Multilevel latent class casemix modelling: a novel approach to accommodate patient casemix

BACKGROUND

Using routinely collected patient data we explore the utility of multilevel latent class (MLLC) models to adjust for patient casemix and rank Trust performance. We contrast this with ranks derived from Trust standardised mortality ratios (SMRs).

METHODS

Patients with colorectal cancer diagnosed between 1998 and 2004 and resident in Northern and Yorkshire regions were identified from the cancer registry database (n = 24,640). Patient age, sex, stage-at-diagnosis (Dukes), and Trust of diagnosis/treatment were extracted. Socioeconomic background was derived using the Townsend Index. Outcome was survival at 3 years after diagnosis. MLLC-modelled and SMR-generated Trust ranks were compared.

RESULTS

Patients were assigned to two classes of similar size: one with reasonable prognosis (63.0% died within 3 years), and one with better prognosis (39.3% died within 3 years). In patient class one, all patients diagnosed at stage B or C died within 3 years; in patient class two, all patients diagnosed at stage A, B or C survived. Trusts were assigned two classes with 51.3% and 53.2% of patients respectively dying within 3 years. Differences in the ranked Trust performance between the MLLC model and SMRs were all within estimated 95% CIs.

CONCLUSIONS

A novel approach to casemix adjustment is illustrated, ranking Trust performance whilst facilitating the evaluation of factors associated with the patient journey (e.g. treatments) and factors associated with the processes of healthcare delivery (e.g. delays). Further research can demonstrate the value of modelling patient pathways and evaluating healthcare processes across provider institutions.

Genetic predisposition to fracture non-union: a case control study of a preliminary single nucleotide polymorphisms analysis of the BMP pathway

Background

Despite the known multi-factorial nature of atrophic fracture non-unions, a possible genetic predisposition for the development of this complication after long bone fractures remains unknown. This pilot study aimed to address this issue by performing a preliminary SNP analysis of specific genes known to regulate fracture healing.

Methods

A total of fifteen SNPs within four genes of the Bone Morphogenetic Protein (BMP) pathway (BMP-2, BMP-7, NOGGIN and SMAD6) were examined, in 109 randomly selected patients with long bone fractures as a result of motor vehicle accident, fall or direct blow. There were sixty-two patients with atrophic non-union and forty-seven patients (54 fractures) with uneventful fracture union. Overall SNPs frequencies were computed with respect to patient's age, gender, smoking habits, fracture-associated parameters and the use of nonsteroidal anti-inflammatory drugs (NSAIDs), and tested for their association to the impaired bone healing process, using binary logistic regression (STATA 11.1; StataCorp, Texas USA).

Results

Statistical analysis revealed age to be an important covariate in the development of atrophic non-union (p = 0.01, OR 1.05 [per year]), and two specific genotypes (G/G genotype of the rs1372857 SNP, located on NOGGIN and T/T genotype of the rs2053423 SNP, located on SMAD6) to be associated with a greater risk of fracture non-union (p = 0.02, OR 4.56 and p = 0.04, OR 10.27, respectively, after adjustment for age).

Conclusions

This is the first clinical study to investigate the potential existence of genetic susceptibility to fracture non-union. Even though no concrete conclusions can be obtained from this pilot study, our results indicate the existence of a potential genetically predetermined impairment within the BMP signalling cascade, initiated after a fracture and when combined with other risk factors could synergistically increase the susceptibility of a patient to develop non-union. Further research is desirable in order to clarify the genetic component and its role and interaction with other risk factors in the development of atrophic long bone non-union, as simple genetic testing may contribute to the early identification of patients at risk in the future and the on-time intervention at the biologic aspects of bone healing.

Impact of missing data on standardised mortality ratios for acute myocardial infarction: evidence from the Myocardial Ischaemia National Audit Project (MINAP) 2004-7

BACKGROUND

Standardised mortality ratios (SMR) are often used to depict cardiovascular care. Data missingness, data quality, temporal variation and case-mix can, however, complicate the assessment of clinical performance.

