Health-seeking behaviour in Pakistan: a narrative review of the existing literature

INTRODUCTION

This narrative review was carried out to collate the work of researchers on health-seeking behaviour in Pakistan, to discuss the methods used, highlight the emerging themes and identify areas that have yet to be studied.

STUDY DESIGN

Review.

METHODS

An overview of studies on health-seeking behaviour in Pakistan, found via searches on scholarly databases intended to locate material of medical and anthropological relevance.

RESULTS

In total, 29 articles were reviewed with a range of different methodologies. A retrospective approach was the most common. A variety of medical conditions have been studied in terms of health-seeking behaviour of people experiencing such conditions. However, a wide range of chronic illnesses have yet to be studied. Nevertheless, some studies highlighting unusual issues such as snake bites and health-seeking behaviour of street children were also found. In terms of geographical area, the majority of studies reviewed were performed in the provinces of Sind and Punjab, with little research targeting the people from the two other provinces (Balochistan and Khyber Pakhtunkhwa) of Pakistan. Predominant utilization of private healthcare facilities, self-medication, involvement of traditional healers in the healthcare system, women's autonomy, and superstitions and fallacies associated with health-seeking behaviour were found to be the themes that repeatedly emerged in the literature reviewed.

CONCLUSIONS

The sociocultural and religious background of Pakistan means that health-seeking behaviour resembles a mosaic. There is a need to improve the quality of service provided by the public healthcare sector and the recruitment of female staff. Traditional healers should be trained and integrated into the mainstream to provide adequate healthcare. Serious efforts are required to increase the awareness and educational level of the public, especially women in rural areas, in order to fight against myths and superstitions associated with health-seeking behaviour.

First-line treatment of advanced ovarian cancer with paclitaxel/carboplatin with or without epirubicin (TEC versus TC)--a gynecologic cancer intergroup study of the NSGO, EORTC GCG and NCIC CTG

BACKGROUND

The addition of anthracyclines to platinum-based chemotherapy may provide benefit in survival in ovarian cancer patients. We evaluated the effect on survival of adding epirubicin to standard carboplatin and paclitaxel.

PATIENTS AND METHODS

We carried out a prospectively randomized phase III study comparing carboplatin plus paclitaxel (TC; area under the curve 5 and 175 mg/m(2)) with the same combination and epirubicin (TEC; 75 mg/m(2) i.v.). Between March 1999 and August 2001, 887 patients with epithelial ovarian, tubal or peritoneal cancer International Federation of Gynecology and Obstetrics stages IIB-IV were randomized to receive either TC (442 patients) or TEC (445 patients).

RESULTS

Median time to progression was 16.4 months in the TEC arm and 16.0 months in the TC arm (hazard ratio 0.99; 95% confidence interval [CI]: 0.9-1.2). Median overall survival time was 42.4 months for the TEC arm and 40.2 for the TC arm (hazard ratio 0.96; 95% CI: 0.8-1.1). Grade 3/4 hematologic toxic effects and most grade 3/4 non-hematologic toxic effects were more frequent in the TEC arm. Accordingly, a quality-of-life analysis showed inferiority of TEC versus TC.

CONCLUSION

The addition of epirubicin to standard carboplatin and paclitaxel treatment did not improve survival in patients with advanced ovarian, tubal or peritoneal cancer.

Soft-x-ray harmonic comb from relativistic electron spikes

We demonstrate a new high-order harmonic generation mechanism reaching the "water window" spectral region in experiments with multiterawatt femtosecond lasers irradiating gas jets. A few hundred harmonic orders are resolved, giving μJ/sr pulses. Harmonics are collectively emitted by an oscillating electron spike formed at the joint of the boundaries of a cavity and bow wave created by a relativistically self-focusing laser in underdense plasma. The spike sharpness and stability are explained by catastrophe theory. The mechanism is corroborated by particle-in-cell simulations.

