Incidence of schizophrenia and other psychoses in England, 1950-2009: a systematic review and meta-analyses

BACKGROUND

We conducted a systematic review of incidence rates in England over a sixty-year period to determine the extent to which rates varied along accepted (age, sex) and less-accepted epidemiological gradients (ethnicity, migration and place of birth and upbringing, time).

OBJECTIVES

To determine variation in incidence of several psychotic disorders as above.

DATA SOURCES

Published and grey literature searches (MEDLINE, PSycINFO, EMBASE, CINAHL, ASSIA, HMIC), and identification of unpublished data through bibliographic searches and author communication.

STUDY ELIGIBILITY CRITERIA

Published 1950-2009; conducted wholly or partially in England; original data on incidence of non-organic adult-onset psychosis or one or more factor(s) pertaining to incidence.

PARTICIPANTS

People, 16-64 years, with first -onset psychosis, including non-affective psychoses, schizophrenia, bipolar disorder, psychotic depression and substance-induced psychosis.

STUDY APPRAISAL AND SYNTHESIS METHODS

Title, abstract and full-text review by two independent raters to identify suitable citations. Data were extracted to a standardized extraction form. Descriptive appraisals of variation in rates, including tables and forest plots, and where suitable, random-effects meta-analyses and meta-regressions to test specific hypotheses; rate heterogeneity was assessed by the I²-statistic.

RESULTS

83 citations met inclusion. Pooled incidence of all psychoses (N = 9) was 31.7 per 100,000 person-years (95%CI: 24.6-40.9), 23.2 (95%CI: 18.3-29.5) for non-affective psychoses (N = 8), 15.2 (95%CI: 11.9-19.5) for schizophrenia (N = 15) and 12.4 (95%CI: 9.0-17.1) for affective psychoses (N = 7). This masked rate heterogeneity (I²: 0.54-0.97), possibly explained by socio-environmental factors; our review confirmed (via meta-regression) the typical age-sex interaction in psychosis risk, including secondary peak onset in women after 45 years. Rates of most disorders were elevated in several ethnic minority groups compared with the white (British) population. For example, for schizophrenia: black Caribbean (pooled RR: 5.6; 95%CI: 3.4-9.2; N = 5), black African (pooled RR: 4.7; 95%CI: 3.3-6.8; N = 5) and South Asian groups in England (pooled RR: 2.4; 95%CI: 1.3-4.5; N = 3). We found no evidence to support an overall change in the incidence of psychotic disorder over time, though diagnostic shifts (away from schizophrenia) were reported.

LIMITATIONS

Incidence studies were predominantly cross-sectional, limiting causal inference. Heterogeneity, while evidencing important variation, suggested pooled estimates require interpretation alongside our descriptive systematic results.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

Incidence of psychotic disorders varied markedly by age, sex, place and migration status/ethnicity. Stable incidence over time, together with a robust socio-environmental epidemiology, provides a platform for developing prediction models for health service planning.

Health system barriers to implementation of collaborative TB and HIV activities including prevention of mother to child transmission in South Africa

In South Africa, the control of TB and HIV co-infection remains a major challenge despite the availability of international and national guidelines for integration of TB and HIV services. This study was undertaken in KwaZulu-Natal, one of the provinces most affected by both TB and HIV, to identify and understand managers' and community care workers' (CCWs) perceptions of health systems barriers related to the implementation of collaborative TB/HIV activities, including prevention of mother to child transmission of HIV (PMTCT). We conducted 29 in-depth interviews with health managers at provincial, district and facility level and with managers of NGOs involved in TB and HIV care, as well as six focus group discussions with CCWs. Thematic analysis of transcripts revealed a convergence of perspectives on the process and the level of the implementation of policy directives on collaborative TB and HIV activities across all categories of respondents (i.e. province-, district-, facility- and community-based organizations). The majority of participants felt that the implementation of the policy was insufficiently consultative and that leadership and political will were lacking. The predominant themes related to health systems barriers include challenges related to structure and organisational culture; management, planning and power issues; unequal financing; and human resource capacity and regulatory problems notably relating to scope of practice of nurses and CCWs. Accelerated implementation of collaborative TB/HIV activities including PMTCT will require political will and leadership to address these health systems barriers.