OBJECTIVES

To study Primary Care Trust (PCT) 30-day SMRs for STEMI and NSTEMI whilst considering the impact of missing data for age, sex and IMD score.

DESIGN

Observational study using data from the Myocardial Ischaemia National Audit Project (MINAP) database to generate PCT SMR maps and funnel plots for England, 2004-2007.

PATIENTS

217,157

PATIENTS

40.4% STEMI and 59.6% NSTEMI.

RESULTS

95% CI 30-day unadjusted mortality: STEMI 5.8% to 6.2%; NSTEMI 6.6% to 6.9%; relative risk, 95% CI 1.14, 1.10 to 1.19. Median (IQR) data missingess by PCT for composite of age, sex and IMD score was 1.4% (0.7% to 2.2%). For STEMI and NSTEMI statistically significant predictors of mortality were mean age (STEMI: P<0.001; NSTEMI: P<0.001), proportion of females (STEMI: P<0.001; NSTEMI: P<0.001) and proportion of missing ages (STEMI: P=0.02; NSTEMI: P<0.001). Proportion of missing sex also predicted 30-day mortality for NSTEMI (P=0.01). Maps of SMRs demonstrated substantial mortality variation, but no evidence of North / South divide. There were significant correlations between STEMI and NSTEMI observed (R² 0.72) and standardised mortality (R² 0.49) rates. PCT data aggregation gave an acceptable model fit in terms of deviance explained. For STEMI there were 33 (21.7%) regions below the 99.8% lower limit of the associated performance funnel plot, and 28 (18.4%) for NSTEMI; the inclusion of missing data did not affect the distribution of SMRs.

CONCLUSIONS

The proportion of missing data was associated with 30-day mortality for STEMI and NSTEMI, however it did not influence the distribution of PCTs within the funnel plots. There was considerable variation in mortality not attributable to key patient-specific factors, supporting the notion of regional-dependent variation in STEMI and NSTEMI care.

Impact of hospital proportion and volume on primary percutaneous coronary intervention performance in England and Wales

AIMS

To quantify the determinants of primary percutaneous coronary intervention (PCI) performance in England and Wales between 2004 and 2007.

METHODS AND RESULTS

All 8653 primary PCI cases admitted to acute hospitals in England and Wales as recorded in the Myocardial Ischaemia National Audit Project (MINAP) 2004-2007. We studied the impact of the volume of primary PCI cases (hospital volume) on door-to-balloon (DTB) times and the proportion of patients treated with primary PCI (hospital proportion) on 30-day mortality and employed regression analysis to identify reasons for DTB time variations with a multilevel component to express hospital variation. The proportion of patients receiving primary PCI increased from 5% in 2004 to 20% in 2007. Median DTB times reduced from 84 min in 2004 to 61 min in 2007. Median DTB times decreased as the number of primary PCI procedures increased. The 30-day all-cause mortality rate for hospitals performing primary PCI on >25% of ST-elevation myocardial infarction patients [5.0%; 95% confidence interval (CI): 3.9-6.1%] was almost double that of hospitals performing primary PCI on more than 75% (2.7%; 95% CI: 2.0-3.5%). Time-of-day, year of admission, sex, and diabetes significantly influenced DTB times. Hospital variation was evident by a hospital-level DTB time standard deviation of 12 min.

CONCLUSIONS

There was a large variation in DTB times between the best and worst performing hospitals. Although patient-related factors impacted upon DTB times, the volume and proportion of patients undergoing primary PCI were significantly associated with delay and early mortality-hospitals with the highest proportion of primary PCI had the lowest mortality.

Key challenges in the development and implementation of telehealth projects

A literature review was carried out to identify the key challenges in the implementation of telehealth. This was followed by a survey of organisations in England involved in telehealth projects in order to understand the challenges they faced. Ten of the 13 health or local authority organisations surveyed had telehealth projects and three were at the planning stage. The analysis revealed seven key challenges facing implementers of telehealth in England. Based on the findings from the literature review and the survey, a model was constructed and a checklist drawn up. The model contained the following elements: identifying issues, needs and partners; producing a strategy; securing funding; implementing changes; and monitoring and evaluating a telehealth project. The checklist was validated by using key informants from the organisations originally surveyed. The checklist may be useful to guide telehealth development and implementation in the future.