HIV encephalitis despite suppressed viraemia: a case of compartmentalized viral escape

There is increasing concern that HIV treatment failure may result from inadequate central nervous system (CNS) penetration of antiretroviral drugs, allowing compartmentalized viral replication and development of resistance. We discuss a patient who maintained a suppressed plasma viral load for four years on antiretroviral therapy (ART) before developing HIV encephalitis with a cerebrospinal fluid (CSF) HIV viral load of 861 copies/mL and newly detectable plasma viral load of 68 copies/mL. Identification of major resistance mutations to his combination therapy supported concerns that resistant HIV had developed within the CNS. His ART was changed to optimize CNS penetration, leading to maintained clinical improvement. Imaging presented demonstrates corresponding radiological improvement. The report illustrates the need to exclude CNS viral rebound or incomplete suppression in HIV patients with neurological symptoms, and suggests that the extent of this emerging problem is only beginning to be recognized as the implications of long-term peripheral HIV suppression unfold.

Scald risk in social housing can be reduced through thermostatic control system without increasing Legionella risk: a cluster randomised trial

OBJECTIVE

To quantify the effects of a thermostatic control system in social (public) housing on the prevalence of dangerous (>60°C) water temperatures and on fuel consumption.

DESIGN

Pair-matched double-blind cluster randomised controlled trial.

SETTING

Social housing in a deprived inner-London borough.

PARTICIPANTS

150 households recruited as clusters from 22 social housing estates. Four small estates were combined into two clusters (resulting in a total of 10 pairs of clusters).

INTERVENTION

Social housing estate boiler houses were randomised to a thermostatic control sterilisation programme (heating water to 65°C during 00:00-06:00 h and to 50°C from 06:00 to 00:00 h daily) or to standard control (constant temperature 65°C).

MAIN OUTCOME MEASURES

Water temperature over 60°C ('dangerous') after running taps for 1 min and daily fuel consumption (cubic feet of gas).

RESULTS

10 clusters (80 households) were allocated to the sterilisation programme and 10 clusters (70 households) to control, of which 73 and 67 households, respectively, were analysed. Prevalence of dangerous (>60°C) hot water temperatures at 1 min was significantly reduced with the sterilisation programme (mean of cluster prevalence 1% in sterilisation programme group vs 34% in control group; absolute difference 33%, 95% CI 12% to 54%; p=0.006). Prevalence of high (>55°C) hot water temperatures at 1 min was significantly reduced (31% sterilisation vs 59% control; absolute difference 28%, 95% CI 9% to 47%; p=0.009). Gas consumption per day reduced more in the control group than in the sterilisation programme group, although not statistically significantly (p=0.125).

CONCLUSIONS

The thermostatic control with daily sterilisation was effective in capping hot water temperatures and therefore reduced scald risk. Although expected to save energy, fuel consumption was increased relative to the control group. Trial registration ClinicalTrials.gov ID: NCT00874692.

Reproductive factors and risk of oesophageal and gastric cancer in the Million Women Study cohort

Background:

Hormonal factors may influence risk for upper gastrointestinal cancers in women. We examined risk of oesophageal and gastric cancers in relation to reproductive factors in a large UK cohort, the Million Women Study.

Methods:

Among 1 319 409 women aged on average 56 years at recruitment, 1186 incident cancers of the oesophagus and 1194 of the stomach were registered during 11.9 million person-years’ observation. Adjusted relative risks (RRs) and 95% confidence intervals (CIs) were estimated using Cox proportional hazards models.

Results:

Risks of both oesophageal and gastric cancer were significantly higher in postmenopausal than in pre- or peri-menopausal women (RRs 1.46, 1.07–2.00 and 1.59, 1.15–2.20, respectively; P⩽0.01 for both); and, among postmenopausal women, risk was higher the younger women were at menopause (RR, 95% CI per 5 years younger at menopause 1.18, 1.05–1.34 for oesophageal cancer and 1.18, 1.04–1.34 for stomach cancer, P_trend=0.01 for both). For factors relating to childbearing, including women's age at first birth, their number of children, and breastfeeding history, the only significant association was a higher risk of oesophageal cancer in nulliparous, compared with parous, women (RR 1.31, 1.11–1.55; P=0.002). When risks for squamous cell and adenocarcinomas of the oesophagus were compared, most did not differ significantly, but statistical power was limited.

