Implementation of the INTERGROWTH-21st Project in the UK

There are approximately 10,000 births per year in the county of Oxfordshire in the UK, which is one of the two European sites for the International Fetal and Newborn Growth Consortium for the 21(st) Century (INTERGROWTH-21(st) ) Project. The samples for both components of the project--the Fetal Growth Longitudinal Study (FGLS) and Newborn Cross-Sectional Study (NCSS)--were drawn from the John Radcliffe Hospital, a major university hospital with a large regional role that covers more than 75% of deliveries in the county. Special activities to encourage participation in this population included the formation of a research coalition to streamline recruitment in the Maternity Unit and the distribution of study information leaflets to women using the hospital's antenatal care service. This was a demanding project and several challenges were overcome to reach recruitment targets and to maintain high standards of data quality. Amongst the major challenges for FGLS at this study site was the level of ineligibility because of maternal age, smoking and body mass index (BMI) ≥ 30. The major challenge for the NCSS field teams was to ensure that all anthropometric data were collected before the early discharge of uncomplicated deliveries, often within 6 hours of birth. It is evident from our experience in implementing this project that, when large-scale clinical studies are meticulously planned and avoid major disruption to routine clinical care, they are well received by hospital staff and can contribute to the improvement of the overall standard of clinical care.

Processing LHC data in the UK

The Large Hadron Collider (LHC) is one of the greatest scientific endeavours to date. The construction of the collider itself and the experiments that collect data from it represent a huge investment, both financially and in terms of human effort, in our hope to understand the way the Universe works at a deeper level. Yet the volumes of data produced are so large that they cannot be analysed at any single computing centre. Instead, the experiments have all adopted distributed computing models based on the LHC Computing Grid. Without the correct functioning of this grid infrastructure the experiments would not be able to understand the data that they have collected. Within the UK, the Grid infrastructure needed by the experiments is provided by the GridPP project. We report on the operations, performance and contributions made to the experiments by the GridPP project during the years of 2010 and 2011--the first two significant years of the running of the LHC.

Exciton diffusion length in complex quantum systems: the effects of disorder and environmental fluctuations on symmetry-enhanced supertransfer

Symmetric couplings among aggregates of n chromophores increase the transfer rate of excitons by a factor n(2), a quantum-mechanical phenomenon called 'supertransfer'. In this work, we demonstrate how supertransfer effects induced by geometrical symmetries can enhance the exciton diffusion length by a factor n along cylindrically symmetric structures, consisting of arrays of rings of chromophores, and along spiral arrays. We analyse both closed-system dynamics and open quantum dynamics, modelled by combining a random bosonic bath with static disorder. In the closed-system case, we use the symmetries of the system within a short-time approximation to obtain a closed analytical expression for the diffusion length that explicitly reveals the supertransfer contribution. When subject to disorder, we show that supertransfer can enhance excitonic diffusion lengths for small disorders and characterize the crossover from coherent to incoherent motion. Owing to the quasi-one-dimensional nature of the model, disorder ultimately localizes the excitons, diminishing but not destroying the effects of supertransfer. When dephasing effects are included, we study the scaling of diffusion with both time and number of chromophores and observe that the transition from a coherent, ballistic regime to an incoherent, random-walk regime occurs at the same point as the change from supertransfer to classical scaling.

Efficient estimation of energy transfer efficiency in light-harvesting complexes

The fundamental physical mechanisms of energy transfer in photosynthetic complexes is not yet fully understood. In particular, the degree of efficiency or sensitivity of these systems for energy transfer is not known given their realistic with surrounding photonic and phononic environments. One major problem in studying light-harvesting complexes has been the lack of an efficient method for simulation of their dynamics in biological environments. To this end, here we revisit the second order time-convolution (TC2) master equation and examine its reliability beyond extreme Markovian and perturbative limits. In particular, we present a derivation of TC2 without making the usual weak system-bath coupling assumption. Using this equation, we explore the long-time behavior of exciton dynamics of Fenna-Matthews-Olson (FMO) portein complex. Moreover, we introduce a constructive error analysis to estimate the accuracy of TC2 equation in calculating energy transfer efficiency, exhibiting reliable performance for system-bath interactions with weak and intermediate memory and strength. Furthermore, we numerically show that energy transfer efficiency is optimal and robust for the FMO protein complex of green sulfur bacteria with respect to variations in reorganization energy and bath correlation time scales.