Does computer-aided clinical decision support improve the management of acute abdominal pain? A systematic review

Acute abdominal pain is a common reason for emergency presentation to hospital. Despite recent medical advances in diagnostics, overall clinical decision-making in the assessment of patients with undifferentiated acute abdominal pain remains poor, with initial clinical diagnostic accuracy being 45-50%. Computer-aided decision support (CADS) systems were widely tested in this arena during the 1970s and 1980s with results that were generally favourable. Inception into routine clinical practice was hampered largely by the size and speed of the hardware. Computer systems and literacy are now vastly superior and the potential benefit of CADS deserves investigation. An extensive literature search was undertaken to find articles that directly compared the clinical diagnostic accuracy prospectively of medical staff in the diagnosis of acute abdominal pain before and after the institution of a CADS programme. Included articles underwent meta-analysis with a random-effects model. Ten studies underwent meta-analysis that demonstrated an overall mean percentage improvement in clinical diagnostic accuracy of 17.25% with the use of CADS systems. There is a role for CADS in the initial evaluation of acute abdominal pain, which very often takes place in the emergency department setting.

Improved pulmonary function after concave rib resection and posterior instrumentation for idiopathic scoliosis

The authors conducted a prospective study in order to evaluate the effect'of concave rib osteotomy on pulmonary function, in the context of posterior instrumentation for the treatment of idiopathic scoliosis. Concave rib osteotomy improves the flexibility of the spine, especially in very rigid curves above 70. Seventy-eight consecutive children with a Cobb angle above 70 degrees were included in the study. Pulmonary function was measured preoperatively and at 12 months postoperatively. After surgery, all patients took part at an intense pulmonary rehabilitation program. The mean preoperative Cobb angle of 91.70 improved to an average of 29.50. Unexpectedly, the postoperative pulmonary function, measured as an absolute value after one year, was significantly better than the preoperative pulmonary function. Very probably the concave rib osteotomy had allowed expansion of the thoracic cage. Most other studies about scoliosis surgery with disruption of the rib cage have reported a stabilized or a diminished pulmonary function. An exception might be the use of expansion thoracostomy with insertion of vertical expandable prosthetic titanium ribs in congenital scoliosis.

Nurse led, primary care based antiretroviral treatment versus hospital care: a controlled prospective study in Swaziland

Background

Antiretroviral treatment services delivered in hospital settings in Africa increasingly lack capacity to meet demand and are difficult to access by patients. We evaluate the effectiveness of nurse led primary care based antiretroviral treatment by comparison with usual hospital care in a typical rural sub Saharan African setting.

Methods

We undertook a prospective, controlled evaluation of planned service change in Lubombo, Swaziland. Clinically stable adults with a CD4 count > 100 and on antiretroviral treatment for at least four weeks at the district hospital were assigned to either nurse led primary care based antiretroviral treatment care or usual hospital care. Assignment depended on the location of the nearest primary care clinic. The main outcome measures were clinic attendance and patient experience.

Results

Those receiving primary care based treatment were less likely to miss an appointment compared with those continuing to receive hospital care (RR 0·37, p < 0·0001). Average travel cost was half that of those receiving hospital care (p = 0·001). Those receiving primary care based, nurse led care were more likely to be satisfied in the ability of staff to manage their condition (RR 1·23, p = 0·003). There was no significant difference in loss to follow-up or other health related outcomes in modified intention to treat analysis. Multilevel, multivariable regression identified little inter-cluster variation.

Conclusions

Clinic attendance and patient experience are better with nurse led primary care based antiretroviral treatment care than with hospital care; health related outcomes appear equally good. This evidence supports efforts of the WHO to scale-up universal access to antiretroviral treatment in sub Saharan Africa.