Conclusion:

Both oesophageal and gastric cancer risks appeared to be related to menopausal status and age at menopause, but there was little consistent evidence for associations with factors related to childbearing.

Fusobacterium nucleatum prosthetic hip infection in an adult with sickle cell-beta thalassemia

Fusobacterium nucleatum is an anaerobic Gram-negative bacillus commensal to the human oropharynx and gastrointestinal tract which causes an array of human infection, yet it has never been associated with infection of prosthetic joints. We report the first case of prosthetic hip infection caused by F. nucleatum in a man with sickle cell-beta thalassemia.

Development and validation of an instrument to measure the impact of genetic testing on self-concept in Lynch syndrome

A positive genetic test result may impact on a person's self-concept and affect quality of life. The purpose of the study was to develop a self-concept scale to measure such impact for individuals carrying mutations for a heritable colorectal cancer Lynch syndrome (LS). Two distinct phases were involved: Phase 1 generated specific colorectal self-concept candidate scale items from interviews with eight LS carriers and five genetic counselors, which were added to a previously developed self-concept scale for BRCA1/2 mutation carriers, Phase II had 115 LS carriers complete the candidate scale and a battery of validating measures. A 20-item scale was developed with two dimensions identified through factor analysis: stigma/vulnerability and bowel symptom-related anxiety. The scale showed excellent reliability (Cronbach's α = 0.93), good convergent validity by a high correlation with impact of event scale (r(102) = 0.55, p < 0.001) and Rosenberg self-esteem scale (r(108) = -0.59, p < 0.001), and a low correlation with the Fear questionnaire (r(108) = 0.37, p < 0.001). The scale's performance was stable across participant characteristics. This new scale for measuring self-concept has potential to be used as a clinical tool and as a measure for future studies.

The contemporary management of midface and craniofacial trauma

The successful management of midface and craniofacial trauma requires a thorough understanding of the anatomy and functional demands of this complex region. To achieve optimal outcomes, it is necessary that these injuries are accurately diagnosed and managed in a multi-disciplinary environment at the appropriate time. This review article discusses an overview of these injuries and highlights some of the key principles of management.

European guideline for the management of genital herpes, 2010

This is the guideline for genital herpes simplex virus (HSV) management for the IUSTI/WHO Europe, 2010. They describe the epidemiology, diagnosis, clinical features, treatment and prevention of genital HSV infection. They include details on the management of HSV in pregnancy, those who are immunocompromised and the clinical investigation and management of suspected HSV-resistant disease.

Smoking in pregnancy and disruptive behaviour in 3-year-old boys and girls: an analysis of the UK Millennium Cohort Study

BACKGROUND

Maternal smoking during pregnancy has been consistently associated with disruptive behaviour in male offspring; however, results for girls are inconsistent and little is known about emergent patterns in young children. Additionally, it is unclear whether maternal smoking is independently associated in offspring with hyperactivity-inattention or only when it co-occurs with conduct problems. Further, few studies have controlled for a broad range of maternal psychosocial problems.

METHODS

Associations between self-reported smoking in pregnancy and maternal reports of externalising behaviour were analysed in more than 13 000 3-year-old boys and girls in the UK Millennium Cohort Study. Conduct and hyperactivity-inattention problems were assessed using the Strength and Difficulties Questionnaire.