Predicting patient-specific rates of bone loss at fracture-prone sites after spinal cord injury

PURPOSE

People with spinal cord injury (SCI) experience bone loss and have an elevated rate of fracture in the paralysed limbs. The literature suggests an exponential time course of bone loss after SCI, but true rates may vary between patients. We propose systematic evaluation of bone status in the early stages of SCI to identify fast bone losers.

METHOD

A case series of six patients with complete SCI were scanned using peripheral quantitative computed tomography within 5 weeks and at 4, 8 and 12 months post-injury. Bone mineral density (BMD) and bone mineral content (BMC) were measured at fracture-prone sites in the tibia and femur. Patient-specific-predictions (PSP) of expected rates of bone loss were produced by individualising published model equations according to each patient's measured values at baseline. Wilcoxon Signed-Rank tests were used to identify changes between time-points; chi-squared tests for differences between measured and PSP values.

RESULTS

In the lower limbs, mean values decreased significantly between baseline and 8 months post-injury, by 19-31% for trabecular BMD, 21-32% for total BMD, and 9-29% for BMC. Most subjects showed no significant differences between PSP and measured values, but individuals with significantly faster rates of bone loss than predicted should be investigated further.

CONCLUSIONS

There was considerable intersubject variability in rates of bone loss after SCI. Patients showing the fastest bone loss could benefit from continued follow-up and possibly treatment.

The comparative efficacy of second-generation antidepressants for the accompanying symptoms of depression: a systematic review

Introduction

Clinicians treating patients with Major Depressive Disorder (MDD) might favor one second-generation antidepressant (SGA) because of perceived benefits for the accompanying symptoms of MDD.

Objectives

To compare the efficacy of bupropion, citalopram, desvenlafaxine, duloxetine, escitalopram, fluoxetine, fluvoxamine, mirtazapine, nefazodone, paroxetine, sertraline, trazodone, and venlafaxine for the treatment of the accompanying symptoms of MDD.

Methods

This review is part of a larger review on the comparative effectiveness of SGAs for MDD. We searched MEDLINE, Embase, The Cochrane Library, and the International Pharmaceutical Abstracts up to May 2010. Two persons independently reviewed the literature, abstracted data, and rated the risk of bias.

Results

We located 26 head-to-head and 7 placebo-controlled trials that provided evidence for this review. We did not locate any studies on treating accompanying appetite change, low energy, melancholia, or psychomotor change. There was no evidence for many comparisons and we were unable to conduct quantitative analysis for any comparisons. For the comparisons that were studied, we concluded that the SGAs are similarly efficacious for treating anxiety, insomnia, pain, and somatization. The strength of the evidence for these conclusions is low (meaning further research is very likely to have an important impact on our confidence in the estimate of the effect and is likely to change the estimate).

Conclusions

Our findings indicate that the existing evidence does not warrant the choice of one second-generation antidepressant over another based on greater efficacy for the accompanying symptoms of depression.

Immediate-release and extended-release formulations of second-generation antidepressants for the treatment of major depressive disorder in adults

Introduction

Extended-release formulations of antidepressants have been marketed as a strategy to increase patient adherence. Changes in the formulation of drugs, however, could be related to changes in efficacy and tolerability. Among second-generation antidepressants, bupropion, fluoxetine, mirtazapine, paroxetine, and venlafaxine are available in immediate- and extended-release formulations.

Objectives

To compare the efficacy, tolerability, and adherence of immediate- versus extended-release formulations of second-generation antidepressants for the treatment of major depressive disorder (MDD) in adults.

Aim

To provide an evidence base for clinicians when choosing immediate- or extended-release formulations of antidepressants for the treatment of MDD.

Methods

We conducted a comparative effectiveness review for the U.S. Agency for Healthcare Research and Quality searching PubMed, EMBASE, The Cochrane Library, and the International Pharmaceutical Abstracts up to May 2010. Two people independently reviewed the literature, abstracted data, and rated the risk of bias.