Paleogene terrestrial vertebrates: northernmost occurrence, ellesmere island, Canada

Recently discovered Paleogene land vertebrates from the Eureka Sound Formation at about latitude 78 degrees north in Arctic Canada include fish, turtles, an alligatorid, and several taxa of mammals. The assemblage, which is probably early or middle Eocene in age, adds to previously known paleobotanical evidence in suggesting temperate to warm-temperate climatic conditions.

Do doctors understand alcohol units?

A survey of 445 doctors in Yorkshire was conducted to ascertain their knowledge and awareness of alcohol units. Only 58% had some knowledge, and general practitioners scored better (69%) than hospital doctors (45%). However, 14% of doctors had no knowledge at all about alcohol units. Those who did not drink alcohol knew less than those who did and trainee doctors had significantly less knowledge than more senior physicians. Junior doctors who often deal with alcohol-related problems in their day-to-day hospital work had a poor knowledge. There needs to be a greater emphasis on alcohol and alcohol-related problems (including how to calculate alcohol units) in undergraduate and postgraduate curricula to improve doctors' knowledge and awareness of this important subject.

Changes in and predictors of length of stay in hospital after surgery for breast cancer between 1997/98 and 2004/05 in two regions of England: a population-based study

Background

Decreases in length of stay (LOS) in hospital after breast cancer surgery can be partly attributed to the change to less radical surgery, but many other factors are operating at the patient, surgeon and hospital levels. This study aimed to describe the changes in and predictors of length of stay (LOS) in hospital after surgery for breast cancer between 1997/98 and 2004/05 in two regions of England.

Methods

Cases of female invasive breast cancer diagnosed in two English cancer registry regions were linked to Hospital Episode Statistics data for the period 1^st April 1997 to 31^st March 2005. A subset of records where women underwent mastectomy or breast conserving surgery (BCS) was extracted (n = 44,877). Variations in LOS over the study period were investigated. A multilevel model with patients clustered within surgical teams and NHS Trusts was used to examine associations between LOS and a range of factors.

Results

Over the study period the proportion of women having a mastectomy reduced from 58% to 52%. The proportion varied from 14% to 80% according to NHS Trust. LOS decreased by 21% from 1997/98 to 2004/05 (LOSratio = 0.79, 95%CI 0.77-0.80). BCS was associated with 33% shorter hospital stays compared to mastectomy (LOSratio = 0.67, 95%CI 0.66-0.68). Older age, advanced disease, presence of comorbidities, lymph node excision and reconstructive surgery were associated with increased LOS. Significant variation remained amongst Trusts and surgical teams.

Conclusion

The number of days spent in hospital after breast cancer surgery has continued to decline for several decades. The change from mastectomy to BCS accounts for only 9% of the overall decrease in LOS. Other explanations include the adoption of new techniques and practices, such as sentinel lymph node biopsy and early discharge. This study has identified wide variation in practice with substantial cost implications for the NHS. Further work is required to explain this variation.

UK health professionals' attitudes and knowledge regarding Human Papillomavirus (HPV) vaccination: a West Yorkshire Study

AIM

To investigate the willingness of clinicians to recommend human papillomavirus (HPV) vaccination, the strength of support for a national HPV vaccine programme and to determine which factors, if any, affected these.

METHODS

An online, invitation-only questionnaire was developed and distributed to three medical professional groups in the West Yorkshire Region, United Kingdom.

RESULTS

Two hundred twenty-two responders were included in the final analysis, from the following specialties: general practice (62), paediatrics (103) and obstetrics and gynaecology (57). The majority of doctors were in favour of an National Health Service-funded national vaccination programme. Over 90% supported vaccination of girls as early as ages 11-13. Fewer doctors felt comfortable recommending vaccination to parents of girls under 16 than to young women. Latent class analysis demonstrated that doctors' self-rated knowledge of the HPV vaccine was an important determinant of willingness to recommend vaccination. Younger, more recently qualified doctors were less likely to be willing to recommend vaccination.

