What happens to new-onset headache in children that present to primary care? A case-cohort study using electronic primary care records

The aim was to describe the consulting behaviour and clinical outcomes of children presenting with headache in primary care. This was a historical cohort study using data from the UK General Practitioner Research Database. Cases were children aged 5-17 years who presented to primary care with primary headache (migraine, tension-type headache, cluster headache) or undifferentiated headache (no further descriptor). Controls were age, sex and practice matched. Their records were examined for consultations, referrals, relevant treatments and specific diseases in the subsequent year. Children with headache (n = 48 575) were identified and matched to controls. At presentation, 9321 (19.2%) of headaches were labelled primary, 549 (1.1%) secondary and 38 705 (79.7%) received no formal diagnosis. Of the latter group, 2084 (5.4%) received a primary headache diagnosis in the subsequent year. Following a diagnosis of migraine, 258 (3.5%) had received a triptan and 1598 (21%) were using propranolol or pizotifen. Total consultations were higher in cases than in controls in the year before the headache: cases ages 5-8 years, mean (s.d.) 5.0 (4.0) consultations; controls 4.0 (3.5) consultations. In 1 year controls had 43 430 consultations, of which 256 (0.6%) were for headache, of whom 64 (25%) were referred to secondary care. Headache was a risk factor for benign and malignant tumours, cerebrovascular disease, primary disorders of raised intracranial pressure and depression. This risk was reduced if a diagnosis of a primary headache disorder could be made. Although there is an increased likelihood of a serious pathology with headache presentations, the risk is small particularly if a diagnosis of a primary headache is made. General practitioners are likely to be underdiagnosing migraine. This study can inform management guidelines for new presentations of headache in primary care, particularly when a secondary pathology is suspected.

Regional anaesthesia for caesarean section: a choice of three techniques

Over the last 20 years, there has been a large increase in the proportion of caesarean sections (Brown and Russell, 1995) which are performed under regional rather than general anaesthesia. A bilateral sensory block from the T4 dermatome (nipple level) to the sacral nerve roots (perineum) is necessary.

Reduced helminth burden increases allergen skin sensitization but not clinical allergy: a randomized, double-blind, placebo-controlled trial in Vietnam

BACKGROUND

Observational evidence suggests that infection with helminths protects against allergic disease and allergen skin sensitization. It is postulated that such effects are mediated by helminth-induced cytokine responses, in particular IL-10.

OBJECTIVE

We tested this hypothesis in a rural area of central Vietnam where hookworm infection is endemic.

METHODS

One thousand five hundred and sixty-six schoolchildren aged 6-17 were randomly allocated to receive either anti-helminthic therapy or a placebo at 0, 3, 6, and 9 months. We compared changes in the prevalence of exercise-induced bronchoconstriction, allergen skin sensitization, flexural eczema on skin examination, questionnaire-reported allergic disease (wheeze and rhinitis symptoms), and immunological parameters (hookworm-induced IFN-gamma, IL-5, IL-10) between 0 and 12 months.

RESULTS

One thousand four hundred and eighty-seven children (95% of these randomized) completed the study. The most common helminth infections were hookworm (65%) and Ascaris lumbricoides (7%). There was no effect of the therapy on the primary outcome, exercise-induced bronchoconstriction (within-participant mean percent fall in peak flow from baseline after anti-helminthic treatment 2.25 (SD 7.3) vs. placebo 2.19 (SD 7.8, P=0.9), or on the prevalence of questionnaire-reported wheeze [adjusted odds ratio (OR)=1.16, 95% confidence interval (CI) 0.35-3.82, P=0.8] and rhinitis (adjusted OR=1.39, 0.89-2.15, P=0.1), or flexural dermatitis on skin examination (adjusted OR=1.15, 0.39-3.45, P=0.8). However, anti-helminthic therapy was associated with a significantly higher allergen skin sensitization risk (adjusted OR=1.31, 1.02-1.67, P=0.03). This effect was particularly strong for children infected with A. lumbricoides at baseline (adjusted OR=4.90, 1.48-16.19, P=0.009). Allergen skin sensitization was inversely related to hookworm-specific IL-10 at baseline (adjusted OR=0.76, 0.59-0.99, P=0.04). No cytokine tested, including IL-10, changed significantly after the anti-helminthic therapy compared with the placebo.

CONCLUSION

A significant reduction in worm burden over a 12-month period in helminth-infected children increases the risk of allergen skin sensitization but not of clinical allergic disease. The effect on skin sensitization could not be fully explained by any of the immunological parameters tested.