The Incidence, Prevalence, and Mortality of Stroke in France, Germany, Italy, Spain, the UK, and the US: A Literature Review

Background. Although the burden of stroke in terms of mortality and disability has been well documented in previous years, data after 2000 are limited. Therefore, the aim of this paper was to identify the epidemiology of stroke in the US and EU5 nations from data published in 2000 and later. Methods. Data from literature databases and online sources were collated to identify information relating to the incidence, prevalence, and mortality of stroke from the year 2000 onwards. Results and Conclusions. Twenty-three data sources were identified. The incidence of and mortality due to stroke both increase with age and are greater in males compared to females. Stroke is a common problem and likely to worsen in the US and EU5 as their populations age. However, pre-2000 trends of decreasing stroke mortality over time have continued after 2000, reflecting a consistent improvement in the treatment and care of patients with stroke.

Training community care workers to provide comprehensive TB/HIV/PMTCT integrated care in KwaZulu-Natal: lessons learnt

OBJECTIVE

To describe a participatory approach to implement and evaluate ways to integrate and train community care workers (CCWs) to enhance collaborative TB/HIV/PMTCT activities, and home-based HIV counseling and testing (HCT) at community level.

METHODS

The intervention study was conducted in Sisonke, a rural district of KwaZulu Natal, South Africa. A baseline household (HH) survey was conducted in 11 villages. Six villages were randomly selected into intervention and control clusters. Training was provided first to CCWs from the intervention cluster (IC) followed by the control cluster (CC). Routine monthly data from CCWs were collected from March-December 2010. The data was subjected to bivariate tests.

RESULTS

The baseline HH survey revealed that of 3012 HH members visited by CCWs in 2008, 21% were screened for TB symptoms, 7% were visited for TB adherence support and 2% for ART adherence, and 1.5% were counselled on infant feeding options. A total of 89 CCWs were trained. Data show that during the study period in IC, 684 adults were offered HCT by CCWs, 92% accepted HCT and tested and 7% tested HIV-positive and were referred to the clinic for further care. Of 3556 adults served in IC, 44% were screened for TB symptoms and 32% for symptoms of sexually transmitted infections (STIs) and 37% of children were traced as TB contact. Out of 6226 adults served in CC, 10% were screened for TB symptoms and 7% for STI symptoms. The differences in uptake of services between IC and CC were statistically significant (p<0.05).

CONCLUSION

The findings of this study suggest higher uptake of TB and STI symptoms screening, TB contact tracing and home based HCT in the intervention clusters. This study suggests that up-skilling CCWs could be one avenue to enhance TB/HIV case finding, TB contact tracing and linkages to care.

Systematic review and meta-analysis of laparoscopic Nissen fundoplication with or without division of the short gastric vessels

BACKGROUND

The aim of this meta-analysis was to provide a pooled analysis of individual trials comparing clinical outcome following laparoscopic Nissen fundoplication with or without division of the short gastric vessels (SGVs).

METHODS

Primary outcome measures were the requirement for reoperation, and the presence of postoperative gastro-oesophageal reflux and postoperative dysphagia. Secondary outcome measures were duration of operation, length of hospital stay, postoperative complications (within 30 days of surgery), postoperative gas bloat syndrome, lower oesophageal sphincter resting pressure and DeMeester score. Pooled odds ratios were calculated for categorical outcomes, and weighted mean differences for secondary continuous outcomes, using random-effects models for meta-analysis.

RESULTS

Five randomized trials were included in the analysis. There was no statistically significant effect on the requirement for reoperation, or presence of postoperative dysphagia or reflux. SGV division was associated with a longer duration of operation and a reduced postoperative lower oesophageal sphincter pressure. There was no statistically significant difference in length of hospital stay, postoperative complications, postoperative gas bloat syndrome or DeMeester score.

CONCLUSION

This meta-analysis has demonstrated that clinical outcome following laparoscopic Nissen fundoplication appears to be similar regardless of whether the short gastric vessels are divided. However, it is not possible to exclude many potentially important clinical differences and further studies are needed.

Novel approaches to in vitro transgenesis

The study of gene expression is a major focus in biological research and is recognised to be critical for our understanding of physiological and pathophysiological processes. Methods to study gene expression range from in vitro biochemical assays through cultured cells and tissue biopsies to whole organisms. In the early stages of project development, considerations about which model system to use should be addressed and may influence future experimental procedures. The aim of this review is to briefly describe advantages and disadvantages of the existing techniques available to study eukaryote gene expression in vitro, including the mechanism of transgene integration (transient or stable), the different transgenesis systems available, including plasmids, viruses and targeted integration and knockin approaches, and paying particular attention to expression systems such as bacterial artificial chromosomes and episomal vectors that offer a number of advantages and are increasing in popularity. We also discuss novel approaches that combine some of the above techniques, generating increasingly complex but physiologically accurate expression systems.

