Estimates of the size of the Baltic grey seal population based on photo-identification data

The size of the year 2000 summer population of grey seals in the Baltic Sea was estimated using identification of individual seals from photographs taken over a period of 6 years. Photos were taken at haul-out sites within all major grey seal areas in the semi-closed Baltic Sea. The point estimate is 15,631, based on a value for annual survival of identification markings of 0.904, which was also estimated using the photo-id data, with 95% confidence limits from 9,592 to 19,005. The estimate is subject to an unknown, but probably small, upward bias resulting from the risk of failure to identify all individuals in the photographs used for the analysis. An estimated minimum of 15,950 seals were counted at moulting haul-outs in 2003, which thus provides a lower bound on the population size in that year and represents 80% of the photo-id point estimate.

Health state utilities for metastatic breast cancer

The aim of the study was to obtain United Kingdom-based societal preferences for distinct stages of metastatic breast cancer (MBC) and six common toxicities. Health states were developed based on literature review, iterative cycles of interviews and a focus group with clinical experts. They described the burden of progressive, responding and stable disease on treatment; and also febrile neutropenia, stomatitis; diarrhoea/vomiting; fatigue; hand-foot syndrome (grade 3/4 toxicities) and hair loss. One hundred members of the general public rated them using standard gamble to determine health state utility. Data were analysed with a mixed model analysis. The study sample was a good match to the general public of England and Wales by demographics and current quality of life. Stable disease on treatment had a utility value of 0.72, with a corresponding gain of +0.07 following a treatment response and a decline by 0.27 for disease progression. Toxicities lead to declines in utility between 0.10 (diarrhoea/vomiting) and 0.15 (febrile neutropenia). This study underlines the value that society place on the avoidance of disease progression and severe side effects in MBC. This may be the largest preference study in breast cancer designed to survey a representative general public sample.

Multicenter comparative trial of the V-scope system for therapeutic ERCP

BACKGROUND AND STUDY AIMS

A new duodenoscope (the V-scope), with a modified elevator used in combination with a dedicated short guide wire, constitutes the V-system. This system is intended to allow fixation of the guide wire at the elevator lever, thereby enhancing the speed and reliability of accessory exchange over a guide wire during ERCP. The aim of this study was to evaluate the extent to which the V-system provides improved efficiency in comparison with conventional duodenoscope and guide wire combinations.

PATIENTS AND METHODS

This was an industry-sponsored multicenter randomized trial. Patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) procedures in which treatment was anticipated were randomly assigned to the V-system or to a conventional duodenoscope and accessories used routinely in each center. The parameters recorded included the total case time, fluoroscopy time, catheter/guide wire exchange time, guide wire repositioning, loss of guide wire access, and success or failure of guide wire fixation when using the V-system.

RESULTS

Fifty patients were included, 22 in the conventional group and 28 in the V-system group. A total of 135 exchanges were carried out. The patients had up to six exchanges. The median exchange time was 19.4 s with the V-system and 31.7 s with the conventional systems ( P < 0.001). Guide wire repositioning was required less often in the V-system group ( P = 0.0005). The V-system effectively locked the guide wire in 63 of 71 exchanges (89 %). Loss of guide wire access occurred in two patients in the conventional group and four in the V-system group, attributable to failure to lock the guide wire early during the experience (no significant differences).

CONCLUSIONS

The V-system can effectively secure the guide wire during accessory exchange in ERCP and reduces the time required to exchange accessories. This may enhance overall efficiency during ERCP.

Health state utility and toxicities in metastatic lung cancer: A qualitative study