Association between migraine, anxiety and depression

Logistic regression was used to evaluate the relationship between self-reported medical diagnosis of migraine, self-reported depressive symptomology (RDS) and self-reported anxious symptomology (RAS) in the National Health Interview Survey ( n = 30 852). Semipartial squared correlations evaluated the population-level variability between RDS, RAS and migraine impairment. Migraine prevalence was 15.2% (overall), 20.5% (women) and 9.4% (men). Migraine risk was higher in participants with RAS [odds ratio (OR) 2.30, 95% confidence interval (CI) 2.09, 2.52), with RDS (OR 2.23, 95% CI 1.93, 2.58), who smoked (OR 1.19, 95% CI 1.09, 1.30), or who consulted a mental health provider (OR 1.45, 95% CI 1.27, 1.65). Although migraine risk was increased in both women (OR 1.93) and men (OR 2.42) with RAS ( P < 0.001), men with RAS had a higher migraine risk than did women with RAS ( P < 0.001). Only 7% of the variability in migraine impairment (population level) was predicted by variability in RDS and/or RAS.

Interventionist causal models in psychiatry: repositioning the mind-body problem

The diversity of research methods applied to psychiatric disorders results in a confusing plethora of causal claims. To help make sense of these claims, the interventionist model (IM) of causality has several attractive features. First, it connects causation with the practical interests of psychiatry, defining causation in terms of 'what would happen under interventions', a question of key interest to those of us whose interest is ultimately in intervening to prevent and treat illness. Second, it distinguishes between predictive-correlative and true causal relationships, an essential issue cutting across many areas in psychiatric research. Third, the IM is non-reductive and agnostic to issues of mind-body problem. Fourth, the IM model cleanly separates issues of causation from questions about the underlying mechanism. Clarifying causal influences can usefully structure the search for underlying mechanisms. Fifth, it provides a sorely needed conceptual rigor to multi-level modeling, thereby avoiding a return to uncritical holistic approaches that 'everything is relevant' to psychiatric illness. Sixth, the IM provides a clear way to judge both the generality and depth of explanations. In conclusion, the IM can provide a single, clear empirical framework for the evaluation of all causal claims of relevance to psychiatry and presents psychiatry with a method of avoiding the sterile metaphysical arguments about mind and brain which have preoccupied our field but yielded little of practical benefit.

J/psi production at HERA

We consider the J/psi photoproduction data collected at the DESY ep collider HERA in the light of next-to-leading order predictions for the color-singlet yield and polarization. We find that, while the shapes of inclusive distributions in the transverse momentum and inelasticity are well reproduced, the experimental rates are larger than those given by the color-singlet contribution alone. Furthermore, the next-to-leading order calculation predicts the J/psi's to be mostly longitudinally polarized at high transverse momentum in contrast with the trend of the preliminary data from the ZEUS Collaboration.

Activated c-Src (Y215) kinase expression predicts for early relapse on tamoxifen in human breast cancer

Abstract #3025

Recent studies have demonstrated activation of the non-receptor tyrosine kinase c-Src in tamoxifen resistant breast cancer cell lines, which when treated with Src inhibitors demonstrate a reduction in motility and invasiveness. However, there are little published translational studies confirming a role for c-Src in tamoxifen resistance in vivo. We aim to determine if activated c-Src expression correlates clinically with increased recurrence on tamoxifen.&#x2028; Methods&#x2028; Tissue microarrays were constructed from a patient cohort of 402 Tamoxifen treated ER positive patients. Immunohistochemistry was performed using commercially available antibodies to Total Src as well as to activated (phosphorylated) c-Src at 2 sites (Y416 and Y215) (pSrc416 and pSrc215 respectively). Expression was assessed by 2 independent scorers (weighted histoscore method). HER1-3 status and expression of membranous phosphorylated ER (sites serine 118 and 167) had previously been determined. All statistical calculations were performed using SPSS 15, including Kaplan-Meier life table analysis with log rank testing of differences in breast cancer related relapse whilst on tamoxifen.&#x2028; Results&#x2028; Membranous pSrc215 was observed in 20.3% of the cases but was more frequently observed in the cytoplasm (85.9%) and nucleus (90.5%). Overexpression of cytoplasmic pSrc215 was associated with an earlier time to recurrence (p = 0.037).&#x2028; &#x2028; Cox regression analysis confirmed this to be independent of grade, nodal and HER1-3 status (p=0.028, HR 3.17 (1.14–8.85)). Cytoplasmic pSrc215 was also strongly correlated with membranous phospho-ER, EGFR and HER3 status (Mann Whitney; p&lt;0.001, p=0.026, p&lt;0.001 respectively). Membranous and nuclear pSrc215 staining were not associated with time to relapse.&#x2028; Over expression of Total Src and pSrc416 did not predict for relapse.&#x2028; Discussion&#x2028; Our findings provide support to in vitro studies linking c-Src with tamoxifen resistance. The phosphorylation site pSrc215 is a putative site of activation by HER2 and PGFR resulting in up to 50 fold activation of Src in vitro. The correlations demonstrated with HER status and membranous ER lead us to speculate that this interplay between non genomic ER and Src activation may provide a mechanism for the lack of response to tamoxifen in these patients.&#x2028; Further studies are required to determine if activated pSrc215 represents activated c-Src alone or may also represent activation of other Src family members as the Y416 and Y215 sequences are highly conserved amongst the Src kinases with homologous activation sites. If confirmed, future use of novel combination therapies with Src inhibitors may have an important role in combating tamoxifen resistance.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 3025.