CONCLUSIONS

There is widespread support for vaccination. Information provision to doctors will be important in maximising clinician confidence in recommending vaccination, and may be most beneficial when targeted at more junior doctors.

The Stroke Outcomes Study 2 (SOS2): a prospective, analytic cohort study of depressive symptoms after stroke

BACKGROUND

Mood disorder is recognised as an important and common problem after stroke but little is known about the longer term effects of mood on functional outcomes. This protocol paper describes the Stroke Outcomes Study 2 (SOS2), a research study conducted in two large acute NHS Trusts in the North of England, which was designed to investigate the impact of early depressive symptoms on outcomes after an acute stroke.

METHODS AND DESIGN

SOS2 was a prospective cohort study that aimed to recruit patients in the first few weeks after a stroke, and to follow them up at regular intervals for one year thereafter in order to describe the trajectory of psychological symptoms and study their impact on physical functional recovery. Measures of mood and function were completed at baseline (approximately 3 weeks) and at four follow-up time-points: approximately 9, 13, 26 and 52 weeks after the index stroke.

DISCUSSION

Recruiting patients to research studies soon after an acute stroke is difficult. Mortality following stroke is approximately 30% and in the region of half the patients that survive the initial event are significantly disabled. Together these factors reduced the number of patients available to participate in SOS2 but once recruited to the study the drop-out rate was relatively low. During the recruitment period over 6000 admissions for stroke or query stroke were screened for eligibility. A cohort of 592 study participants was finally achieved.

Functional data analysis applied to a randomized controlled clinical trial in hemodialysis patients describes the variability of patient responses in the control of renal anemia

The achievement of desirable hemoglobin levels in renal anemia that is treated with epoetins is often incomplete and subject to much variation of outcome values and applied dosage. The further development of clinical decision support for renal anemia requires the characterization of patient responses and an analysis of the dynamics of the dosage and response variables. In this methodologic article, the extended data of a randomized, controlled clinical trial comparing two epoetins were examined by the techniques of functional data analysis to establish how precisely the patterns of treatment response might be described and analyzed. The description of the trajectory of hemoglobin values in each patient as a mathematical function allowed the characterization of individual responses, with a wide variety of patterns being revealed. An analysis of the degree of system control in the management of the anemia was then possible through phase plotting. The analysis also allowed an expression of the dynamic characteristics of the entire experimental system, analyzed in summary group waveforms with standard statistical properties. In addition, a quantification of the notional instability of patient responses enabled the determination of a subset of patients for whom control might be improved in a modified management system. It is concluded that functional data analysis does provide the basis for further characterization and experimental study of the control of renal anemia.

Health intervention in social context: understanding social networks and neighbourhood

Recruiting lay people from the neighbourhoods of target communities as Community Health Educators (CHEs) is an increasingly popular strategy for health interventions in the UK. CHEs are assumed to have a distinct advantage in reaching 'difficult to reach' groups by virtue of their network membership. However, results obtained from a recent intervention study [Chiu (2002). Straight talking: Communicating breast screening information in primary care. Leeds: Nuffield Institute for Health, University of Leeds] raised concerns about the much-asserted efficacy of networks and suggested that neighbourhood was a contextual factor that would potentially affect the results of health interventions. In addition, it suggested that the concept of social networks and other related concepts i.e. 'social embeddedness', 'social capital', and 'neighbourhoods' that underpin CHE interventions needed to be better understood. In order to examine these concepts in relation to CHE interventions, we conducted a pilot study involving 53 CHEs (26 White, 27 Black and Minority Ethnic) in seven health organisations across the UK. The CHEs took part in focus group interviews to explore their perceptions of social networks and neighbourhood. Quantitative information on their personal networks was also mapped using three proformas. This paper explores CHEs' networks with a specific focus on the concept of 'social embeddedness' and the effect of neighbourhood. Implications of these findings on the effectiveness of intervention are discussed.