Results

Six RCTs and one observational study provided evidence about the comparative efficacy, tolerability, and adherence of bupropion SR (sustained release) versus bupropion XL (extended release), fluoxetine daily vs. fluoxetine weekly, paroxetine IR (immediate release) versus paroxetine CR (continuous release), and venlafaxine IR versus venlafaxine XR (extended release). Overall, no substantial differences in efficacy and safety could be detected. Open-label and observational evidence indicated better adherence for bupropion XL and fluoxetine weekly than for immediate-release medications. No differences in adherence could be detected between paroxetine IR and paroxetine CR.

Conclusions

Our findings indicate similar efficacy and tolerability between immediate- and extended-release formulations. Whether extended-release formulations lead to better adherence remains unclear.

An examination of certain factors which might, or do, affect the vascular response to oxytocin

1. A number of different observations were made on anaesthetized rats and some dogs to try to discover why it is that oxytocin is a vasodilator in dioestrus and anoestrus, and develops constrictor properties in oestrus and following sympathectomy.2. In those circumstances in which oxytocin in small or moderate doses raises blood pressure in the rat, the pressor effect is eliminated if the hormone is given during an infusion of adrenaline. In this respect the rat is closely similar to the dog.3. It was confirmed in anaesthetized oestrous rats that intravenous eserine eliminated the pressor response to oxytocin, and it was found that prostigmine did not reduce or change it. Thus, it may be concluded that the effect of eserine depends on its central sympathetic stimulant action and not on a peripheral effect.4. Rats which had been acutely or chronically adrenalectomized responded normally to oxytocin and both eserine and adrenaline were able to reduce, though not wholly eliminate, the pressor type of response. These results indicate that neither the adrenal medulla nor the cortex is essential for the action of oxytocin, nor for a large part of the action of eserine and adrenaline.5. The plasma concentrations of sodium, potassium and calcium were studied in a number of conditions affecting the response to oxytocin, namely, dioestrus, oestrus, and after administration of oestrogens, progesterone, adrenaline, eserine, hexamethonium, and dihydroergotamine. The cation changes observed could not be correlated with the type of response to oxytocin. The only measure found to affect the response was raising the plasma Na concentration by the infusion of disodium hydrogen phosphate. This reduced the pressor effect of oxytocin seen in oestrous female rats and in oestrogen treated males. The pressor response returned before the plasma sodium had fallen to normal levels.6. The administration of the oxytocin analogue, tyrosine-methyl(2) oxytocin which has a high receptor affinity and a low intrinsic activity, prevented the pressor response to oxytocin of oestrous rats, and the vasodilator response in the hind limb vessels of normal dogs. It is concluded that there is probably a single receptor for oxytocin from which both the constrictor and dilator effects are initiated.7. Oxytocin exerted apparently normal effects on the systemic blood pressure of oestrous or dioestrous rats given the beta-blocking agents pronethalol or propranolol.8. The present results, like previous ones, indicate that adrenaline is the factor linking both the gonadal state and the peripheral sympathetic nervous system with the type of response to oxytocin.9. An incidental observation was that male and female rats show differences in their response to sympathetic blocking agents and to a raised plasma sodium concentration.

The price is right: making workplace wellness financially sustainable

Purpose

The public health argument for developing and maintaining workplace wellness programmes in organisations is well‐documented, particularly within the healthcare sector which aims to “set the example” for workplace health. However, workplace wellness also makes good business sense, since it is established that investing in employee health can reduce absenteeism, improve job satisfaction and productivity and enhance corporate image. Organisations often place workplace wellness low in their priorities. The purpose of this paper is to present the case for an initial resource investment and top‐level support to pump‐prime a financially sustainable, and even profitable, programme.

Design/methodology/approach

A discussion is presented based on academic literature and practical applications from the authors' experiences in practice.

Findings

The authors use their own in‐house scheme, “Q‐active” as a case example based in an NHS Trust setting, to demonstrate how such schemes can be developed and successfully implemented and maintained in practice. The paper presents the use of the Business Healthcheck Tool for developing a business case for such schemes.

Originality/value

Workplace wellness schemes are financially viable and can become a vital part of a large organisations' infrastructure embedded within policies and internal “health culture”.