Lack of transmission of porcine circovirus type 2 to weanling pigs by feeding them spray-dried porcine plasma

An experiment was conducted to determine whether spray-dried porcine plasma containing 2.47 x 10(5) dna copies of porcine circovirus type 2 (pcv-2) could infect weanling pigs when fed to them. Five specific pathogen-free (spf) weanling pigs were fed ad libitum for 45 days a control diet and six pigs were fed a test diet containing 8 kg sdpp per 100 kg feed. The two groups were housed in separate biosecurity level-3 rooms. None of the pigs in either group developed any clinical signs or became pcv-2 viraemic or seroconverted.

Measuring the Impact of Headache in Children: A Critical Review of the Literature

Headache is the most frequent neurological symptom and commonest manifestation of pain in childhood. Measuring the impact of headache in terms of health status, functioning and quality of life can inform the prioritization of competing resource claims, screen for unmet need, improve communication between patient and physician and monitor response to treatment. We undertook a critical review of the literature measuring the impact of headache in children and identified 33 papers that contained relevant information. Findings reflected a wide range of settings, age groups, methodologies and outcome measures. Considerable methodological limitations affected all studies, including inadequate description of study design, methodology and data analysis. Nevertheless, although we found the existing literature to be of inconsistent quality, the impact of headache in children and adolescents is substantial. Rigorous studies are required to quantify this burden using measures that are valid and reliable and whose development has been informed by both theoretical and practical perspectives.

Upsilon production at Fermilab Tevatron and LHC energies

We update the theoretical predictions for direct Upsilon(nS) hadroproduction in the framework of nonrelativistic QCD. We show that the next-to-leading order corrections in alpha(S) to the color-singlet transition significantly raise the differential cross section at high p(T) and substantially affect the polarization of the Upsilon. Motivated by the remaining gap between the next-to-leading order yield and the cross-section measurements at the Fermilab Tevatron, we evaluate the leading part of the alpha(S)(5) contributions, namely, those coming from Upsilon(nS) associated with three light partons. The differential color-singlet cross section at alpha(S)(5) is in substantial agreement with the data, so that there is no evidence for the need of color-octet contributions. Furthermore, we find that the polarization of the Upsilon(nS) is longitudinal. We also present our predictions for Upsilon(nS) production at the LHC.

An evaluation of the effectiveness of a videotape programme on interobserver reliability in outcome assessment for ankylosing spondylitis

AIMS

A study was designed to assess the effects of a standardized instructional videotape on training senior medical students to acceptable levels of reliability in performing several commonly used obsever dependent outcome measures in patients with ankylosing spondylilis (AS).

METHODS

During a single day, six third-year medical students independently examined five patients with AvS in predetermined order using a Latin Square design, before and after viewing a standardized videotape demonstrating 14 examination techniques. Reliability coefficients were calculated based on the variance components of the analysis of variance (ANOVA) table.

RESULTS

Prestandardization reliability coefficients were < 0.80 for three measures. Following standardization 12 reliability coefficients exceeded 0.80. For the majority of measures prestandardization reliability coefficients were high and no further improvement in reliability could be demonstrated.

CONCLUSIONS

High levels of interobserver agreement were noted prior to viewing the instructional videotape. This may represent the success of undergraduate clinical skills training programmes, or it may be the result of having reviewed an illustrated instructional text just prior to the initial patient examinations. With the exception of chest excursion, high levels of prestandardization reliability, by necessity, precluded the demonstration of significant effects from viewing the videotape. Nevertheless, the data indicate that senior medical students arc capable of reliably performing quantitative measurement in AS. Recent surveys in Canada and Australia, showing a general lack of quantitative clinical measurement in the longitudinal follow up of AS outpatients by rheumatologists, suggest that the lack of quantitation is not due to inability to reliably perform the measurements.

