A spatial and seasonal assessment of river water chemistry across North West England

This paper presents information on the spatial and seasonal patterns of river water chemistry at approximately 800 sites in North West England based on data from the Environment Agency regional monitoring programme. Within a GIS framework, the linkages between average water chemistry (pH, sulphate, base cations, nutrients and metals) catchment characteristics (topography, land cover, soil hydrology, base flow index and geology), rainfall, deposition chemistry and geo-spatial information on discharge consents (point sources) are examined. Water quality maps reveal that there is a clear distinction between the uplands and lowlands. Upland waters are acidic and have low concentrations of base cations, explained by background geological sources and land cover. Localised high concentrations of metals occur in areas of the Cumbrian Fells which are subjected to mining effluent inputs. Nutrient concentrations are low in the uplands with the exception sites receiving effluent inputs from rural point sources. In the lowlands, both past and present human activities have a major impact on river water chemistry, especially in the urban and industrial heartlands of Greater Manchester, south Lancashire and Merseyside. Over 40% of the sites have average orthophosphate concentrations >0.1mg-Pl(-1). Results suggest that the dominant control on orthophosphate concentrations is point source contributions from sewage effluent inputs. Diffuse agricultural sources are also important, although this influence is masked by the impact of point sources. Average nitrate concentrations are linked to the coverage of arable land, although sewage effluent inputs have a significant effect on nitrate concentrations. Metal concentrations in the lowlands are linked to diffuse and point sources. The study demonstrates that point sources, as well as diffuse sources, need to be considered when targeting measures for the effective reduction in river nutrient concentrations. This issue is clearly important with regards to the European Union Water Framework Directive, eutrophication and river water quality.

Rectal Chlamydia trachomatis infection in women. Is it overlooked?

Screening for rectal chlamydia was not routinely offered in our department until we had a local outbreak of lymphogranuloma venereum (LGV) in men who have sex with men (MSM) in 2004/2005. We later decided to extend the screening to high-risk women (women who had receptive anal sex, contacts of gonorrhoea, women, with anorectal symptoms, women who had been sexually assaulted). A retrospective study of 152 women from whom 160 rectal chlamydia swabs were taken was carried out. Twenty (12.5%) swabs were positive, 19 of which were also positive at the cervix. All were non-LGV serovars. The groups at greatest risk were high-risk women aged less than 20 years and women with proven gonococcal infection where the prevalence was 22.6% and 30%, respectively. We conclude that rectal chlamydial infection in women may be common and further studies are needed to elucidate its importance.

GADA testing: the current state of knowledge

This review considers the current knowledge and practice of GADA testing people with diabetes in Europe and the UK. Important issues are raised, including interpretation of the results and the clinical relevance of the GADA titre. Recommendations are made towards standardising GADA testing, using World Health Organization units.

Multidimensional self reports as a measure of characteristics in people with eating disorders

This study used multidimensional self report assessments to measure perfectionism, impulsivity and obsessive compulsive characteristics in females with anorexia nervosa (AN), bulimia nervosa (BN) and in matched healthy controls (HC). The Frost Multidimensional Perfectionism Scale (FMPS), Barrett Impulsivity Scale (BIS) and Obsessive Compulsive Inventory-Revised (OCI-R) scale were completed by 107 participants (AN=30, BN=26, HC=51), in parallel with clinical measures. Results show that people with AN have the highest scores on the dimensions of the FMPS as well as on the overall score; the AN and BN groups have the highest scores on the dimensions and on the overall score of the OCI-R; on the BIS, the AN and BN groups have the highest scores on the attention subscale, but there are no group differences on the overall BIS scores. In relation to the FMPS, the global score, and the subscales 'concern over mistakes' and 'doubts about actions' are all highly correlated with both eating pathology (Eating Disorder Examination Questionnaire, EDE-Q) and low global functioning (Structured Clinical Interview for DSM IV, SCID). The subscale 'obsessing' on the OCI-R shows a strong correlation with eating pathology. The overall score and also the subscales of the BIS do not show strong correlations with eating pathology or poor global functioning. In conclusion, therapies should seek to address these specific areas which are highly correlated with eating disorder pathology.