Determining water sensitive urban design project benefits using a multi-criteria assessment tool

The integration of urban water cycle management with urban planning and design is referred to as 'Water Sensitive Urban Design' or 'WSUD' in Australia; one of the key elements of WSUD is the management of urban stormwater. In early 2006, the Victorian Government released the Yarra River Action Plan, which allocated $20 million towards tackling urban stormwater pollution. To help ensure this money is allocated in an equitable and transparent manner across all metropolitan local governments a multi-criteria assessment tool has been developed. This paper presents an overview of the multi-criteria assessment tool developed and adopted for selecting WSUD projects that are eligible for funding through Melbourne Water's Stormwater Program. This tool considers three types of indicators: environmental, engagement (engagement with stakeholders and local government capacity building) and financial. Within each category, a series of indicators of different weightings are applied to score a project. Where initial concept designs do not meet the Program criteria, additional work is undertaken to refine and improve the project. The tool and its use are illustrated with a case study.

Urinary estrogen metabolites in patients at high risk for breast cancer

Abstract #4080

Background:
 Variations in estrogen metabolism may be associated with increased breast cancer risk. Women who have preferential metabolism via 16α-hydroxylation are reported to have a higher risk of developing breast cancer compared to women who have preferential metabolism via 2α-hydroxylation. Profiling estrogen metabolites may identify women who are more likely to develop breast cancer within a population of women with known risk factors. Our aim was to evaluate estrogen metabolism in a group of high risk women.
 Methods:
 Women were recruited from the Magee-Women's Hospital High Risk Breast Cancer program. Risk factors included first degree family history, atypia, fibrocystic breast disease, BRCA1/2, Ashkenazi Jewish descent. Urine 2:16 OHE ratios were compared among the high risk group, an average risk control group, and a group of women with breast cancer. We also evaluated the relationship between urine 2:16 OHE ratios and epidemiological risk factors including BMI, alcohol use, smoking history and first degree family history.
 Results:
 There were 65 high risk patients, 30 breast cancer patients, and 41 controls. The Kruskaul-Wallis rank test and Wilcoxon rank-sum test were used for analysis. There was a significant difference in 2:16 OHE ratios among all three groups, p=0.0001. Urine 2:16 OHE ratios were lower in the high risk group (median 1.15) compared to the control group (2.22), p=0.00, and were lower in the breast cancer group (1.09) compared to the controls, p=0.00. There was a difference in BMI among all three groups, p=0.002. Overall, the 2:16 OHE ratio was positively associated with BMI, p=0.0006, and with alcohol use, p=0.02. Smoking history did not differ among all groups, and there was no association between smoking history and 2:16 OHE ratio. Within the high risk group, family history was not associated with 2:16 OHE ratio.
 Conclusions:
 Our research suggests that there is an association between lower urine 2:16 OHE ratios and high risk breast cancer. This association may be linked to specific risk factors such as BMI and alcohol use. This information may help to further elucidate the clinical relevance of using urinary 2:16 OHE ratios as clinical markers and prognostic indicators in this population.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 4080.

Pneumonyssoides species infestation in two Pekingese dogs in the UK

Two male, neutered, Pekingese dogs aged four years and 12 years were presented for acute-onset nasal pruritus and sneezing following a visit to a beach in northern Scotland. Routine nasal investigations revealed the presence of the canine nasal mite Pneumonyssoides both by direct visualisation and histopathologically. Resolution of clinical signs was observed following selamectin treatment. To the authors' knowledge, this report describes the first cases of Pneumonyssoides infestation in non-travelled UK dogs.

The implementation of European Association of Urology guidelines in the management of acute epididymo-orchitis

INTRODUCTION

Acute epididymo-orchitis is a common and increasing problem. This retrospective study reviewed whether the European Association of Urology guidelines for the management of acute epididymo-orchitis, which form the basis of this Trust's present inter-departmental guidelines, are being effectively implemented.

PATIENTS AND METHODS

Case notes of 53 patients attending the emergency department with acute epididymo-orchitis over a 6-month period were reviewed retrospectively. The hospital results' database was used to confirm the diagnostic tests requested on patients at the time of their initial presentation.