Epitaxially-grown Ge/Si avalanche photodiodes for 1.3 microm light detection

We designed and fabricated Ge/Si avalanche photodiodes grown on silicon substrates. The mesa-type photodiodes exhibit a responsivity at 1310 nm of 0.54 A/W, a breakdown voltage thermal coefficient of 0.05%/ degrees C, a 3 dB-bandwidth of 10 GHz. The gain-bandwidth product was measured as 153 GHz. The effective k value extracted from the excess noise factor was 0.1.

Prospective surveillance of women with a family history of breast cancer: auditing the risk threshold

To evaluate current guidelines criteria for inclusion of women in special ‘breast cancer family history’ surveillance programmes, records were reviewed of women referred to Scottish breast cancer family clinics between January 1994 and December 2003 but discharged as at ‘less than ‘moderate’ familial risk’. The Scottish Cancer Registry was then interrogated to determine subsequent age-specific incidence of breast cancer in this cohort and corresponding Scottish population figures. Among 2074 women, with an average follow-up of 4.0 years, 28 invasive breast cancers were recorded up to December 2003, where 14.4 were expected, a relative risk (RR) of 1.94. Eleven further breast cancers were recorded between January 2004 and February 2006 (ascertainment incomplete for this period). The overall RR for women in the study cohort exceeded the accepted ‘cutoff’ level (RR=1.7) for provision of special counselling and surveillance. The highest RR was found for the age group 45–59 years and this group also generated the majority of breast cancers. The National Institute for Clinical Excellence (‘NICE’) guidelines appear to be more accurate than those of the Scottish Intercollegiate Guidelines Network (‘SIGN’) in defining ‘moderate’ familial risk, and longer follow-up of this cohort could generate an evidence base for further modification of familial breast cancer services.

Differences between systematic reviews/meta-analyses of hyaluronic acid/hyaluronan/hylan in osteoarthritis of the knee

OBJECTIVE

To explore reasons for discrepant results between systematic reviews (SR)/meta-analyses (MA) of the efficacy and safety of hyaluronic acid/hyaluronan/hylan (HA) therapy in the treatment of osteoarthritis (OA) of the knee.

METHODS

A decision algorithm was utilised to identify reasons for discordance among six SR. Sources of discordance such as clinical question, trial selection and inclusion, data extraction, assessment of study quality, assessment of the ability to combine trials, and statistical methods for data synthesis were examined.

RESULTS

A similar question was asked in all six SR. Different trials were selected for inclusion in the reviews mainly because of differences in the search strategies and selection criteria. Although similar methods for data extraction were utilised, differences were found both in the outcome measures and time-points selected for extraction. Methodological quality was not always formally assessed. Different statistical methods for data synthesis resulted in conflicting estimates of therapeutic effect.

CONCLUSIONS

Reasons for the inconsistency of results reported in the six SR were identified. Using the principles of the GRADE approach for estimating the therapeutic effect of HA in the treatment of OA of the knee, there is moderate evidence suggesting that further research is unlikely to change our confidence in the estimate of the effect. In the balance of benefit to harm, the trade-off is probable benefit with respect to pain reduction and physical function improvement with low risk of harm.

The effects of limit feeding a high-energy barley-based diet to backgrounding cattle in western Canada

A series of three completely randomized design trials were conducted to compare the effects of a limit-fed high-grain diet relative with that of an ad libitum-fed high-forage diet on performance of growing cattle with similar total energy intakes. In trial 1, the ad libitum-fed high-forage diet was formulated to 1.58 and 0.98 Mcal NEm and NEg kg-1 DM. The high-grain diet was formulated to 1.91 Mcal NEm and 1.23 Mcal NEg kg-1 DM. Projected liveweight gains (1.22 kg d-1) and the amount of DM provided to the limit-fed high-grain cattle were based on the NEm and NEg equations for liveweight gain of large-frame steers (NRC 1984). A similar feeding regime was employed for trials 2 and 3; however, it was necessary to reduce energy intake equally after 30 d on feed to control weight gains. In trial 1, the limit-fed high-grain cattle had similar (P > 0.05) ADG and lower (P < 0.05) DMI than the ad libitum-fed high-forage cattle, leading to a 15.4% improvement (P < 0.05) in feed efficiency. Feed efficiency was improved (P < 0.05) by 16.9% in trial 2 and by 21.2% in trial 3 for the limit-fed high-grain cattle, primarily as a result of reduced (P < 0.05) DM intake and similar (P > 0.05) daily gains. Back fat accretion rates were greater (P < 0.05) in the limit-fed high-grain cattle, indicating differences in energy partitioning. The incidence of severe liver abscesses was greater (P < 0.05) for the limit-fed high-grain cattle in trial 2. These results indicate that limit feeding a high-grain diet to backgrounding cattle can be employed to target specific rates of gain and improve feed efficiency although managing acidosis to prevent liver abscesses may be an issue. Key words: Cattle, limit feeding, feed efficiency, liver abscesses