Standards for research ethics committees: purpose, problems and the possibilities of other approaches

Criticism of ethical review of research continues and research ethics committees (RECs) need to demonstrate that they are "fit for purpose" by meeting acknowledged standards of process, debate and outcome. This paper reports a workshop in Warsaw in April 2008, organised by the European Forum for Good Clinical Practice, on the problems of setting standards for RECs in the European Union. Representatives from 27 countries were invited; 16 were represented. Problems identified were the limited and variable resources, difficulties of setting standards for ethical debate and its outcomes and that REC members, as volunteers, may resent the imposition of standards. Other ways to set standards were discussed, including analysis of current multicentre review, collecting REC member reports for review, learning from appeals and feedback from applicants, and use of other regional and national meetings. The place of a central, national board or ethics committee was debated as was the need for collaborating with partners in other fields.

A New Methodology of Assessing Adult Attachment: Exploring its Validity and Clinical Relevance

Aims:

Attachment research has provided useful concepts towards an interpersonal approach to psychopathology. Although it suggests that psychological processes are defined by three relational dichotomies (self vs. other, relatedness vs. autonomy, and dependent vs. dependent-on positions), it has not yet assessed separately and simultaneously the eight components generated by the intersection of these dichotomies (e.g. self requesting relatedness, self providing relatedness etc). The aim of the present research was to investigate the validity and potential clinical usefulness of such a neglected approach.

Methods:

In Study 1, thirty Cognitive Analytic Therapy outpatients at Guy's Hospital, London, were interviewed before treatment on their couple relationships and filled out the Brief Symptom Inventory (BSI) and Inventory of Interpersonal Problems (IIP). A content-analytic method was applied to the transcripts. In Study 2, a new attachment questionnaire was completed by 400 undergraduates, along with the BSI and IIP.

Results:

In Study 1, at a six-month follow-up, BSI scores were predicted by the Self Requests Autonomy [R Sq = .29, F(1,23) = 10.84, p = .003] and the Other Provides Closeness [R Sq = .23, F(1,23) = 9.72, p=.001] attachment dimensions, while IIP scores were predicted by Self Provides Support [R Sq = .11, F(1,23) = 7.87, p=.003]. In Study 2, factor analysis yielded eight components matching the theoretical expectations and correlating with BSI and IIP scores (rs ranging from .18 to.41).

Conclusions:

The present findings provide some preliminary support for the validity and potential clinical relevance of the method.

Latent autoimmune diabetes in adults (LADA) in South Wales: incidence and characterization

AIM

To define the incidence and characteristics of latent autoimmune diabetes in adults (LADA).

METHODS

We estimated the incidence of LADA by examining the incidence of Type 2 diabetes and calculating the proportion that were antibody positive. The incidence of Type 2 diabetes was calculated by analysis of computer records of 35 out of 36 general practices in Swansea. In addition, thirty-two practices participated in recruiting people with Type 2 diabetes to have glutamic acid decarboxylase (GAD) antibody testing.

RESULTS

The crude proportion of Type 2 patients testing positive for GAD antibodies (GADA) was 4.0% (28/683). This figure did not change when we analysed only the practices that tested more than 60% of all eligible patients. In these practices, 79% (387/487) of all eligible patients were GADA tested and 14/387 [3.6% (95% confidence interval: 2.1-6.1%)] were classified as having LADA. This gives an incidence of LADA of 9 per 100,000 (95% confidence interval: 4.4-17.8 per 100,000) people per year registered with a general practitioner. Patients testing positive for GADA were more likely to have a lower body mass index, other antibodies, to present with acute symptoms and to have higher glycated haemoglobin.

CONCLUSIONS

This is the first study of the incidence of LADA in primary care. People with LADA make up a significant proportion of people with apparent Type 2 diabetes. Patients with LADA are likely to be symptomatic, have poorer glycaemic control and have other autoimmune antibodies.