RESULTS

Boys whose mothers persistently smoked throughout pregnancy were at significant risk of conduct and hyperactivity-inattention problems compared with sons of non-smokers: the effect was stronger for heavy smokers. After excluding children with co-occurring problems, conduct-only problems remained a significant risk for sons of heavy smokers, OR 1.92 (95% CI 1.29 to 2.86); and hyperactivity-inattention only for sons of light or heavy smokers, OR 1.79 (95% CI 1.27 to 2.51) and 1.64 (1.10 to 2.46). Daughters of light or heavy smokers were at significant risk of conduct-only problems, OR 1.73 (95% CI 1.14 to 2.61) and 1.73 (1.06 to 2.83). Relative to non-smokers, daughters of pregnancy quitters had significantly reduced odds of having conduct 0.61(0.39 to 0.97) or co-occurring problems 0.26(0.08 to 0.82), although only 79 and 20 girls met these criteria, respectively. All findings were robust to controlling for key social and psychosocial factors.

CONCLUSIONS

Associations between maternal smoking during pregnancy and disruptive behaviour in 3-year-old children vary by sex, smoking status and whether or not conduct or hyperactivity problems occur together or separately.

Fluid intake and incidence of renal cell carcinoma in UK women

Background:

It has been suggested that the apparent protective effect of alcohol intake on renal cell carcinoma may be due to the diluting effect of carcinogens by a high total fluid intake. We assessed the association between intakes of total fluids and of specific beverages on the risk of renal cell carcinoma in a large prospective cohort of UK women.

Methods:

Information on beverage consumption was obtained from a questionnaire sent ∼3 years after recruitment into the Million Women Study. Cox proportional hazards models were used to estimate relative risks (RRs) and 95% confidence intervals (CIs) for renal cell carcinoma associated with beverage consumption adjusted for age, region of residence, socioeconomic status, smoking, and body mass index.

Results:

After an average of 5.2 years of follow-up, 588 cases of renal cell carcinoma were identified among 779 369 women. While alcohol intake was associated with a reduced risk of renal cell carcinoma (RR for ⩾2 vs <1 drink per day: 0.76; 95% CI: 0.61–0.96; P for trend=0.02), there was no association with total fluid intake (RR for ⩾12 vs <7 drinks per day: 1.15; 95% CI: 0.91–1.45; P for trend=0.3) or with intakes of specific beverages.

Conclusions:

The apparent protective effect of alcohol on the risk of renal cell carcinoma is unlikely to be related to a high fluid intake.

Pemetrexed for the maintenance treatment of locally advanced or metastatic non-small cell lung cancer

This paper presents a summary of the evidence review group (ERG) report into the clinical effectiveness and cost-effectiveness of pemetrexed for the maintenance treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC), in accordance with the licensed indication, based upon the evidence submission from the manufacturer (Eli Lilly) to the National Institute for Health and Clinical Excellence (NICE) as part of the single technology appraisal (STA) process. The primary clinical outcome measure was progression free survival (PFS). Secondary outcomes included overall survival (OS), time to worsening of symptoms, objective tumour response rate, adverse events and changes in lung cancer symptom scale. Data for two populations were presented: patients with non-squamous NSCLC histology and patients with adenocarcinoma histology. The clinical evidence was derived from a double-blind, placebo-controlled randomised controlled trial (RCT), the JMEN trial. The trial compared the use of pemetrexed + best supportive care (BSC ) as maintenance therapy, with placebo + BSC in patients with NSCLC (n = 663) who had received four cycles of platinum-based chemotherapy (CTX) and whose disease had not progressed. In the licensed population (patients with non-squamous histology), the trial demonstrated greater median PFS for patients treated with pemetrexed than for patients in the placebo arm [4.5 vs 2.6 months; hazard ratio (HR) 0.44; 95% confidence interval (CI) 0.36 to 0.55, p < 0.00001]. Median OS was also greater for the pemetrexed- treated patients (15.5 vs 10.3 months; HR 0.70; 95% CI 0.56 to 0.88, p = 0.002). In addition, tumour response and disease control rates were statistically significantly greater for patients who received pemetrexed. Patient survival rates at 1 year and 2 years were higher in the pemetrexed arm. The incremental cost-effectiveness ratios (ICERs) estimated by the manufacturer's model were 33,732 pounds per quality adjusted life-year (QALY) for the licensed nonsquamous population, and 39,364 pounds per QALY for the adenocarcinoma subgroup. Both of these ICERs were above the standard NICE willingness-to-pay range (20,000 pounds-30,000 pounds per QALY). The manufacturer also presented a case for pemetrexed to be considered as an end of life treatment. The ERG identified a number of problems in the economic model presented by the manufacturer; after correction, the base case ICER was re-estimated as 51,192 pounds per QALY gained and likely to exceed NICE's willingness-to-pay thresholds. Following a revised economic analysis submitted by the manufacturer, the AC accepted that an ICER of 47,000 pounds per QALY gained was most plausible. The AC also considered that maintenance treatment with pemetrexed fulfilled the end of life criteria.The guidance issued by NICE, on 20 June 20 2010, in TA190 as a result of the STA states that: People who have received pemetrexed in combination with cisplatin as first-line chemotherapy cannot receive pemetrexed maintenance treatment. 1.1 Pemetrexed is recommended as an option for the maintenance treatment of people with locally advanced or metastatic non-small-cell lung cancer other than predominantly squamous cell histology if disease has not progressed immediately following platinum-based chemotherapy in combination with gemcitabine, paclitaxel or docetaxel.