SF-36 summary and subscale scores are reliable outcomes of neuropsychiatric events in systemic lupus erythematosus

OBJECTIVE

To examine change in health-related quality of life in association with clinical outcomes of neuropsychiatric events in systemic lupus erythematosus (SLE).

METHODS

An international study evaluated newly diagnosed SLE patients for neuropsychiatric events attributed to SLE and non-SLE causes. The outcome of events was determined by a physician-completed seven-point scale and compared with patient-completed Short Form 36 (SF-36) health survey questionnaires. Statistical analysis used linear mixed-effects regression models with patient-specific random effects.

RESULTS

274 patients (92% female; 68% Caucasian), from a cohort of 1400, had one or more neuropsychiatric event in which the interval between assessments was 12.3 ± 2 months. The overall difference in change between visits in mental component summary (MCS) scores of the SF-36 was significant (p<0.0001) following adjustments for gender, ethnicity, centre and previous score. A consistent improvement in neuropsychiatric status (N=295) was associated with an increase in the mean (SD) adjusted MCS score of 3.66 (0.89) in SF-36 scores. Between paired visits when the neuropsychiatric status consistently deteriorated (N=30), the adjusted MCS score decreased by 4.00 (1.96). For the physical component summary scores the corresponding changes were +1.73 (0.71) and -0.62 (1.58) (p<0.05), respectively. Changes in SF-36 subscales were in the same direction (p<0.05; with the exception of role physical). Sensitivity analyses confirmed these findings. Adjustment for age, education, medications, SLE disease activity, organ damage, disease duration, attribution and characteristics of neuropsychiatric events did not substantially alter the results.

CONCLUSION

Changes in SF-36 summary and subscale scores, in particular those related to mental health, are strongly associated with the clinical outcome of neuropsychiatric events in SLE patients.

Nacre Evolution : A Proteomic Approach

From an evolutionary viewpoint, the molluscan nacre constitutes a fascinating object. This microstructure appeared early, in the Lower Cambrian period, about 530 million years ago, and since then, has been kept unchanged until today. Nacre is restricted to the conchiferan mollusks, where it occurs in t least three main classes, bivalves, gastropods and cephalopods. The aim of the present study is to investigate whether all nacres are built from the same “macromolecular tools”, proteins of the nacre matrix. To this end, we studied three new nacre models, the freshwater bivalve Unio pictorum, the cephalopod Nautilus macromphalus, and the gastropod Haliotis asinina, to which we applied a combined biochemical and proteomic characterization of their respective nacre matrices. The results of our approach, that can be defined as “shellomics” (proteomics applied to shell proteins) shed a new light on the macroevolution of nacre matrix proteins and on the in vitro design of nacre-like biomaterials.

Cost-effectiveness of CT perfusion for selecting patients for intravenous thrombolysis: a US hospital perspective

BACKGROUND AND PURPOSE

Improved selection of patients with stroke for IV tPA treatment may enhance clinical outcomes. Given the limited availability of MR imaging in hospitals, we examined the cost-effectiveness of adding CTP to the usual CT-based methods for selecting patients on the basis of the presence and extent of penumbra.

MATERIALS AND METHODS

A decision-analytic model estimated the costs and outcomes associated with penumbra-based CTP selection in a patient population similar to that enrolled in the IV tPA clinical trials. Model inputs were obtained from published literature, clinical trial data, standard US costing sources, and expert opinion. Cost per life-year saved and cost per QALY gained were estimated from a hospital perspective.

RESULTS

Addition of penumbra-based CTP to standard unenhanced CT improved favorable outcome (mRS, ≤1) by 0.59% and reduced cost by $42 compared with selection based on unenhanced CT alone. Life-years and QALYs improved. Multivariate sensitivity analysis predicted cost-effectiveness (≤$50,000 per QALY) in 89.2% of simulation runs.

CONCLUSIONS

Using penumbra-based CTP after routine CT to select patients with ischemic stroke for IV tPA is cost-effective compared with the usual CT-based methods for hospitals. With the ease of access of CTP, penumbra-based selection methods may be readily available to hospitals. Thus, this economic analysis may lend further support to the consideration of a paradigm shift in acute stroke evaluation.

