Objective-To determine the causes of nonattendance at new outpatient appointments.Design-Case-control study of non-attenders and attenders.Setting-Outpatient department of a general hospital.Subjects-All non-attenders (n= 277) for first outpatient appointments in six specialties during a three month period were included. Controls (n= 135) were the attenders who followed every second nonattender; thus they attended the same consultant on the same day that the non-attenders were expected.Interventions -None. Measurements and main results-Information on the clinical problem, difficulties in attending the hospital, and reasons for non-attendance from the questionnaire were coded and classified. Nonattenders had received shorter notice of their appointment than attenders (14% v 1% had received three days' notice or less). There were small differences in the seriousness of patients' clinical condition.Conclusions-Client factors are less important than aspects of the service in explaining nonattendance at outpatient appointments. IntroductionOutpatient departments are at the critical interface between primary care and hospital practice. Here is perhaps the greatest opportunity to influence the use of resources in the pursuit of efficient health care. Nonattendance at outpatient departments may lead to inefficient use of facilities and result in unnecessary costs and delays in assessing patients. Given the concern expressed by managers, planners, and politicians over the consequences of non-attendance' it is surprising how few studies have been reported on this problem as it is experienced in the NHS. This contrasts with the number of studies reported from the United States. The difference in emphasis may reflect the differing economic consequences of nonattendance in the two countries rather than any difference in the scale of the problem.Studies have concentrated on the social and medical characteristics of non-attenders. Those of lower social class23 and from certain ethnic groups4' are less likely to attend, though not all studies have found such associations.67 The dominant assumption in reports as well as in the perceptions of those concerned with managing outpatient care is that non-attendance is primarily a problem of compliance. Such a view begs the question that this study addresses, for it is also possible that the problem is one of non-invitation by the hospital. Accordingly we attempted to answer the more general question "Why do appointments fail?" to avoid the assumptions underlying the usual question

Background: In the UK and other developed countries the prevalence of asthma symptoms has increased in recent years. This is likely to be the result of increased exposure to environmental factors. A study was undertaken to investigate the association between maternal use of chemical based products in the prenatal period and patterns of wheeze in early childhood. Methods: In the population based Avon Longitudinal Study of Parents and Children (ALSPAC), the frequency of use of 11 chemical based domestic products was determined from questionnaires completed by women during pregnancy and a total chemical burden (TCB) score was derived. Four mutually exclusive wheezing patterns were defined for the period from birth to 42 months based on parental questionnaire responses (never wheezed, transient early wheeze, persistent wheeze, and late onset wheeze). Multinomial logistic regression models were used to assess the relationship between these wheezing outcomes and TCB exposure while accounting for numerous potential confounding variables. Complete data for analysis was available for 7019 of 13 971 (50%) children. Results: The mean (SD) TCB score was 9.4 (4.1), range 0-30. Increased use of domestic chemical based products was associated with persistent wheezing during early childhood (adjusted odds ratio (OR) per unit increase of TCB 1.06 (95% confidence interval (CI) 1.03 to 1.09)) but not with transient early wheeze or late onset wheeze. Children whose mothers had high TCB scores (.90th centile) were more than twice as likely to wheeze persistently throughout early childhood than children whose mothers had a low TCB score (,10th centile) (adjusted OR 2.3 (95% CI 1.2 to 4.4)). Conclusion: These findings suggest that frequent use of chemical based products in the prenatal period is associated with persistent wheezing in young children. Follow up of this cohort is underway to determine whether TCB is associated with wheezing, asthma, and atopy at later stages in childhood.

The aims of the present study were to assess the effects of maternal use of domestic chemicals during pregnancy on wheezing and lung function in children aged f8.5 yrs and to explore the potential modifying effect of atopy.In the Avon Longitudinal Study of Parents and Children, a cohort study, a maternal composite household chemical exposure (CHCE) score was derived. Wheezing phenotypes from birth to age 7 yrs were assigned on the basis of reported wheeze. Lung function (forced expiratory volume in one second (FEV1), forced vital capacity (FVC), forced midexpiratory flow between 25 and 75% of FVC (FEF25-75%)) was measured at age 8.5 yrs; and atopy by skin-prick tests at age 7.5 yrs. Multinomial logistic and linear regression models assessed the relationship between wheezing outcomes, lung function and CHCE score, and interactions with atopy.Increased CHCE score was associated with early-(,18 months) and intermediate-(18-30 months) persistent and late-onset (.30 months) wheezing in nonatopic children (adjusted odds ratio per z-score of CHCE (95% confidence interval) 1.41 (1.13-1.76), 1.43 (1.02-2.13) and 1.69 (1.19-2.41), respectively). Increasing CHCE score was associated with decrements in FEV1 and FEF25-75%.Higher domestic chemical exposure during pregnancy was associated with persistent wheeze and lung function abnormalities in nonatopic children. This may result from pre-natal developmental effects or post-natal irritant effects on the developing airway, but is unlikely to be mediated through increased hygiene in the home.

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Implications for health and safety risks cannot be assessed without longitudinal research on workforces with substantial numbers of workers over age 60 in order to address the healthy worker effect.

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Background: The use of electrophysical agents has a historically important role in