Calcitriol counteracts endothelial cell pro-inflammatory processes in a chronic kidney disease-like environment

In advanced chronic kidney disease (CKD), hypocalcemia, high levels of advanced glycation end products (AGEs), and parathyroid hormone (PTH) coexist and are considered to play a role in the development of chronic vasculopathies. The aim of the present study was to evaluate the impact of a CKD-like environment on cultured endothelial cell (EC) functions and to assess the impact of calcitriol on the expression of parameters such as endothelial nitric oxide synthase (eNOS), receptor of AGEs (RAGE), interleukin 6 (IL-6) and nuclear factor kappa B (NFκB). Human umbilical vein cord endothelial cells (HUVEC) were grown in medium containing low Ca(2+) concentration stimulated with AGE-HSA and PTH and treated with calcitriol for additional incubation. mRNA expression was established by reverse transcriptase-PCR, protein expression by Western blot analysis, IL-6 secretion by ELISA, NOS activity by conversion of [(14)C]arginine to [(14)C]citrulline and DNA-binding activity of NFκB-p65 assayed colorimetrically in nuclear extracts. The CKD-like environment characterized by the association of low Ca(2+) and high levels of AGEs and PTH, depressed eNOS system activity and enhanced RAGE and IL-6 expression/secretion. DNA-binding activity of nuclear NFκB-p65 was increased and the expression of IκBα decreased. Addition of calcitriol normalized the expression, secretion and activity of eNOS, RAGE and IL-6. The enhanced NFκB activity was also counteracted probably due to the increased IκBα expression. The effect of CKD-like environment on EC may partly explain the increased vasculopathies in CKD patients, in contrast to calcitriol, which suggests a vascular protective action.

Pemetrexed for the first-line treatment of locally advanced or metastatic non-small cell lung cancer