Evidence for the role of oxidative stress in the acetylation of histone H3 by ethanol in rat hepatocytes

The relationship between ethanol-induced oxidative stress and acetylation of histone H3 at lysine 9 (H3AcK9) remains unknown and was therefore investigated in primary cultures of rat hepatocytes. Cells were treated with ethanol, and a select group of pharmacological agents and the status of H3AcK9 and reactive oxygen species (ROS) were monitored. Pretreatment of hepatocytes with N-acetyl cystein (ROS reducer), or dietary antioxidants (quercetin, reserveratrol), or NADPH (reduced nicotinamide adenine dinucleotide phosphate) oxidase inhibitor apocynin, significantly reduced ethanol (50 mM, 24 h) induced increases in ROS and H3AcK9. In contrast, l-buthionine sulfoximine (ROS inducer) and inhibitor of mitochondrial complexes I (rotenone) and III (antimycin) increased ethanol-induced H3AcK9 (P<.01). Oxidative stress also affected ethanol-induced alcohol dehydrogenase 1 mRNA expression. These results demonstrate for the first time that oxidative stress is involved in the ethanol-induced histone H3 acetylation in hepatocytes.

Effects of teacher attention on study behavior

The effects of contingent teacher attention on study behavior were investigated. Individual rates of study were recorded for one first-grade and five third-grade pupils who had high rates of disruptive or dawdling behavior. A reinforcement period (in which teacher attention followed study behavior and non-study behaviors were ignored) resulted in sharply increased study rates. A brief reversal of the contingency (attention occurred only after periods of non-study behavior) again produced low rates of study. Reinstatement of teacher attention as reinforcement for study once again markedly increased study behavior. Follow-up observations indicated that the higher study rates were maintained after the formal program terminated.

Survival of infants in the context of prevention of mother to child HIV transmission in South Africa

AIM

We sought to study the survival of newborn children according to HIV status of the mother, that of the child and the timing of infection.

METHODS

This is a prospective cohort study of 883 mothers (665 HIV-positive and 218 HIV-negative) and their infants. Data were collected using semi-structured questionnaires during home visits between the antenatal period and 36 weeks post-delivery. Infant HIV status was determined at 3, 24 and 36 weeks by HIV DNA PCR.

RESULTS

The majority (81.3%) of infected infants who died were infected by 3 weeks of age. Of the HIV-exposed infants who died, 19 (28.4%) died before 6 weeks and 38 (56.7%) died by 12 weeks. The hazard ratio (HR) of mortality at 36 weeks of age in HIV-infected infants compared with exposed but negative infants was 8.9 (95% CI: 6.7-11.8). There was no significant difference in 36 week survival rates between HIV-non-exposed and HIV-exposed but negative infants (HR: 0.7; 95% CI: 0.3-1.5). The infant being HIV-positive at age 3 weeks (HR: 32 95% CI: 14.0-73.1) and rural site (HR: 4.4 95% CI: 1.2-23.4) were the two independent risk factors for infant death amongst HIV-exposed infants.

CONCLUSION

The prognosis for infants with early HIV infection was very poor in this cohort. A greater focus on prevention of early infection, earlier screening for HIV infection and access to antiretrovirals for eligible infants is recommended.

Developing a methodology for assigning glycaemic index values to foods consumed across Europe

There is growing evidence that the glycaemic index (GI) of the diet is important with respect to body weight and metabolic disease risk. However, research is limited by the paucity of GI values for commonly consumed carbohydrate-rich foods in European countries. A new methodology has been developed for consistent assignment of GI values to foods across five European databases used in the Diogenes intervention study. GI values were assigned according to five decreasing levels of confidence (1) Measured values for specific foods; (2) Published values from published sources; (3) Equivalent values where published values for similar foods existed; (4) Estimated values assigned as one of three values representing low/medium/high GI ranges and (5) Nominal values assigned as 70, where no other value could be assigned with sufficient confidence. GI values were assigned to 5105 foods. In food records collected at baseline, the contribution to carbohydrate intake of foods assigned levels 1-2 ranged from 16% to 43% depending on country, and this increased to 53-81% including level 3 foods. The degree of confidence to assigned GI values differed across Europe. This standardized approach of assigning GI values will be made available to other researchers to facilitate further investigation into the effects of dietary GI on health.

Concomitant mutations and splice variants in KRAS and BRAF demonstrate complex perturbation of the Ras/Raf signalling pathway in advanced colorectal cancer

BACKGROUND AND AIMS

KRAS and BRAF mutations occur in colorectal cancers (CRCs) and are considered mutually exclusive methods of activating the RAS/RAF/MEK/ERK pathway. This pathway is a therapeutic target and KRAS mutation may predict tumour responsiveness. The purpose of this study was to investigate the relationship between KRAS and BRAF mutations in 24 CRC cell lines and 29 advanced CRCs.