Routine glutamic acid decarboxylase autoantibody (GADA) testing: patients' perspective

BACKGROUND

Latent autoimmune diabetes in adults (LADA) is a form of type 1 diabetes which in the UK is often diagnosed and treated as type 2 diabetes (T2D). People with LADA show slow progression to insulin dependence and can be distinguished from T2D by blood tests for glutamic acid decarboxylase autoantibodies (GADA). Aims. This study explores the views and experiences of patients who are newly diagnosed with LADA, with particular reference to (i) routine GADA testing; (ii) whether this diagnosis has any influence on the self-management of their diabetes; and (iii) the information needs of patients newly diagnosed with LADA.

METHODS

Ten consecutive patients newly diagnosed with LADA (GADA positive) were invited to participate in individual qualitative semi-structured interviews. Their views and experiences were analysed into codes and categories, using a constant comparative method.

FINDINGS

Participants supported routine GADA testing in all patients with diabetes because the provision of a correct diagnosis has an empowering effect on patients, as it encourages the consideration of treatment options early on in the condition. Participants preferred to rely on future Hba(1c) levels and their doctor's opinion to determine a change in treatment to insulin. Some participants had difficulty distinguishing between the different types of diabetes, including LADA. Others needed to ask questions about LADA in addition to written information.

CONCLUSIONS

Participants were supportive of routine GADA testing, would prefer not to start insulin immediately following a diagnosis of LADA and needed to discuss treatment options with health professionals who were knowledgeable on LADA.

How can we provide effective training for research ethics committee members? A European assessment

Training for members of research ethics committees (RECs) varies from state to state in Europe. To follow this up, the European Forum for Good Clinical Practice organised a workshop in March 2007 to explore these issues and look for solutions. This article summarises the discussion, providing ways forward to develop REC training.

Frequent activating FGFR2 mutations in endometrial carcinomas parallel germline mutations associated with craniosynostosis and skeletal dysplasia syndromes

Endometrial carcinoma is the most common gynecological malignancy in the United States. Although most women present with early disease confined to the uterus, the majority of persistent or recurrent tumors are refractory to current chemotherapies. We have identified a total of 11 different FGFR2 mutations in 3/10 (30%) of endometrial cell lines and 19/187 (10%) of primary uterine tumors. Mutations were seen primarily in tumors of the endometrioid histologic subtype (18/115 cases investigated, 16%). The majority of the somatic mutations identified were identical to germline activating mutations in FGFR2 and FGFR3 that cause Apert Syndrome, Beare-Stevenson Syndrome, hypochondroplasia, achondroplasia and SADDAN syndrome. The two most common somatic mutations identified were S252W (in eight tumors) and N550K (in five samples). Four novel mutations were identified, three of which are also likely to result in receptor gain-of-function. Extensive functional analyses have already been performed on many of these mutations, demonstrating they result in receptor activation through a variety of mechanisms. The discovery of activating FGFR2 mutations in endometrial carcinoma raises the possibility of employing anti-FGFR molecularly targeted therapies in patients with advanced or recurrent endometrial carcinoma.

Interventions for latent autoimmune diabetes (LADA) in adults

BACKGROUND

Latent autoimmune diabetes in Adults (LADA) is a slowly developing type 1 diabetes which presents as non-insulin dependent diabetes and progresses to insulin dependence. However, the best treatment strategy for LADA is unclear.

OBJECTIVES

To compare interventions used for LADA.

SEARCH STRATEGY

Studies were obtained from searches of electronic databases (including MEDLINE, EMBASE), supplemented by hand searches, conference proceedings and consultation with experts.

SELECTION CRITERIA

Selection was in duplicate by two independent reviewers. RCT and controlled clinical trials evaluating interventions for LADA or type 2 diabetes with antibodies were included.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed study quality. Studies were summarised in a descriptive manner.