This paper presents a summary of the evidence review group (ERG) report into the clinical effectiveness and cost-effectiveness of pemetrexed for the first-line treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC), in accordance with the licensed indication, based upon the evidence submission from Eli Lilly Ltd to the National Institute for Health and Clinical Excellence (NICE) as part of the single technology appraisal process. The majority of the efficacy evidence described in the manufacturer's submission is derived from a phase III open-label randomised controlled trial (RCT) known as the JMDB trial. The trial achieved its primary objective to demonstrate non-inferiority of pemetrexed/cisplatin to gemcitabine/cisplatin for overall survival in all patients with NSCLC. Because no other studies were found comparing pemetrexed/cisplatin with any other relevant comparator, additional efficacy evidence was presented from two phase III RCTs comparing gemcitabine/cisplatin with gemcitabine/carboplatin and docetaxel/cisplatin. The manufacturer's submission reported from its indirect comparisons' analysis that median overall survival and progression-free survival and tumour response rates were more favourable for pemetrexed/cisplatin than for any other comparator. The manufacturer did not identify any published cost-effectiveness analyses of pemetrexed for the first-line treatment of patients with NSCLC. Therefore economic evidence was derived solely from a de novo economic model developed by the manufacturer. A Markov model was developed to evaluate the cost-effectiveness of pemetrexed/cisplatin compared to gemcitabine/cisplatin, docetaxel/cisplatin and gemcitabine/carboplatin. The clinical data used in the economic evaluation were primarily generated from the JMDB trial, with additional data from the two further trials used in the indirect comparisons analysis. The ERG identified a series of problems with this economic model. As a result, three different versions of the model were submitted to NICE and considered by the ERG. The ICERs estimated by this final version of the model ranged from 8056 pounds to 33,065 pounds per QALY, depending on the comparator, the population and the application of a continuation rule. The ERG considered that the model required extensive modification and redesign, and should be subjected to thorough validation against the JMDB trial results. A full quality audit was also required as it was likely that further model inconsistencies may be present that had not yet been identified. The manufacturer subsequently included evidence in the form of three cost effectiveness analyses (two models and an 'in-trial' analysis), stating that a thorough validation process had been followed according to the NICE request. The very short time available to the ERG to consider the new evidence precluded a comprehensive assessment. Instead, the ERG chose to present a simple exploratory analysis combining its own survival projections with key cost estimates obtained from the JMDB trial individual patient data. Compared to gemcitabine, this resulted in ICERs ranging from 17,162 pounds to 30,142 pounds per QALY, depending on the patient population, the maximum number of cycles of chemotherapy and whether a cycle based efficacy adjustment was applied or not. The guidance issued by NICE in September 2009 states that pemetrexed in combination with cisplatin is recommended as an option for the first-line treatment of patients with locally advanced or metastatic NSCLC only if the histology of the tumour has been confirmed as adenocarcinoma or large-cell carcinoma.

Pemetrexed for the maintenance treatment of locally advanced or metastatic non-small cell lung cancer

This paper presents a summary of the evidence review group (ERG) report into the clinical effectiveness and cost-effectiveness of pemetrexed for the maintenance treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC), in accordance with the licensed indication, based upon the evidence submission from the manufacturer (Eli Lilly) to the National Institute for Health and Clinical Excellence (NICE) as part of the single technology appraisal (STA) process. The primary clinical outcome measure was progression free survival (PFS). Secondary outcomes included overall survival (OS), time to worsening of symptoms, objective tumour response rate, adverse events and changes in lung cancer symptom scale. Data for two populations were presented: patients with non-squamous NSCLC histology and patients with adenocarcinoma histology. The clinical evidence was derived from a double-blind, placebo-controlled randomised controlled trial (RCT), the JMEN trial. The trial compared the use of pemetrexed + best supportive care (BSC ) as maintenance therapy, with placebo + BSC in patients with NSCLC (n = 663) who had received four cycles of platinum-based chemotherapy (CTX) and whose disease had not progressed. In the licensed population (patients with non-squamous histology), the trial demonstrated greater median PFS for patients treated with pemetrexed than for patients in the placebo arm [4.5 vs 2.6 months; hazard ratio (HR) 0.44; 95% confidence interval (CI) 0.36 to 0.55, p < 0.00001]. Median OS was also greater for the pemetrexed- treated patients (15.5 vs 10.3 months; HR 0.70; 95% CI 0.56 to 0.88, p = 0.002). In addition, tumour response and disease control rates were statistically significantly greater for patients who received pemetrexed. Patient survival rates at 1 year and 2 years were higher in the pemetrexed arm. The incremental cost-effectiveness ratios (ICERs) estimated by the manufacturer’s model were £33,732 per quality adjusted life-year (QALY) for the licensed nonsquamous population, and £39,364 per QALY for the adenocarcinoma subgroup. Both of these ICERs were above the standard NICE willingness-to-pay range (£20,000–£30,000 per QALY). The manufacturer also presented a case for pemetrexed to be considered as an end of life treatment. The ERG identified a number of problems in the economic model presented by the manufacturer; after correction, the base case ICER was re-estimated as £51,192 per QALY gained and likely to exceed NICE’s willingness-to-pay thresholds. Following a revised economic analysis submitted by the manufacturer, the AC accepted that an ICER of £47,000 per QALY gained was most plausible. The AC also considered that maintenance treatment with pemetrexed fulfilled the end of life criteria.The guidance issued by NICE, on 20 June 20 2010, in TA190 as a result of the STA states that: People who have received pemetrexed in combination with cisplatin as first-line chemotherapy cannot receive pemetrexed maintenance treatment. 1.1 Pemetrexed is recommended as an option for the maintenance treatment of people with locally advanced or metastatic non-small-cell lung cancer other than predominantly squamous cell histology if disease has not progressed immediately following platinum-based chemotherapy in combination with gemcitabine, paclitaxel or docetaxel.