METHODS

KRAS and BRAF mutations were detected using high resolution melting and sequencing. Expression of mutations was confirmed by reverse transcription- PCR (RT-PCR) and sequencing. CpG island methylator phenotype (CIMP) was tested by methylation-specific PCR.

RESULTS

KRAS or BRAF mutation occurred in 79% of cell lines and 59% of CRCs. In the cell lines, KRAS mutations occurred in 54% of cases (with 62% in codons 12/13 and 38% in other codons). Four cell lines had a homozygous mutation. Only heterozygous BRAF mutations were detected in 29% cell lines. The V600E mutation occurred most commonly and was associated with CIMP+ status (p = 0.005). Mutations at codons 529 and 581 were also found and, in one case, BRAF and KRAS mutation co-occurred. Unexpectedly, BRAF splice variants (with a predicted kinase-dead protein) were found in 5/24 (21%) cell lines. In advanced CRCs, KRAS mutations occurred in 48% of cases (64% codons 12/13, 36% other codons) and BRAF mutations in 10% (66% V600E, 33% exon 11). A compound KRAS/BRAF mutation was not seen.

CONCLUSIONS

Disrupted Ras/Raf signalling is common in CRC. Homozygous KRAS mutations and concomitant KRAS/BRAF mutations may be indicative of a gene dosage effect. The significance of BRAF splice variants is uncertain but may represent another layer of complexity. Finally, if KRAS mutation is to be used for predictive testing, then the whole gene may need to be screened as mutations occur outside codons 12/13.

HER2 FISH ratio cut-points and pathologic complete response (pCR), residual tumor (RT), HER2 status, and survival prediction in HER2-positive breast cancer (BC)

e22033

Background: We demonstrated that pCR is correlated with increasing HER2-FISH ratio, while disease-free survival (DFS) with pCR and ER-positivity in HER2-positive breast cancer treated with trastuzumab (SABCS 2008). It is known that quantitative HER2-FISH ratio correlates with ER levels and HER2-positivity imparts a higher grade in ER-positive BC. Collectively, we hypothesized that combined ER (≥10) and a HER2 ratio cut-point may subdivide HER2-positive BC into pCR predictive subtypes.Methods: Of the 80 HER2-positive (IHC3+/FISH+) BC, quantitative HER2 FISH ratio (widely spread over 1–18.3) and ER correlation was noted (r=0.34, p=0.002). Moreover, HER2 ratio (>4) correlated with higher Ki-67 (r= 0.5, p=0.01) and grade (p trend=0.05) in ER-positive subtype, inferring a biologic cut-point. Results: Of patients with stage I-IV BC treated neoadjuvantly (92% trastuzumab-based), pCR was 0% (0/13) in ER-positive-low-HER2 compared to 77% (10/13, p=0.0001), 75% (24/32, p<0.0001) and 37.5% (3/8, p=0.043) in ER-positive-high-HER2, ER-negative-high-HER2 and ER-negative-low-HER2, respectively. DFS was 100, 90, 80% and 60% (logrank-trend p<0.05) in these 4 subtypes (excluding stage IV), respectively, at a median follow-up of 38 months (range 6–72). In ER-negative subtypes, DFS was 97% and 29% (logrank p=0.0001) in patients with or without pCR; of the six with RT, 0% DFS was noted in four with HER2-negative/HER2-reduced (HER2-R) RT, compared to 100% in the two with unchanged HER2 (p=<0.05, logrank test). In ER-positive subtypes, DFS is 95% overall, and 100% in patients with RT; 7 of 10 tested RT were HER2- R. Conclusions: pCR is crucial and high in ER-negative-high-HER2 and is crucial (but low) in ER-negative-low-HER2-positive BC for improved outcome. Improved DFS is associated with high pCR in ER-positive-high-HER2 BC, but is independent of the low pCR in ER-positive-low-HER2-subtype. Thus, combined HER2 and ER offer improved prediction. In hypothesis generating analysis, HER2-R may underlie relapse in ER-negative subtypes (HER2-basal-transitional-residual), while it may be beneficial in ER-positive subtypes (luminal-B- A-transitional) by reducing HER2-pathway mediated endocrine resistance.