A longitudinal assessment of aflatoxin M1 excretion in breast milk of selected Egyptian mothers

Aflatoxins are potent toxins and carcinogens which can be excreted in the milk of exposed lactating mothers mainly in the form of aflatoxin M(1) (AFM(1)). We previously evaluated the level and frequency of AFM(1) in breast milk in a group of Egyptian mothers attending the New El-Qalyub Hospital, Qalyubiyah governorate, Egypt. In this study, fifty of those women who were AFM(1) positive were revisited monthly for 12 months to assess the temporal variation in breast milk AFM(1). AFM(1) was detected in 248 of 443 (56%) samples. In a multilevel model of the data there was a highly significant (p<0.001) effect of month of sampling on the frequency of AFM(1) detection with summer months having the highest frequency (>80%) and winter months the lowest frequency (<20%) of detection. AFM(1) was observed most frequently in June [OR 63, 95% CI (7.6, 522)]. The level of AFM(1) detection also followed this seasonal pattern with highest mean level in July (64 pg/ml milk, range 6.3-497 pg/ml milk) and the lowest mean level in January (8 pg/ml milk, range 4.2-108 pg/ml milk). The duration of lactation [p=0.0035, OR=1.08, 95% CI (1.02, 1.13)], and peanut consumption [p=0.06, OR=1.69, 95% CI (0.9, 2.9)] also contributed to the model. The identification and understanding of factors determining the presence of toxicants in human milk is important and may provide a knowledge driven basis for controlling the transfer of chemicals to infants.

Loss and spontaneous recovery of forelimb evoked potentials in both the adult rat cuneate nucleus and somatosensory cortex following contusive cervical spinal cord injury

Varying degrees of neurologic function spontaneously recovers in humans and animals during the days and months after spinal cord injury (SCI). For example, abolished upper limb somatosensory potentials (SSEPs) and cutaneous sensations can recover in persons post-contusive cervical SCI. To maximize recovery and the development/evaluation of repair strategies, a better understanding of the anatomical locations and physiological processes underlying spontaneous recovery after SCI is needed. As an initial step, the present study examined whether recovery of upper limb SSEPs after contusive cervical SCI was due to the integrity of some spared dorsal column primary afferents that terminate within the cuneate nucleus and not one of several alternate routes. C5-6 contusions were performed on male adult rats. Electrophysiological techniques were used in the same rat to determine forelimb evoked neuronal responses in both cortex (SSEPs) and the cuneate nucleus (terminal extracellular recordings). SSEPs were not evoked 2 days post-SCI but were found at 7 days and beyond, with an observed change in latencies between 7 and 14 days (suggestive of spared axon remyelination). Forelimb evoked activity in the cuneate nucleus at 15 but not 3 days post-injury occurred despite dorsal column damage throughout the cervical injury (as seen histologically). Neuroanatomical tracing (using 1% unconjugated cholera toxin B subunit) confirmed that upper limb primary afferent terminals remained within the cuneate nuclei. Taken together, these results indicate that neural transmission between dorsal column primary afferents and cuneate nuclei neurons is likely involved in the recovery of upper limb SSEPs after contusive cervical SCI.

Networks and governance: the case of intermediate care

The present paper describes a novel approach to the study of services conceptualised as networks. It uses data collected as part of a case study evaluation of intermediate care, a 'joined-up government' policy that was explicitly intended to dissolve the boundaries between health and social care services. The evaluation was undertaken in five localities in England. Routine service use data were collated and standardised for the 12-month period from November 2002 to October 2003. A cohort of 258 service users was recruited during a census month (June 2003), and more detailed data on their personal characteristics and experiences prior to and during their intermediate care episode were collected. Information was obtained for 153 of these people, covering their experience during the 6 months following discharge. A graphical method of depicting individuals' movements between services was devised and a number of measures were used to investigate the network-like features of the data. User outcomes were explored by examining the relationship of characteristics of service users to their location at 6 months after discharge. The results of the analyses show that the five sites were developing service configurations that facilitated transitions between health, social care and other services, and that individual needs were taken into account in the decisions made about which people transferred into which services. While the results cannot be said to show that joined-up government works, they are consistent with the argument that joined-up government goes beyond partnership-type concepts, and in practice, involves the creation of what might be termed integrated service networks.