Bacterial metabolic 'toxins': a new mechanism for lactose and food intolerance, and irritable bowel syndrome

Lactose and food intolerance cause a wide range of gut and systemic symptoms, including gas, gut pain, diarrhoea or constipation, severe headaches, severe fatigue, loss of cognitive functions such as concentration, memory and reasoning, muscle and joint pain, heart palpitations, and a variety of allergies (Matthews and Campbell, 2000; Matthews et al., 2005; Waud et al., 2008). These can be explained by the production of toxic metabolites from gut bacteria, as a result of anaerobic digestion of carbohydrates and other foods, not absorbed in the small intestine. These metabolites include alcohols, diols such as butan 2,3 diol, ketones, acids, and aldehydes such as methylglyoxal (Campbell et al., 2005, 2009). These 'toxins' induce calcium signals in bacteria and affect their growth, thereby acting to modify the balance of microflora in the gut (Campbell et al., 2004, 2007a,b). These bacterial 'toxins' also affect signalling mechanisms in cells around the body, thereby explaining the wide range of symptoms in people with food intolerance. This new mechanism also explains the most common referral to gastroenterologists, irritable bowel syndrome (IBS), and the illness that afflicted Charles Darwin for 50 years (Campbell and Matthews, 2005a,b). We propose it will lead to a new understanding of the molecular mechanism of type 2 diabetes and some cancers.

A framework to support safe blood transfusion practice

In response to reports of fragmentation in care, treatment delays and concern over the safety of patients receiving blood transfusion support, a collaborative project between NHS Blood and Transplant and the Scottish National Blood Transfusion Service explored the feasibility of nurses and midwives extending their role to prescribe blood components. The project identified that there were no legal barriers to role development and, following extensive consultation, a governance framework to support safe practice is now available for all NHS trusts and boards.

Encoding instructions and stimulus presentation in local environmental context-dependent memory studies

Murnane and Phelps (1993) recommend word pair presentations in local environmental context (EC) studies to prevent associations being formed between successively presented items and their ECs and a consequent reduction in the EC effect. Two experiments were conducted to assess the veracity of this assumption. In Experiment 1, participants memorised single words or word pairs, or categorised them as natural or man made. Their free recall protocols were examined to assess any associations established between successively presented items. Fewest associations were observed when the item-specific encoding task (i.e., natural or man made categorisation of word referents) was applied to single words. These findings were examined further in Experiment 2, where the influence of encoding instructions and stimulus presentation on local EC dependent recognition memory was examined. Consistent with recognition dual-process signal detection model predictions and findings (e.g., Macken, 2002; Parks & Yonelinas, 2008), recollection sensitivity, but not familiarity sensitivity, was found to be local EC dependent. However, local EC dependent recognition was observed only after item-specific encoding instructions, irrespective of stimulus presentation. These findings and the existing literature suggest that the use of single word presentations and item-specific encoding enhances local EC dependent recognition.

Cigarette smoking and risk of acoustic neuromas and pituitary tumours in the Million Women Study

Background:

The relationship between cigarette smoking and incidence of acoustic neuromas and pituitary tumours is uncertain.

