Opt-out testing for HIV: perspectives from a high prevalence community in south-east England, UK

Peoples' perspectives and attitudes towards being offered opt-out HIV testing were explored in a geographical area of high HIV prevalence. Users (n = 31) of sexually transmitted infection (STI) testing services took part in community focus groups in the south-east of England, UK. There was broad support for opt-out HIV testing based on public health and individual health benefits. For this sample, opt-out HIV testing when registering with a general practice surgery and on elective or emergency admission to a general hospital was acceptable, although there were concerns about the rigour of informed consent. Heterosexual participants' criticism of people from higher prevalence groups for HIV declining tests, while maintaining their own right to opt-out, suggested that attitudes towards testing may be influenced by levels of perceived risk. Innovations in HIV testing policies to increase testing rates will benefit from an acknowledgement of the different meanings that testing has.

Improving allergy management in the primary care network--a holistic approach

The incidence, prevalence and costs of allergy have increased substantially in recent decades in many parts of Europe. The dominant model of allergy care within Europe is at the moment specialist-based. This model will become unsustainable and undeliverable with increasing disease prevalence. One solution to increase provision of allergy services is to diversify the providers. A new model for the provision of allergy care in the community with the general practitioner at the forefront is proposed. Pre- and postgraduate allergy education and training, implementation of pathways of care, allergy specialization and political will to generate resources and support are essential to achieve this new model. In parallel the holistic view of allergic diseases should be maintained, including assessment of severity and risk, psychological factors and health-care related costs in the context of the patient-centered decision making process.

Small intestinal angiosarcoma masquerading as an appendiceal abscess

Angiosarcomas of the small intestine are rare and present non-specifically. They usually manifest with abdominal discomfort, altered bowel habits, anaemia and gastrointestinal bleeding. Diagnosis is often challenging and occurs at an advanced tumour stage. We describe a case of a terminal ileum angiosarcoma masquerading as an appendiceal abscess, and discuss salient clinicopathological features in diagnosing and managing this disease.

Giant light extraction enhancement of medical imaging scintillation materials using biologically inspired integrated nanostructures

We have utilized biologically inspired (bio-inspired), moth-eye nanostructures and further improved this biomimetic structure to enhance the scintillator materials external quantum efficiency significantly. As a proof of concept, we have demonstrated very high light output efficiency enhancement for Lu(2)SiO(5):Ce(3+) (LSO:Ce) film in large area, the X-ray mammographic instrument was employed to demonstrate the light output enhancement of the Lu(2)SiO(5):Ce thin film with biologically inspired (bio-inspired) moth-eye-like nanophotonic structures. Our work could be extended to other thin film scintillator materials and is promising to achieve lower patient dose, higher resolution images of human organs and even smaller scale medical imaging.

Increasing prevalence of domiciliary ventilation: changes in service demand and provision in the South West of the UK

We examine the incidence and prevalence of domiciliary ventilation in the South West region of the UK, assess trends over 15 years, and describe patient outcome. We conducted a retrospective review of all patients below 18 years receiving domiciliary ventilation in the South West region of the UK between January 1994 and August 2009. Children who received long-term ventilation solely in hospital were excluded from the study. Information was obtained from a locally held database, medical notes, and hospital administration systems. One hundred-six patients were identified. Prevalence has increased since 1994 from 0.2 to 6.7 per 100,000 children. The incidence of both invasive and non-invasive ventilations has increased with a trend towards more non-invasive therapy. The commonest underlying disorders were airway pathology (37 patients), neuromuscular disease (34 patients), and central congenital hypoventilation disorder (17 patients). Sixty-seven patients had significant co-morbidities. Of 38 non-current patients, 19 were transferred to adult ventilation services, 11 died, and 6 were successfully weaned from ventilatory support. In conclusion, there has been a 30-fold increase in the prevalence of paediatric domiciliary ventilation, in the South West region of the UK, since 1994. Co-morbidities are common. Very few children discontinue long-term ventilation, and increasing numbers of ventilated children are transferred to adult services.