[Table: see text]

The putative tumour modifier gene ATP5A1 is not mutated in human colorectal cancer cell lines but expression levels correlate with TP53 mutations and chromosomal instability

BACKGROUND

Both the putative modifier gene ATP5a1 and the tumour suppressor gene TP53 are involved in the regulation of apoptosis and may be involved in the development of colorectal cancers.

AIMS

To investigate the relationship between these genes in 16 colorectal cancer cell lines.

METHODS

Each gene was screened for mutation using high resolution melting analysis and sequencing. Expression of ATP5a1 mRNA was tested by quantitative PCR.

RESULTS

Sequence changes in ATP5a1 were found in 9/16 (56%) cell lines and consisted of mainly novel single nucleotide polymorphisms (SNPs) found in the 5' UTR, introns 4/5/9 and exon 7. TP53 mutations were also found in 9/16 (56%) cell lines; these were consistent with previous reports. High levels of ATP5a1 expression were seen in cell lines with TP53 mutation compared with those with wild type TP53 (p = 0.02). Furthermore, an A-->G change at the -18 position in intron 4 of ATP5a1 was significantly associated with increased gene expression (p = 0.0391). Comparison with genotype showed that cell lines with chromosomal instability (CIN) had significantly higher levels of ATP5a1 expression than those with microsatellite instability (MSI) (p = 0.02).

CONCLUSION

Higher levels of ATP5a1 expression are associated with certain SNPs and with TP53 mutation. High expression also occurs in CIN and may facilitate tumour development along this pathway. Conversely, low levels of ATP5a1 expression may facilitate development of tumours with MSI.

Stapled haemorrhoidopexy compared to Milligan-Morgan and Ferguson haemorrhoidectomy: a systematic review

PURPOSE

The aim of this study was to perform a systematic review and meta-analysis of the short- and long-term outcomes of stapled haemorrhoidopexy.

METHODS

A literature search identified randomised controlled trials comparing stapled haemorrhoidopexy with Milligan-Morgan/Ferguson haemorrhoidectomy. Data were extracted independently for each study and differences analysed with fixed and random effects models.

RESULTS

Thirty-four randomised trials and two systematic reviews were identified, and 29 trials included. Stapled haemorrhoidopexy was statistically superior for hospital stay (p < 0.001) and numerically superior for post-operative pain (peri-operative and mid-term), operation time and bleeding (post-operative and long-term). Recurrent prolapse and re-intervention for recurrence were more frequent following stapled haemorrhoidopexy. No difference was observed in the rates of complications.

CONCLUSIONS

Stapled haemorrhoidopexy reduces the length of hospital stay and may have an advantage in terms of decreased operating time, reduced post-operative pain and less bleeding but is associated with an increased rate of recurrent prolapse.

Addressing shortfalls in TIA care in the UK: an economic perspective

OBJECTIVE

To estimate the clinical outcomes and costs associated with reconfiguring the management of TIA in the UK to offer patients rapid access to outpatient clinics for specialist assessment and treatment.

METHODS

An economic deterministic model was run comparing two pathways--one arm representing current clinical care based on national guidelines and clinical practice and patient referral to a weekly outpatient clinic, and a revised care pathway replicating phase 2 of the EXPRESS study with patient referral to a daily outpatient clinic. The outcomes of the model were measured in terms of recurrent strokes avoided and net budget impact to secondary care.

RESULTS

Reconfiguring TIA care pathways in the UK could result in the avoidance of 8,164 recurrent stroke events. The model predicts savings of £25,573,279 for the UK healthcare system over 12 months. Annual net savings are predicted in England (£24,916,011), Scotland (£80,554) and Northern Ireland (£1,041,817). In Wales, increased costs of £450,435 are estimated.

LIMITATIONS

Using the data published from the EXPRESS study, it is not possible to model a stepwise approach to implementing the revised TIA care pathway. It is therefore assumed that it would be possible to implement the revised TIA care pathway as detailed in the EXPRESS study across the UK and achieve the reduction in recurrent stroke risk that was reported.

CONCLUSIONS

The model suggests that the reconfiguration of TIA care pathways in the UK to offer rapid access to treatment and assessment could prevent TIA-related future stroke events and potentially result in cost savings to the healthcare system.

