↗
PubMed2004

MRI of the wrist in early rheumatoid arthritis can be used to predict functional outcome at 6 years.

OBJECTIVES: To determine whether magnetic resonance (MR) scans of the dominant wrist of patients with early rheumatoid arthritis (RA) can be used to predict functional outcome at 6 years' follow up. METHODS: Dominant wrist MR scans were obtained in 42 patients with criteria for RA at first presentation. Patients were followed up prospectively for 6 years, and further scans obtained at 1 year (42 patients) and 6 years (31 patients). Two radiologists scored scans for synovitis, tendonitis, bone oedema, and erosions. The Stanford Health Assessment Questionnaire (HAQ) score, indicating functional outcome, and standard measures of disease activity were assessed at 0, 1, 2, and 6 years. The physical function component of the SF-36 score (PF-SF36) was also used as a functional outcome measure at 6 years. RESULTS: Baseline MR parameters, including bone oedema score and the total baseline MR score, were predictive of the PF-SF36 at 6 years (R2 = 0.22, p = 0.005 and R2 = 0.16, p = 0.02, respectively). The PF-SF36 score correlated strongly with the HAQ score at 6 years (rs = -0.725, p<0.0001); none of the baseline MR parameters predicted the 6 year HAQ score. The total MR score obtained at 1 year was predictive of the 6 year HAQ (R2 = 0.04, p = 0.01). Standard clinical and radiographic measures at baseline were not predictive of the 6 year PF-SF36, but when combined in a model with baseline MR oedema score, prediction increased from 0.09 to 0.23, or 23% of the 6 year variance. CONCLUSION: MR imaging of the wrist in patients with early RA can help to predict function at 6 years and could be used to plan aggressive management at an earlier stage.

Antirheumatic Agents↗
PubMed2004

Randomisation in trials: do potential trial participants understand it and find it acceptable?

OBJECTIVE: To examine lay persons' ability to identify methods of random allocation and their acceptability of using methods of random allocation in a clinical trial context. DESIGN: Leaflets containing hypothetical medical, non-medical, and clinical trial scenarios involving random allocation, using material from guidelines for trial information leaflets. SETTING AND PARTICIPANTS: Adults attending further education colleges (n = 130), covering a wide range of ages, occupations, and levels of education. MAIN MEASURES: Judgements of whether each of five methods of allocation to two groups was random in a medical or non-medical scenario. Judgements of whether these allocation methods were acceptable in a randomised clinical trial scenario, with or without a scientific justification for randomisation. RESULTS: The majority of our group of participants judged correctly that allowing people their preference was not random, and that the following were random: using a computer with no information about the individual (recommended wording for MREC trial leaflets), tossing a coin, drawing a name out of a hat. Judgements were split over allocating people in turn (not a random allocation method but shares features with randomisation). Judgements were no different in medical and non-medical scenarios. Few of the correctly identified random methods were judged to be acceptable in a clinical trial scenario. Inclusion of a scientific justification for randomising significantly increased the acceptability of only one random method: allocation by computer. CONCLUSIONS: Current UK guidelines' recommended description of random allocation by computer seems warranted. However, while potential trial participants may understand what random allocation means, they may find it unacceptable unless offered an acceptable justification for its use.

Adolescent↗
PubMed2003

Stress and lack of social support as risk factors for small-for-gestational-age birth.

AIM: To determine the contributions of social support and perceived stress to the risk of small-for-gestational-age birth. METHODS: The investigation was a case-control study of mothers of infants born at 37 or more completed weeks of gestation. Cases weighed less than the sex-specific 10th percentile for gestational age at birth (small for gestational age (SGA), n = 836), and controls (appropriate for gestational age (AGA), n = 870) comprised a random selection of heavier babies. RESULTS: In univariate analyses measures of informal social support, but not perceived stress or formal social support, were associated with SGA birth. It was found that Asian mothers are less likely to receive support from families and friends. After adjustment for ethnicity, informal social support was not associated with SGA. CONCLUSIONS: Support appears to reduce the risk of SGA births, but after adjustment for ethnicity this is no longer the case. Stress during pregnancy was not associated with SGA birth.

Case-Control Studies↗
PubMed2003

Attitudes and behaviour of general practitioners and their prescribing costs: a national cross sectional survey.

BACKGROUND: General practitioner (GP) prescribing accounts for about 10% of NHS expenditure. GPs at the top of the range have annual prescribing costs that are almost twice as much as those at the bottom of the range. This variation cannot be accounted for purely in terms of differences in underlying need for health care. OBJECTIVES: To describe the relationship between GPs' prescribing costs and their attitudes towards prescribing decisions and prescribing information sources, and to identify potentially modifiable attitudinal and behavioural factors associated with high cost prescribing. DESIGN: A postal questionnaire was designed on the basis of hypotheses developed from a literature search and an earlier qualitative survey. This questionnaire was sent to a national sample of GPs with equal numbers of practices in the upper, middle, and lowest quintile of prescribing costs. SETTING: GP practices in England. PARTICIPANTS: 1714 GPs in NHS practice. OUTCOME MEASURES: GPs' self-reported practices, attitudes and personal characteristics. RESULTS: There was a 64% response rate. Responders were more likely to be from larger practices, in less deprived areas, and with lower prescribing costs than were non-responders. Multivariable analysis showed that GPs with high prescribing costs were significantly more likely to work in dispensing practices, in practices with low income populations, in single handed practices, and in practices without a GP trainer. They were also significantly more likely to see drug company representatives more frequently, to prescribe newly available drugs more freely, to prescribe more readily to patients who expect a prescription, to report high levels of frustration from lack of time in the consultation, to find unsatisfactory those consultations which ended in advice only, and to express dissatisfaction with their review methods for repeat prescribing. They were significantly less likely to find useful criticism of prescribing habits by colleagues, and to check the BNF rather than other sources when uncertain about an aspect of drug treatment. CONCLUSIONS: While they cannot be held to have a causal relationship, the pattern of attitudes towards prescribing of GPs in the highest quintile of prescribing costs provide the basis for developing an educational intervention which may be an acceptable method of modifying the attitudes of GPs and consequently reducing their prescribing costs.

Attitude of Health Personnel↗