QI methodologies from industry can have significant effects on improving surgical care, from reducing infection rates to increasing operating room efficiency. The evidence is generally of suboptimal quality, and rigorous randomized multicentre studies are needed to bring evidence-based management into the same league as evidence-based medicine.

Cardiovascular disease is the leading cause of morbidity and mortality in patients with Type II (non-insulin-dependent) diabetes mellitus accounting for up to 75 % of deaths [1]. Although insulin and insulin resistance have been considered major factors in the pathogenesis of cardiovascular disease [2,3], given the close links between the insulin-like growth factor-system and insulin action we examined the potential role of the insulin-like growth factor-system in the pathogenesis of macrovascular disease. Diabetologia (2001) Abstract Aims/hypothesis. Insulin resistance/hyperinsulinaemia is implicated in the development of cardiovascular disease and diabetes but its role and causal pathways are not clear. We tested the hypothesis that the insulin-like growth factor system is independently associated with cardiovascular risk within susceptible populations based on previous reports of the links between low circulating insulin-like growth factor binding protein-1 concentrations and increased macrovascular disease in Type II (non-insulin-dependent) diabetes mellitus. Methods. In a population-based study 272 subjects (142 subjects of European and 130 Pakistani of origin) underwent a 75 g oral glucose tolerance test and standardised anthropometry. Fasting concentrations of insulin-like growth factor binding protein-1 (IG-FBP-1), insulin-like growth factor-I (IGF-I), insulinlike growth factor-II (IGF-II), intact insulin and lipids were measured and were related to 2-h glucose tolerance test status. Insulin sensitivity was calculated using the homeostasis model assessment (HOMA). Results. Insulin-like growth factor binding protein-1 was significantly lower in subjects with impaired glucose tolerance when compared with normal glucose tolerance in both ethnic groups (Europeans F = 6.7, p = 0.002 and Pakistanis F = 4.4, p = 0.01). Multiple linear regression modelling showed that insulin-like growth factor binding protein-1 was independently associated with 2-h glucose (b = 0.16, p = 0.009) and logistic regression indicated a 40 % reduction in risk of impaired glucose tolerance for every 2.7 ng/ml increase in the insulin-like growth factor binding protein-1 concentration [odds ratio 0.6 (CI = 0.49±0.71), p = 0.001)]. In addition, insulin-like growth factor binding protein-1 was significantly correlated negatively with several established cardiovascular factors, and positively with insulin sensitivity. Conclusion/interpretation. Insulin-like growth factor binding protein-1 is closely related to risk factors for diabetes and cardiovascular disease in people of European and Pakistani origin. It has potential use as a marker of (hepatic) insulin resistance in clinical intervention studies and further implicates the insulin-like growth factor system in the development of macrovascular disease. [Diabetologia (2001) 44: 333±339]

Objective: To identify groups of subjects with similar food consumption patterns so that complex disease ± diet relationships can be investigated at the level of the whole diet, rather than just in terms of nutrient intake. Subjects: 33,971 women in the UK Women's Cohort Study. 60,000 women on the World Cancer Research Fund mailing list were initially invited to take part. Subjects were selected to include a high proportion of vegetarians. Design: The cohort completed a 217 item food frequency questionnaire. Cluster analysis was used to identify groups of women with similar food consumption patterns. Clusters were compared on socio-demographic characteristics, indicators of health and diet, and nutrient intakes. Results: Seven clusters were identi®ed including two vegetarian clusters. Groups appeared to be differentiated by differences in food types and in diversity of diet. Socio-demographic, health and diet characteristics and nutrient intakes all differed signi®cantly between groups. Conclusion: Classifying diets in more pragmatic terms than just nutrient intake should provide valuable insight into understanding complex diet-disease relationships. Dietary advice, whilst based on nutrient content of meals, needs to take account of the combinations of different food types that people naturally choose to use together. Sponsorship:World Cancer Research Fund. Descriptors: cohort studies; multivariate analysis; diet; food habits European Journal of Clinical Nutrition (2000) 54, 314±320 IntroductionIn nutritional research it is more common to consider food consumption in terms of nutrient intake, rather than type of food consumed. Conventionally nutrient intake is compared with recommended levels or adherence to dietary guidelines to identify groups of people with various levels of intake of speci®c nutrients. These groups can then be described in terms of their socio-demographic characteristics. This enables the researcher to identify individuals or more often subgroups of the population whose diets may be nutritionally de®cient in some way.Whilst researchers have concentrated on classifying people on the basis of their nutrient intake, consumers consider more than nutrient content when choosing food. In addition it is unlikely that the aetiology of diseases such as cancer can be explained by levels of single nutrients and it may be that non-nutritive substances, such as phytochemicals, may be involved. Most consumers eat foods in certain combinations or patterns, and interest is therefore now focussing on whole diets and lifestyles rather than single nutrients. Identi®cation of these patterns would be useful to explore complex diet-disease relationships (such as investigating potential effects of the Mediterranean diet) and also to intervene to provide relevant nutritional advice and education.Cluster analysis has been used in similar contexts to identify groups or clusters of people with similar characteristics (Wirfalt & Jeffery, 1997;Schroll et al, 1996;Tucker et al, 1992;Hulshof et al, 1992;Bisgrove et al, 198...