Are the UK clinical guidelines for H1N1 influenza infection valid in the hospital setting?

The diagnosis of pandemic influenza is clinical. This prospective study questions the validity of the Department of Health guidelines in 77 children admitted to hospital. The positive predictive value for the guidelines was 0.39. Although H1N1 was identified in a sizeable minority of cases using the guidelines, virology testing is still required.

Higher-order optical resonance node detection of integrated disk microresonator

We have demonstrated higher-order optical resonance node detection by using an integrated disk microresonator from through port of the coupling bus waveguide. In addition to the fundamental mode, the disk resonator has higher-order whispering gallery modes. The excited second-order higher-order mode has a node at the position where the electromagnetic energy of the fundamental mode is close to a maximum. This high resolution measurement of optical resonance mode profile has a variety of applications for optical sensing and detection. The self-referencing characteristics of the two optical resonance modes have potential to achieve optical detection independent of external perturbation, such as temperature change.

Interpretations of Polar Bear (

Due to their tracking experience in pursuing Polar Bears (Ursus maritimus), Inuit hunters could provide non-invasive estimates of Polar Bear characteristics from tracks, and Polar Bear monitoring programs could benefit from Inuit input. We determined i) inter-rater reliability of estimates of the sex, age, and size of Polar Bears, and estimates of the age of tracks made by a group of nine Inuit hunters who interpreted 78 tracks; ii) we made preliminary comparisons of sex and size estimates with conventional (scientific) estimates; iii) we catalogued the Polar Bear hunting experience and track interpretation techniques of nine Inuit hunters; and iv) we explored relationships between hunting experience and the ability to interpret tracks. The group of Inuit hunters made reliable and consistent estimates of Polar Bear sex, age, and size, as well as estimates of age of track (after data from one participant was excluded). Although our comparisons are based on small samples, our findings suggest that Inuit hunters may be accurate in estimating the sex of Polar Bears (74.42% agreement with genetic determinations) and the size of Polar Bears from their tracks. Our data indicate shared tracking techniques used by hunters may explain high agreement in making specific estimates, while individual hunting experience and particular methods used to interpret tracks may lead to inter-rater reliability and accuracy in interpreting tracks.

Localization of phytochrome in etioplasts and its regulation in vitro of gibberellin levels

Etioplasts isolated from barley leaves and purified on a Sephadex G-50 (coarse) column were characterized by electron microscopy and nucleic acid analysis. The majority of etioplasts retained an intact outer envelope, and contamination by other fragments was extremely low. The level of gibberellin-like substances extractable from intact etioplast suspensions was enhanced within 5 min of the termination of a saturating red irradiation, and the response was far-red reversible. Ultra-sonication caused a 3-fold increase in extractable activity both in dark control suspension and suspensions treated with red light. It is concluded that phytochrome, as a function of its interconversions, probably causes the transport of gibberellin from inside the etioplast into the surrounding medium. This leads to increased production of active gibberellins, possibly by release of feedback control of late steps of the biosynthetic pathway. Dual wavelength difference spectrophotometry has demonstrated the presence of a proportion of total cellular phytochrome within the etioplast.

Use of proteinase K for RT-PCR of cytokine mRNA in formalin fixed tissue

Fresh tissue from cases of sudden infant death syndrome is becoming increasingly scarce and therefore researchers interesting in studying the aetiology of this syndrome have had to resort to archival tissue, usually in the form of paraffin wax sections. A simple method for isolating mRNA from formalin fixed, paraffin wax embedded material of sufficient purity for reverse transcription (RT)-PCR is described. Proteinase K treatment of formalin fixed, wax embedded tissue followed by RNA STAT-60 extraction was successful in isolating mRNA suitable for RT-PCR. Interleukin (IL)-1alpha, IL-6 and tumour necrosis factor (TNF) transcripts were amplified successfully from heart, but not thyroid, kidney or liver tissue, of a patient who died following rejection of a transplanted heart, and IL-1alpha, but not IL-6 or TNF, transcripts from lung tissue of a six month old baby who died of viral pneumonia. Transcripts of a housekeeping gene were detected in all tissues. This method should be useful for examining gene expression in archival material.