QCD corrections to J/psi and Upsilon production at hadron colliders

We calculate the cross section for hadroproduction of a pair of heavy quarks in a (3)S(1) color-singlet state at next-to-leading order in QCD. This corresponds to the leading contribution in the nonrelativistic QCD expansion for J/psi and Upsilon production. The higher-order corrections have a large impact on the p(T) distributions, enhancing the production at high p(T) at both the Fermilab Tevatron and the CERN Large Hadron Collider. The total decay rate of a (3)S(1) into hadrons at next-to-leading order is also computed, confirming for the first time the result obtained by Mackenzie and Lepage in 1981.

High rates of psychosocial stress among Hispanic breast cancer survivors

9113

Background: Due to early detection and improved treatments, women with breast cancer are living longer. We conducted a survey of attitudes about physical health, psychosocial issues, and health-related behaviors among female breast cancer survivors. Methods: Consecutive women with early-stage breast cancer who were ≥3 months post-completion of primary treatment and had no evidence of residual disease were asked to complete a 127-item self-administered questionnaire assessing physical/emotional health, complementary/alternative medicine use, and employment/financial concerns. Baseline demographic and clinical data were collected, including stage, tumor characteristics, and treatments. Endpoints were differences in responses between Hispanic and white patients on a 5-point scale, or dichotomized for each item. Results: Of 133 respondents, 66 were white and 67 were Hispanic. Their median age was 54 (26–90) years, and their median time since diagnosis was 3 (1–20) years. Compared to whites, Hispanic patients were younger (age <45, 34% vs. 9%, p=0.01), less educated (40% vs. 5% not completing high school, p<0.0001), and more likely to have a yearly household income <$10,000 (58% vs. 7%, p<0.0001). Hispanics were more likely than whites to report depression (31% vs 8%, p=0.0008) and depression-related symptoms and stressors such as: anorexia, pain, financial stress, and infidelity by spouse ( Table 1 ). Hispanics were also more likely to have religious beliefs that helped them cope with cancer. Differences between groups in fatigue, memory loss, and anxiety were not statistically significant. Conclusions: Our study suggests that Hispanic breast cancer survivors may have higher rates of depression and psychosocial stressors than white women. Further research is warranted to assess factors that contribute to depression in cancer survivors, and interventions to diagnose and treat it effectively.

[Table: see text]

No significant financial relationships to disclose.

Watershed nitrogen and mercury geochemical fluxes integrate landscape factors in long-term research watersheds at Acadia National Park, Maine, USA

This paper is an overview of this special issue devoted to watershed research in Acadia National Park (Acadia NP). The papers address components of an integrated research program on two upland watersheds at Acadia NP, USA (44 degrees 20' N latitude; 68 degrees 15' E longitude). These watersheds were instrumented in 1998 to provide a long-term foundation for regional ecological and watershed research. The research was initiated as part of EPA/NPS PRIMENet (Park Research and Intensive Monitoring of Ecosystems Network), a system of UV-monitoring stations and long-term watershed research sites located in US national parks. The initial goals at Acadia NP were to address research questions about mercury, acid rain, and nitrogen saturation developed from prior research. The project design was based on natural differences in forests and soils induced by an intense wildfire in one watershed in 1947. There is no evidence of fire in the reference watershed for several hundred years. We are testing hypotheses about controls on surface water chemistry, and bioavailability of contaminants in the contrasting watersheds. The unburned 47-ha Hadlock Brook watershed is 70% spruce-fir mature conifer forest. In contrast, burned 32-ha Cadillac Brook watershed, 4 km northeast of the Hadlock watershed, is 20% regenerating mixed northern hardwoods and 60% shrub/rocky balds. Differences in atmospheric deposition are controlled primarily by forest stand composition and age. The watersheds are gauged and have water chemistry stations at 122 m (Cadillac) and 137 m (Hadlock); watershed maximum elevations are 468 and 380 m, respectively. The stream water chemistry patterns reflect, in part, the legacy of the intense fire, which, in turn, controls differences in forest vegetation and soil characteristics. These factors result in higher nitrogen and mercury flux from the unburned watershed, reflecting differences in atmospheric deposition, contrasting ecosystem pools of nitrogen and mercury, and inferred differences in internal cycling and bioavailabilty.