Thermal signatures of the Kondo volume collapse in cerium

X-ray diffraction measurements of cerium in the vicinity of the isostructural gamma-alpha transition have been performed with high precision and accuracy from room temperature to almost 800 K. The disputed location of the critical point has been found to occur at 1.5+/-0.1 GPa and 480+/-10 K. The data are well fit by the Kondo volume collapse model plus a quasiharmonic representation of the phonons. The resultant free energy is validated against data for the thermodynamic Grüneisen parameter and, beyond the dominant spin-fluctuation contribution, indicates a dramatic change in the lattice Grüneisen parameter across the transition.

Intratumoural lymphatics in benign and malignant soft tissue tumours

Soft tissue sarcomas do not generally metastasise via lymphatics, and the presence or absence of lymphatic vessels within sarcomas and benign soft tissue tumours is not known. In this study, we determined whether lymphatic vessels were present in a wide range of benign and malignant soft tissue lesions by examining intratumoural expression of the lymphatic endothelial cell markers, Lyve-1 and podoplanin. Intratumoural Lyve-1+/podoplanin+ lymphatics were not identified in sarcomas apart from all cases of epithelioid sarcoma (a tumour which is known to metastasise to lymph nodes) and a few cases of leiomyosarcoma, rhabdomyosarcoma and synovial sarcoma. Intratumoural lymphatics were also absent in most benign soft tissue tumours. Reparative and inflammatory soft tissue lesions contained lymphatics, as did all (pseudosarcomatous) proliferative myofibroblastic lesions including nodular, proliferative and ischaemic fasciitis, elastofibroma, nuchal fibroma and deep fibromatosis. Our results show that most soft tissue sarcomas do not contain intratumoural lymphatics, a finding which is consistent with the infrequent finding of sarcoma metastasis to lymph nodes. In contrast to fibrosarcoma and a number of other malignant spindle cell tumours, proliferative fibroblastic/myofibroblastic lesions of soft tissue contain intralesional lymphatic vessels.

Elderly patients with stage III or IV ovarian cancer: should they receive standard care?

Due to the higher risk of morbidity and perioperative mortality compared to younger patients, elderly patients with advanced ovarian cancer are challenging to treat. A population-based analysis was performed to predict treatment outcomes and establish risk factors for early death of elderly patients with advanced ovarian cancer using a cohort of 3994 women diagnosed with stage III or IV ovarian cancer between 1992 and 1999, registered with the Surveillance, Epidemiology and End Results Cancer Registries. A multivariate accelerated failure time model allowed estimation of a risk factor model for overall survival. Patient's age, stage at presentation, presence of comorbidities, and oncology treatment facility were independently associated with overall survival at 12 months from diagnosis. Patients were assigned to low (0–7 points), moderate (8–14 points) or high (≥15 points) risk groups according to accumulation of risk factors, which showed good ability to predict 12-month mortality (receiver–operator characteristics curve [ROC] derivation cohort = 0.763; ROC validation cohort = 0.756). Across all three risk groups, patients who received both surgery and chemotherapy showed significantly improved survival as compared to patients who received only surgery or chemotherapy. For patients 80 years and over who had upfront surgery, perioperative mortality was significantly greater in the high-risk group (21%; 95% CI = 16–26%) compared to patients within the moderate (8%; 95% CI = 5–12%) and low-risk groups (0%; 95% CI = 0–11%). The risk factor profile established could be helpful to plan future clinical trials to establish optimal treatment for elderly patients with advanced stage ovarian cancer

Closed gastroschisis: total parenteral nutrition-free survival with aggressive attempts at bowel preservation and intestinal adaptation

BACKGROUND

In infants with gastroschisis antenatal closure of the umbilical defect results in a proximal atresia with ischemia and/or volvulus of the extracorporeal midgut. It has been described as "closed gastroschisis" or "vanishing midgut."

METHODS

A 10-year review of 219 gastroschisis patients identified 10 infants with this rare complication.

RESULTS

In these 10 infants, the extracorporeal midgut was invariably matted and fibrosed. In 3 cases, the midgut had completely "vanished." In the remaining 7 cases, the remnant midgut was surgically reduced into the abdominal cavity with care not to compromise the diminutive vascular pedicle. Abdominal exploration was performed several weeks later to reestablish bowel continuity; 4 required an ostomy and 2 underwent a serial transverse enteroplasty. Mean residual length of salvaged small bowel was 79 cm with retention of the distal half of the colon. Eight infants survived the initial hospitalization, with a mean length of stay of 121 days and mean hospital charge of $287,094. Six of the 7 long-term survivors have been completely weaned off total parenteral nutrition.

CONCLUSION

A nihilistic attitude toward infants with closed gastroschisis may not be uniformly supported because in the majority of these infants' long-term independence from total parenteral nutrition was achieved.