Separation of antigens by immunological specificity: Use of disulphide-linked antibodies as immunosorbents

1. gamma-Globulin concentrates of antisera prepared against ovalbumin and human serum albumin were thiolated and cross-linked to form insoluble polymers. 2. These immunosorbents were of low solubility and of high capacity for homologous antigen. 3. The high specificity of these immunosorbents was demonstrated by fractionation of various binary mixtures of fluorescent ovalbumin, (131)I-labelled human serum albumin, lysozyme and ribonuclease.

Separation of antigens by immunological specificity: Use of cellulose-linked antibodies as immunosorbents

1. Immunosorbents were prepared by coupling activated aminocellulose with the gamma-globulin concentrates of antisera prepared against ovalbumin and human serum albumin. 2. The immunosorbents were low in solubility, but high in capacity for homologous antigens. 3. The high specificity of these immunosorbents was demonstrated by their use in fractionating various mixtures of fluorescent ovalbumin, (131)I-labelled human serum albumin, lysozyme and ribonuclease.

Effectiveness of five different approaches in management of urinary tract infection: randomised controlled trial

OBJECTIVE

To assess the impact of different management strategies in urinary tract infections.

DESIGN

Randomised controlled trial.

SETTING

Primary care.

PARTICIPANTS

309 non-pregnant women aged 18-70 presenting with suspected urinary tract infection.

INTERVENTION

Patients were randomised to five management approaches: empirical antibiotics; empirical delayed (by 48 hours) antibiotics; or targeted antibiotics based on a symptom score (two or more of urine cloudiness, urine smell, nocturia, or dysuria), a dipstick result (nitrite or both leucocytes and blood), or a positive result on midstream urine analysis. Self help advice was controlled in each group.

MAIN OUTCOME MEASURES

Symptom severity (days 2 to 4) and duration, and use of antibiotics.

RESULTS

Patients had 3.5 days of moderately bad symptoms if they took antibiotics immediately. There were no significant differences in duration or severity of symptoms (mean frequency of symptoms on a 0 to 6 scale: immediate antibiotics 2.15, midstream urine 2.08, dipstick 1.74, symptom score 1.77, delayed antibiotics 2.11; likelihood ratio test for the five groups P=0.177). There were differences in antibiotic use (immediate antibiotics 97%, midstream urine 81%, dipstick 80%, symptom score 90%, delayed antibiotics 77%; P=0.011) and in sending midstream urine samples (immediate antibiotics 23%, midstream urine 89%, dipstick 36%, symptom score 33%, delayed antibiotics 15%; P<0.001). Patients who waited at least 48 hours to start taking antibiotics reconsulted less (hazard ratio 0.57 (95% confidence interval 0.36 to 0.89), P=0.014) but on average had symptoms for 37% longer than those taking immediate antibiotics (incident rate ratio 1.37 (1.11 to 1.68), P=0.003), particularly the midstream urine group (73% longer, 22% to 140%; none of the other groups had more than 22% longer duration).

CONCLUSION

All management strategies achieve similar symptom control. There is no advantage in routinely sending midstream urine samples for testing, and antibiotics targeted with dipstick tests with a delayed prescription as backup, or empirical delayed prescription, can help to reduce antibiotic use.

STUDY REGISTRATION

National Research Register N0484094184 ISRCTN: 03525333.

Women's views about management and cause of urinary tract infection: qualitative interview study

OBJECTIVES

To explore the views of women with urinary tract infection on the acceptability of different strategies for managing the infection, including delayed use of antibiotics, and the cause of infection.

DESIGN

Qualitative interview study with semistructured one to one interviews within a randomised controlled trial of different management strategies. Analysis drew on some of the principles of constant comparison to generate key themes grounded in reported experiences and understandings.

SETTING

Seven general practices across four counties in southern England.