Methods:

We examined the relation between smoking and risk of acoustic neuromas and pituitary tumours in a prospective study of 1.2 million middle-aged women in the United Kingdom.

Results:

Over 10.2 million person years of follow-up, 177 women were diagnosed with acoustic neuromas and 174 with pituitary tumours. Current smokers at recruitment were at significantly reduced risk of incident acoustic neuroma compared with never smokers (adjusted relative risk (RR)=0.41, 95% confidence interval (CI)=0.24–0.70, P=0.001). Past smokers did not have significantly different risk of acoustic neuroma than never smokers (RR=0.87, 95% CI=0.62–1.22, P=0.4). Smoking was not associated with incidence of pituitary tumours (RR in current vs never smokers=0.91, 95% CI=0.60–1.40, P=0.7).

Conclusion:

Women who smoke are at a significantly reduced risk of acoustic neuromas, but not of pituitary tumours, compared with never smokers. Acoustic neuromas are much rarer than the cancers that are increased among smokers.

Pemetrexed for the first-line treatment of locally advanced or metastatic non-small cell lung cancer

This paper presents a summary of the evidence review group (ERG) report into the clinical effectiveness and cost-effectiveness of pemetrexed for the first-line treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC), in accordance with the licensed indication, based upon the evidence submission from Eli Lilly Ltd to the National Institute for Health and Clinical Excellence (NICE) as part of the single technology appraisal process. The majority of the efficacy evidence described in the manufacturer’s submission is derived from a phase III open label randomised controlled trial (RCT) known as the JMDB trial. The trial achieved its primary objective to demonstrate non-inferiority of pemetrexed/cisplatin to gemcitabine/cisplatin for overall survival in all patients with NSCLC. Because no other studies were found comparing pemetrexed/cisplatin with any other relevant comparator, additional efficacy evidence was presented from two phase III RCTs comparing gemcitabine/cisplatin with gemcitabine/carboplatin and docetaxel/cisplatin. The manufacturer’s submission reported from its indirect comparisons’ analysis that median overall survival and progression-free survival and tumour response rates were more favourable for pemetrexed/cisplatin than for any other comparator. The manufacturer did not identify any published cost-effectiveness analyses of pemetrexed for the first-line treatment of patients with NSCLC. Therefore economic evidence was derived solely from a de novo economic model developed by the manufacturer. A Markov model was developed to evaluate the cost-effectiveness of pemetrexed/cisplatin compared to gemcitabine/cisplatin, docetaxel/cisplatin and gemcitabine/carboplatin. The clinical data used in the economic evaluation were primarily generated from the JMDB trial, with additional data from the two further trials used in the indirect comparisons analysis. The ERG identified series problems with this economic model. As a result, three different versions of the model were submitted to NICE and considered by the ERG. The ICERs estimated by this final version of the model ranged from £8056 to £33,065 per QALY, depending on the comparator, the population and the application of a continuation rule. The ERG considered that the model required extensive modification and redesign, and should be subjected to thorough validation against the JMDB trial results. A full quality audit was also required as it was likely that further model inconsistencies may be present that had not yet been identified. The manufacturer subsequently included evidence in the form of three cost effectiveness analyses (two models and an ‘in-trial’ analysis), stating that a thorough validation process had been followed according to the NICE request. The very short time available to the ERG to consider the new evidence precluded a comprehensive assessment. Instead, the ERG chose to present a simple exploratory analysis combining its own survival projections with key cost estimates obtained from the JMDB trial individual patient data. Compared to gemcitabine, this resulted in ICERs ranging from £17,162 to £30,142 per QALY, depending on the patient population, the maximum number of cycles of chemotherapy and whether a cycle based efficacy adjustment was applied or not. The guidance issued by NICE in September 2009 states that pemetrexed in combination with cisplatin is recommended as an option for the first-line treatment of patients with locally advanced or metastatic NSCLC only if the histology of the tumour has been confirmed as adenocarcinoma or large-cell carcinoma.