Waterpipe smoking in students: prevalence, risk factors, symptoms of addiction, and smoke intake. Evidence from one British university

BACKGROUND

Anecdotal reports suggest waterpipe smoking is becoming common in students in western countries. The aim was to examine prevalence, risk factors, symptoms of addiction, and smoke intake.

METHODS

This was a cross-sectional survey of students with subsidiary survey of regular waterpipe user and survey of exhaled carbon monoxide (CO) before and after waterpipe smoking in customers of a waterpipe café. 937 students of Birmingham University completed the initial survey with a follow up of 21 regular waterpipe smokers. 63 customers of a waterpipe café near the University completed the study of CO intake.

RESULTS

355 (37.9%, 95% confidence intervals (CI) 34.8 to 41.1%) students had tried waterpipes, the prevalence of trying rising with duration at University. 75 (8.0%, 95%CI 6.4 to 10.0%) were regular smokers, similar to the prevalence of cigarette smoking (9.4%). Although cigarette smoking was the major risk factor for being a regular waterpipe smoker, odds ratio (95%CI) 2.77 (1.52 to 5.06), 65% of waterpipe smokers did not smoke cigarettes. Seven of 21 (33.3%) regular waterpipe smokers experienced cravings. Nearly all regular waterpipe users thought it less harmful than smoking cigarettes. The mean (standard deviation) rise in CO was 37.4 (25.8)ppm, nearly twice as high as a typical cigarette smoker seeking cessation treatment.

CONCLUSION

Waterpipe smoking is a common part of student culture in one British university, as in the Middle East and in the United States. It poses a potential threat to public health, with evidence of dependence and high smoke intake.

Hypnotizability, Absorption and Negative Cognitions as Predictors of Dental Anxiety

BACKGROUND

The authors conducted two pilot studies that investigated the roles of hypnotizability, absorption (defined as the ability to maintain focused attention on a task or stimulus) and state versus trait anxiety as predictors of dental anxiety. One of the studies also examined the effectiveness of hypnosis in managing dental anxiety.

METHODS

Participants in study 1 completed measures of hypnotizability and anxiety, viewed a video of a dental procedure either under hypnosis or not, and completed dental anxiety questionnaires. Participants in study 2 were told either that the video showed major dental work or a routine polishing. All subjects watched the video and then completed measures assessing their perceptions of the video and their anxiety.

RESULTS

The authors found a positive relationship between hypnotizability and scores on the Dental Anxiety Scale (DAS) (F(1,290) = 3.45, P = .06), as well as an interaction between hypnotizability and hypnosis (F(1,290) = 6.55, P = .01). An analysis of covariance found a relationship between trait and dental anxiety (F(1,290) = 11.50; P = .001). A two-way analysis of variance found a main effect for hypnosis (F(1,290) = 3.20, P = .07). The authors found an effect for group on the DAS (F(1,228) = 3.67, P = .057), such that subjects in the negative-cognition group scored higher on the DAS. The authors found an interaction between absorption and cognition in perceptions of pain experienced by the patient in the video (F(1,228) = 3.70, P = .05) and in ratings of one's own pain level if in the same situation (F(1,228) = 4.38, P < .05).

CONCLUSIONS

Hypnotizability or absorption, pre-existing anxiety and cognitions about dental procedures predict dental anxiety, and hypnosis may be helpful for some, but not all, patients.

CLINICAL IMPLICATIONS

Characteristics such as hypnotizability, trait anxiety and negative cognitions predict which people develop dental anxiety and who will be more responsive to hypnosis. The authors provide suggestions for dentists treating anxious patients.

Assessing the environmental risk from hot particles in the vicinity of Dounreay--a case for inaction?

This study assesses the impact on species other than humans associated with radioactive particles present in the marine environment close to the UKAEA Dounreay site, through a review of marine survey data, to establish the distribution of species and the likelihood of encountering a particle, and considering retention, dissolution or absorption of the particle. Assumptions are made regarding particle density, distribution, size and bio-availability of the radioactive materials. From this, impacts are assessed against the likelihood of mortality or other significant harm to individuals and interpreted in terms of local populations. Results obtained indicate that no significant impact, at the population level, is likely to be observed. This does not preclude that some individuals will be affected. It does, however, suggest that any decision to remediate, if based predominantly on environmental considerations, should be cognisant of the damage caused by remediation itself and subsequent exploitation of the environment by humans.