A new role for nurses as Primary Care Cancer Lead Clinicians in Primary Care Trusts in England

AIM

The aim of this study was to evaluate the Primary Care Cancer Lead Clinician initiative in England. One of the objectives was to examine the impact of the Primary Care Cancer Lead Clinicians' clinical background on how they perform their role. This study compares nurses and General Practitioners in the Primary Care Cancer Lead Clinician role.

BACKGROUND

The Primary Care Cancer Lead Clinician initiative developed from the National Health Service Cancer Plan. Primary Care Cancer Lead Clinicians are expected to work strategically to raise the standards of cancer care within primary care.

METHODS

A postal questionnaire survey was sent to Primary Care Cancer Lead Clinicians and one manager in each Primary Care Trust in England. Telephonic interviews were also undertaken with a range of stakeholders in six case study areas.

RESULTS

There were striking similarities between nurses and General Practitioners in the Primary Care Cancer Lead Clinician role. Differences related to the wider roles of the two groups. Nurses placed greater emphasis on fitting in whereas General Practitioners were more likely to expect to take charge and look for administrative support.

CONCLUSIONS

There is evidence to show that whether the Primary Care Cancer Lead Clinician was a nurse or a General Practitioner was less important than having local credibility and the support of their Primary Care Trust.

The response to sertraline in men with chronic pelvic pain syndrome

OBJECTIVES

Male chronic pelvic pain syndrome (CPPS) is difficult to manage. Although antidepressants are frequently used in clinical practice, to date no interventional study has been published. We investigated men with CPPS to assess their response to the serotonin specific reuptake inhibitor (SSRI) antidepressant, sertraline.

METHODS

Men with CPPS underwent a four glass test to exclude an infective cause for their symptoms. They were randomised to sertraline or matched placebo for 13 weeks after which they were unblinded. They were then allowed to either continue sertraline or cross over to active treatment for a further 13 weeks. Prostatic symptom severity (PSS) and frequency (PSF) scores, the Hospital Anxiety and Depression (HAD) scale and a psychosexual (PSex) questionnaire were completed at 0, 6, 13, and 26 weeks. Statistical analysis was by the Mann-Whitney U and Wilcoxon signed rank tests.

RESULTS

14 men enrolled. At week 13 there was a mean reduction in PSS scores of 6.1 in the active and 2.0 in placebo group, and in PSF scores of 3.6 and 1.0, respectively. There was no statistically significant difference in the PSS and PSF scores between the active versus placebo group because of the small subject numbers. If analysed as a case series, there was a significant reduction in PSS (11.7; p = 0.01) and PSF (5.9; p = 0.03) from baseline following 13 weeks of sertraline. There was also a decrease in mean HAD depression score from 4.6 at baseline to 2.4.

CONCLUSION

Sertraline led to a significant improvement in prostatic symptom severity and frequency from baseline following 13 weeks of treatment. Although this analysis does not exclude a placebo effect, the randomised placebo controlled findings show a trend to improvement with sertraline when compared to placebo.

Markov chain Monte Carlo techniques and spatial–temporal modelling for medical EIT