MAIN RESULTS

Searches identified 8067 citations. Eight publications (seven studies) were included, involving 735 participants. All studies had high risk of bias. There were no data on use of metformin or glitazones alone. Rosiglitazone or sulphonylurea (SU) with insulin did not improve metabolic control significantly more than insulin alone. SU alone gave either poorer (one study, mean difference in HbA1c 2.8% (95% confidence interval (CI) 0.9 to 4.7) or equivalent metabolic control compared to insulin alone (two studies). There was evidence that SU caused earlier insulin dependence (insulin treated at two years: 60% (SU) and 5% (conventional care) (P < 0.001); classified insulin dependent: 64% (SU) and 12.5% (insulin group) (P = 0.007)). No interventions influenced fasting C-peptide, but insulin maintained stimulated C-peptide better than SU (one study, mean difference 7.7 ng/ml (95% CI 2.9 to 12.5) and insulin with rosiglitazone was superior to insulin alone (one study) at maintaining stimulated C-peptide. A pilot study showed better metabolic control at six months with subcutaneously administered glutamic acid decarboxylase (GAD) GAD65, a major autoantigen in autoimmune diabetes, compared to placebo. There was no information regarding quality of life, mortality, complications or costs in any of the publications. Time from diagnosis varied between recruitment at diagnosis to recruitment at nine years of disease duration and there was a great deal of variation in the selection criteria for LADA patients, making it difficult to generalise findings from these studies.

AUTHORS' CONCLUSIONS

There are few studies on this topic and existing studies have a high risk of bias. However, there does seem to be an indication that SU should not be a first line treatment for antibody positive type 2 diabetes. There is no significant evidence for or against other lines of treatment of LADA.

Accuracy of femoral templating in reproducing anatomical femoral offset in total hip replacement

Restoration of hip biomechanics is a crucial component of successful total hip replacement. Preoperative templating is recommended to ensure that the size and orientation of implants is optimised. We studied how closely natural femoral offset could be reproduced using the manufacturers' templates for 10 femoral stems in common use in the UK. A series of 23 consecutive preoperative radiographs from patients who had undergone unilateral total hip replacement for unilateral osteoarthritis of the hip was employed. The change in offset between the templated position of the best-fitting template and the anatomical centre of the hip was measured. The templates were then ranked according to their ability to reproduce the normal anatomical offset. The most accurate was the CPS-Plus (Root Mean Square Error 2.0 mm) followed in rank order by: C stem (2.16), CPT (2.40), Exeter (3.23), Stanmore (3.28), Charnley (3.65), Corail (3.72), ABG II (4.30), Furlong HAC (5.08) and Furlong modular (7.14). A similar pattern of results was achieved when the standard error of variability of offset was analysed. We observed a wide variation in the ability of the femoral prosthesis templates to reproduce normal femoral offset. This variation was independent of the seniority of the observer. The templates of modern polished tapered stems with high modularity were best able to reproduce femoral offset. The current move towards digitisation of X-rays may offer manufacturers an opportunity to improve template designs in certain instances, and to develop appropriate computer software.

AutoCSA, an algorithm for high throughput DNA sequence variant detection in cancer genomes

The undertaking of large-scale DNA sequencing screens for somatic variants in human cancers requires accurate and rapid processing of traces for variants. Due to their often aneuploid nature and admixed normal tissue, heterozygous variants found in primary cancers are often subtle and difficult to detect. To address these issues, we have developed a mutation detection algorithm, AutoCSA, specifically optimized for the high throughput screening of cancer samples.

AVAILABILITY

http://www.sanger.ac.uk/genetics/CGP/Software/AutoCSA.

Identification of a novel panel of cerebrospinal fluid biomarkers for Alzheimer's disease

An early and accurate diagnosis of Alzheimer's disease (AD) is required to initiate symptomatic treatment with currently approved drugs and will be of even greater importance if disease modifying compounds in development display a clinical effect. Protein profiles of human cerebrospinal fluid samples from AD patients (n=95) and population-based healthy controls (n=72) were analyzed by SELDI-TOF-MS in order to discover and characterize novel candidate biomarker combinations that differentiate AD patients from normal aging in this explorative study. Thirty candidate biomarkers (ROC AUC>0.7) were discovered that could differentiate patients with AD from healthy controls. Protein sequence determination and positive identification of 15 biomarkers revealed potential associations between the identified markers and AD pathogenesis. A multi-marker combination of five peaks could distinguish AD from healthy control individuals with high sensitivity (97%) and specificity (98%). The panel of five markers was tested on a blinded independent data set of 30 AD samples and 28 controls giving 100% sensitivity and 97% specificity. This novel panel of biomarkers could potentially be used to improve the accuracy of diagnosis of AD.