PARTICIPANTS

21 women presenting to general practices who were taking part in the larger trial.

RESULTS

Women preferred not to take antibiotics and were open to alternative management approaches. With a strategy of "antibiotic delay" some women felt a lack of validation or that they were not listened to by their general practitioner. Women attributed urinary tract infection to lifestyle habits and behaviours, such as poor hygiene, general "negligence," and even a "penalty of growing old."

CONCLUSION

A clear acknowledgment of women's triggers to consult is needed. If women are asked to delay taking antibiotics, the clinician must address the particular worries that women might have and explain the rationale for not using antibiotics immediately.

Presentation, pattern, and natural course of severe symptoms, and role of antibiotics and antibiotic resistance among patients presenting with suspected uncomplicated urinary tract infection in primary care: observational study

OBJECTIVE

To assess the natural course and the important predictors of severe symptoms in urinary tract infection and the effect of antibiotics and antibiotic resistance.

DESIGN

Observational study.

SETTING

Primary care.

PARTICIPANTS

839 non-pregnant adult women aged 18-70 presenting with suspected urinary tract infection.

MAIN OUTCOME MEASURE

Duration and severity of symptoms.

RESULTS

684 women provided some information on symptoms; 511 had both laboratory results and complete symptom diaries. For women with infections sensitive to antibiotics, severe symptoms, rated as a moderately bad problem or worse, lasted 3.32 days on average. After adjustment for other predictors, moderately bad symptoms lasted 56% longer (incidence rate ratio 1.56, 95% confidence interval 1.22 to 1.99, P<0.001) in women with resistant infections; 62% longer (1.62, 1.13 to 2.31, P=0.008) when no antibiotics prescribed; and 33% longer (1.33, 1.14 to 1.56, P<0.001) in women with urethral syndrome. The duration of symptoms was shorter if the doctor was perceived to be positive about diagnosis and prognosis (continuous 7 point scale: 0.91, 0.84 to 0.99; P=0.021) and longer when the woman had frequent somatic symptoms (1.03, 1.01 to 1.05, P=0.002; for each symptom), a history of cystitis, urinary frequency, and more severe symptoms at baseline.

CONCLUSION

Antibiotic resistance and not prescribing antibiotics are associated with a greater than 50% increase in the duration of more severe symptoms in women with uncomplicated urinary tract infection. Women with a history of cystitis, frequent somatic symptoms (high somatisation), and severe symptoms at baseline can be given realistic advice that they are likely to have severe symptoms lasting longer than three days.

Conducting oral examinations for cancer in general practice: what are the barriers?

BACKGROUND

The incidence of oral (mouth) cancer in the UK is continuing to rise. Individuals who are at greatest risk rarely visit a dentist but do consult general medical practitioners (GMPs). Therefore, GMPs could have an important role in the early detection of oral cancer. Research has shown that GMPs do not opportunistically screen high-risk individuals; however, the barriers to screening are poorly understood.

OBJECTIVES

To understand the reasons why GMPs may not screen for oral cancer.

METHODS

A questionnaire was developed, using the Theory of Planned Behaviour (TPB), to measure GMPs attitudes to and screening for oral cancer. The questionnaire was designed using all the key theoretical constructs of the TPB and incorporating the themes identified in a qualitative elicitation study. The questionnaire was posted to 499 GPs in Surrey Primary Care trust.

RESULTS

Two hundred and twenty-eight completed questionnaires were returned (46%). Two TPB constructs [subjective norm (e.g. peer pressure) and perceived external control factors (e.g. adequate equipment, time constraints)] were identified as significant predictors of 'intention' to perform oral screening. Intention and perceived internal control factors (e.g. self-efficacy) were predictive of actually performing oral screening with patients.

CONCLUSIONS

The results of the study suggest that there is considerable potential for improving intention to perform oral cancer screening in general practice. Theory-based interventions could include further training to enhance confidence, expertise, knowledge and ease of examination, the provision of adequate equipment in the surgery and increasing the motivation to comply with significant others by introducing guidelines on opportunistic screening.