Many imaging problems such as imaging with electrical impedance tomography (EIT) can be shown to be inverse problems: that is either there is no unique solution or the solution does not depend continuously on the data. As a consequence solution of inverse problems based on measured data alone is unstable, particularly if the mapping between the solution distribution and the measurements is also nonlinear as in EIT. To deliver a practical stable solution, it is necessary to make considerable use of prior information or regularization techniques. The role of a Bayesian approach is therefore of fundamental importance, especially when coupled with Markov chain Monte Carlo (MCMC) sampling to provide information about solution behaviour. Spatial smoothing is a commonly used approach to regularization. In the human thorax EIT example considered here nonlinearity increases the difficulty of imaging, using only boundary data, leading to reconstructions which are often rather too smooth. In particular, in medical imaging the resistivity distribution usually contains substantial jumps at the boundaries of different anatomical regions. With spatial smoothing these boundaries can be masked by blurring. This paper focuses on the medical application of EIT to monitor lung and cardiac function and uses explicit geometric information regarding anatomical structure and incorporates temporal correlation. Some simple properties are assumed known, or at least reliably estimated from separate studies, whereas others are estimated from the voltage measurements. This structural formulation will also allow direct estimation of clinically important quantities, such as ejection fraction and residual capacity, along with assessment of precision.

Histocompatibility antigens and La Crosse encephalitis

Major histocompatibility complex antigens (HLA-ABC and -DR loci) on lymphocytes from 79 patients with La Crosse encephalitis were compared with those of 69 control subjects. Nine patients (11%) and none of the control population had HLA-B49 (P < .01, uncorrected for multiple comparisons). Of La Crosse encephalitis patients with acute-phase seizures, only 2 (7%) were positive for HLA-DR5, whereas 16 (37%) of nonseizure patients were positive for that antigen (P < .025). These findings suggest that susceptibility and complications associated with this disease may have an immunogenetic component.

Detection of borreliacidal antibodies in hamsters by using flow cytometry

Flow cytometry can be used to detect antibody that kills Borrelia burgdorferi. Borreliacidal activity was detected within 3 h of incubating B. burgdorferi with immune serum and complement. Right-angle light scatter and propidium iodide fluorescence were the cytometric parameters which correlated best with in vitro killing of B. burgdorferi. Flow cytometry is a rapid method for determining the presence of borreliacidal activity and may lead to a better serodiagnostic test for the detection of Lyme disease.

Arctic Terrestrial Biota: Paleomagnetic Evidence of Age Disparity with Mid-Northern Latitudes During the Late Cretaceous and Early Tertiary

Magnetostratigraphic correlation of the Eureka Sound Formation in the Canadian high Arctic reveals profound difference between the time of appearance of fossil land plants and vertebrates in the Arctic and in mid-northern latitudes. Latest Cretaceous plant fossils in the Arctic predate mid-latitude occurrences by as much as 18 million years, while typical Eocene vertebrate fossils appear some 2 to 4 million years early.

Neogene Vertebrate Paleontology and Stratigraphy of Nepal

ABSTRACT For the past 150 years, the Siwalik Group, a Miocene through Pleistocene molasse along the flank of the Himalaya has been studied intensively stratigraphically and paleontologically in both India and Pakistan. This work recently has been extended into Nepal, where a presumably complete Siwalik section is present, and a modest number of vertebrate fossils have been found. All but one of Nepalese Siwalik vertebrates hare been collected along the southern edge of the Dang Valley in western Nepal. Two assemblages are now known. The older is of presumed Miocene age and likely equivalent to the fauna of the Chinji Formation in Pakistan. The other is of late Pliocene to early Pleistocene age and similar to the Indian Pinjor fauna. In addition, Plio-Pleistocene vertebrates have been reported from fluvial intermontane deposits in the Kathmandu Valley. As studies of radiometric dating, magnetostratigraphy, physical stratigraphy and fossil distributions are extended into Nepal, the place of the Nepalese Siwaliks and basin deposits will become increasingly clear.

Binding of quinacrine to the human Y chromosome

Human chromosome spreads were stained with 3H-quinacrine and their fluorescence observed. The exact location of specific spreads on each slide was noted and photographs taken. Autoradiographs were then prepared so that the quinacrine fluorescence of any specific chromosome could be compared directly with the distribution of grains over the same chromosome on the autoradiograph. The Y chromosome fluoresced much more intensely than any of the other chromosomes, but there were no more grains over the Y chromosome than over the other chromosomes. Therefore the enhanced fluorescence of the human Y chromosome is not due to an increased binding of quinacrine.