RESULTS

Of the study cohort, 26 patients were aged </= 35 years and 27 patients were aged > 35 years. The results demonstrated that a sexual history was documented in only 43.4% of cases. A mid-stream urine sample was sent for routine culture in 54.7% of cases whilst urine for the Chlamydia polymerase chain reaction (PCR) test was obtained in 17% and a urethral swab performed in 5.6%. Antibiotics were prescribed in 81% of cases. Of these patients, 46.5% received ciprofloxacin alone (mean age, 52 years; range, 18-87 years), 25.5% received doxycycline alone (mean age, 30 years; range, 18-45 years) and 21% received both ciprofloxacin and doxycycline (mean age, 33 years; range 18-49 years). In 26.4% of cases, verbal advice to attend a genito-urinary medicine clinic was given, whilst a formal telephone referral was made in only one case. Formal urological follow-up was arranged for only three out of 11 patients aged > 50 years.

CONCLUSIONS

Although a joint emergency department/urology clinical protocol for the investigation and treatment of acute epididymo-orchitis already exists within the Trust, our current management conforms to this in only a minority of cases. Many different strategies can be employed in the implementation of clinical practice guidelines and all are associated with variable degrees of success. The regular movement of junior staff through each department necessitates that the distribution of management protocols and guidelines occurs at frequent intervals throughout the year and that their implementation is continuously monitored so that, if necessary, further implementation strategies can be employed.

Accessory nerve: anatomy and surgical identification

The XIth cranial nerve or accessory nerve provides the motor supply to the sternocleidomastoid and trapezius muscles. It is frequently encountered during neck surgery, and as such is at risk of iatrogenic injury, resulting in the ‘shoulder syndrome’. Historically, the nerve was sacrificed on oncological grounds during radical neck dissection. However, the basis for sacrifice is unfounded in the majority of cases, and accessory nerve sparing selective neck dissection has equal oncological efficacy. The path of the nerve in the neck is very variable, and there is not a wholly reliable landmark for its identification. However, there are a number of methods described in the literature to guide the surgeon in its identification. This paper provides a systematic review of all the methods available for identification of the accessory nerve, and comments on the reliability of each. In doing so, the detailed anatomy of the accessory nerve is also described.

Calciphylaxis: calcific uraemic arteriolopathy--a case study

Having worked in nephrology for more than 20 years, and never encountering this condition before, we came across three patients who had been diagnosed with calciphylaxis in the space of 12 months. This condition is also known as calcific uraemic arteriolopathy and is a syndrome of medical calcification of the small arteries, which leads to painful ischaemia of the surrounding subcubitis and skin (1). Prevalence of 1-4% has been estimated in various haemodialysis populations. Also 1% per year in dialysis patients has also been suggested (3). The mortality rate for distal lesions is 23%, whilst the mortality for proximal lesions is 63% (4). The pathogenesis of this condition remains uncertain. However, vascular calcium deposition is thought to be important, and raised serum phosphate levels were associated with a substantially increased risk of calciphylaxis. Although PTH levels were high, plasma PTH was not consistently higher in patients with calciphylaxis than controls (5). The important aspect of the condition for the patients is the sheer pain and distress suffered, as well as the high mortality rate. Therefore, the implications for nurses are early detection, to allow speedy treatment to take place and involvement of the multidisciplinary team to enhance care and provide as much support as possible, thus facilitating optimal outcome and comfort.

Quantum Coherent Tunable Coupling of Superconducting Qubits

To do large-scale quantum information processing, it is necessary to control the interactions between individual qubits while retaining quantum coherence. To this end, superconducting circuits allow for a high degree of flexibility. We report on the time-domain tunable coupling of optimally biased superconducting flux qubits. By modulating the nonlinear inductance of an additional coupling element, we parametrically induced a two-qubit transition that was otherwise forbidden. We observed an on/off coupling ratio of 19 and were able to demonstrate a simple quantum protocol.

The association between domestic violence and self harm in emergency medicine patients

AIMS

This study compared rates of self harm among victims of domestic assault presenting to an emergency department (ED) with those rates among other ED patients. It also explored the temporal and numeric relation between domestic assaults and self harm.

METHODS

A retrospective matched cohort study was conducted using the medical records of a single ED. The cases were patients who had presented to the ED as a consequence of domestic assault. Two control groups matched for age, sex, and Cambridge postcode were randomly generated from the ED patient list. The second control group cases were also matched for postcode sector as a surrogate approximate for socioeconomic status in addition to age and sex. Cases and controls were followed up between November 1996 and 1 October 2004 documenting the number and timing of episodes of self harm reported in the study period.

RESULTS

Altogether, 294 cases and 558 controls were followed up. Patients suffering domestic assault were more likely to present with self harm than controls (RR 3.6 95% CI 2.1-6.5). This effect appeared to be independent of deprivation. Patients suffering domestic assault had more ED contacts than controls. There was a moderate correlation between the number of episodes of self harm and number of assaults (Spearman's rho 0.3 p<0.001). Socioeconomic status was a poor predictor of self harm. Emergency physicians should consider asking about suicidal ideation in victims of domestic assault.

Haematology and biochemistry in healthy young pheasants and red-legged partridges and effects of spironucleosis on these parameters

Plasma biochemical and haematological parameters were examined in 4-week-old to 12-week-old game birds. Healthy, uninfected pheasants and partridges had similar levels of total protein, albumin, osmolality, Na+, Cl-, K+, Mg2+ and glucose. Triglyceride, globulin and Ca2+ were significantly higher and PO43- was lower in the partridges. Pheasants carrying a light to moderate infection with Spironucleus had significantly lower total protein, albumin, osmolality, Na+, Cl-, Ca2+ and PO43-. In severely affected pheasants, the osmolality, Na+ and Cl- fell further. Triglyceride and glucose were significantly lower than in healthy birds, and Mg2+ was higher. Similar data were obtained from infected partridges. Red cell parameters rose significantly in pheasants severely affected by spironucleosis, and the percent of heterophils was significantly higher and lymphocytes and basophils lower in their blood smears. The breast and leg muscle wet weight from severely affected pheasants was 22.2 and 37.7% that of uninfected birds, although the water content of the breast muscle was significantly higher.

Updated surgical experience with bone-anchored hearing aids in children

BACKGROUND

We present the results of a retrospective review of children undergoing implantation with bone-anchored hearing aids (BAHAs) at the Great Ormond Street Hospital for Children.

METHODS

The case notes of 71 children undergoing BAHA placement at the Great Ormond Street Hospital for Children between December 1990 and August 2002 were reviewed. Outcome measures included hearing thresholds, incidence of fixture loss, skin reaction and need for revision. Quality of life outcomes were also measured.

RESULTS

Eighty-five ears had been implanted. Fifty-four per cent of children had experienced no complications, 42 per cent had required revision surgery and 26 per cent had experienced fixture loss at some point. Young age at implantation was associated with an adverse outcome. Trauma and failure of osseointegration had been the commonest reasons for failure. A skin reaction around the abutment had occurred at some point in 37 per cent of children but had persisted for longer than six months in only 9 per cent; this had been associated with fixture loss. The use of fixture site split skin grafts had reduced problems with skin hypertrophy and hair overgrowth. Hearing thresholds when using BAHAs had been comparable to those when using bone conduction hearing aids. However, BAHAs had significant additional benefits in terms of sound quality, ease of use and overall quality of life.

CONCLUSION

Bone-anchored hearing aids provide significant benefits over other types of hearing aid, both audiologically and in terms of quality of life. Careful selection of candidates and meticulous follow up are required in order to minimize complications.

Glomus jugulare tumour presenting with isolated accessory nerve palsy

Glomus tumours of the skull base are rare, and most frequently present with symptoms of hearing loss and tinnitus. Diagnosis is often delayed due to the slow growth of the tumour. We describe the previously unreported occurrence of a glomus tumour presenting with a unilateral accessory nerve palsy.

Simple keel fixation technique for endoscopic repair of anterior glottic stenosis

The use of keels in the treatment of anterior glottic stenosis is well established. A variety of methods for keel fixation have previously been documented. We describe a simple technique of securing a Silastic keel, placed endoscopically, with a simple percutaneous suture, after laser vaporization of an anterior commissure web.