16017

Background: In metastatic lung cancer, it is expected that quality of life is impacted both by the efficacy and toxicity of therapy. Previous research has reported health states either based on response to therapy or on toxicity, but not in combination. Using methodology applied in breast cancer (Narewska 2005), we developed health state descriptions for advanced non-small cell lung cancer (NSCLC) for use in cost-utility analyses. Methods: An interview discussion and content validation guide was produced based on literature review and clinical input. Response to therapy was described as responding disease, stable disease, or progressive disease. The most common toxicities were selected based on randomized clinical trials. Descriptions of health states were reviewed by clinical specialists. Final health states will be piloted and then used in a societal-based valuation study using standard gamble technique. The contributory effect of disease state and toxicity will be estimated using a mixed model analysis and compared with the data from the previous breast cancer utility study. Results: Eight toxicities were identified: alopecia and grade 3/4 neutropenia, febrile neutropenia, hand-foot syndrome, gastrointestinal (diarrhea/vomiting), rash, stomatitis and fatigue. These were combined with response to therapy to yield 19 health states: 9 responding disease (one with each toxicity plus one with no toxicity), 9 stable disease (one with each toxicity plus one with no toxicity) and one progressive disease (toxicity not included). These health states were reviewed by 6 pulmonary oncologists and 3 specialist nurses. Conclusions: Development of health states that combine both efficacy and toxicity will be useful in evaluating the relative value of therapies for advanced NSCLC and comparison with other diseases. Input by clinical experts has provided validation for the proposed health states. Evaluation of these health states by members of society will provide appropriate perspective for economic evaluations.

[Table: see text]

Health state utility and toxicities in metastatic lung and breast cancer: A qualitative study

16021

Background: In metastatic lung cancer, it is expected that quality of life is impacted both by the efficacy and toxicity. Previous research has reported health states either based on response to therapy or on toxicity, but not in combination. Using methodology applied in breast cancer (Narewska 2005), we developed health state descriptions for advanced non-small cell lung cancer (NSCLC) for use in cost-utility analyses. Methods: An interview discussion and content validation guide was produced based on literature review and clinical input. Response to therapy was described as responding disease, stable disease, or progressive disease. The most common toxicities were selected based on randomized clinical trials. Descriptions of health states were reviewed by clinical specialists. Final health states will be piloted and then used in a societal-based valuation study using standard gamble technique. The contributory effect of disease state and toxicity will be estimated using a mixed model analysis and compared with the data from the previous breast cancer utility study. Results: Eight toxicities were identified: alopecia and grade 3/4 neutropenia, febrile neutropenia, hand-foot syndrome, gastrointestinal (diarrhea/vomiting), rash, stomatitis and fatigue. These were combined with response to therapy to yield 19 health states: 9 responding disease (one with each toxicity plus one with no toxicity), 9 stable disease (one with each toxicity plus one with no toxicity) and one progressive disease (toxicity not included). These health states were reviewed by 6 pulmonary oncologists and 3 specialist nurses. Conclusion: Development of health states that combine both efficacy and toxicity will be useful in evaluating the relative value of therapies for advanced NSCLC and comparison with other diseases. Input by clinical experts has provided validation for the proposed health states. Evaluation of these health states by members of society will provide appropriate perspective for economic evaluations.

[Table: see text]

Council tax valuation bands, socio-economic status and health outcome: a cross-sectional analysis from the Caerphilly Health and Social Needs Study

Council tax valuation bands (CTVBs) are a categorisation of household property value in Great Britain. The aim of the study was to assess the CTVB as a measure of socio-economic status by comparing the strength of the associations between selected health and lifestyle outcomes and CTVBs with two measures of socio-economic status: the National Statistics Socio-Economic Classification (NS-SEC) and the 2001 UK census-based Townsend deprivation index.

Development of a measure to assess the impact of epilepsy on people with an intellectual disability: the Glasgow Epilepsy Outcome Scale - Client version (GEOS-C)

BACKGROUND

Epilepsy is common in people with intellectual disability, yet clinicians and researchers seldom obtain information directly from the client. The development and preliminary validation of a novel measure for use with people with mild to moderate intellectual disabilities is described.

METHODS

Focus group methods (6 groups; 24 participants) identified issues of concern, and qualitative analysis (NUD*IST) was applied to derive items and themes for a draft scale. Psychometric scale development techniques were then used in a pilot study and subsequent field-testing to investigate validity and reliability (n = 46).

RESULTS

A total of 148 issues of concern was reduced initially to 52 and then to 42 items using these methods. The derived scale comprised sub-scales reflecting (1) concerns about having seizures; (2) about injury; (3) about issues during; and (4) after seizures; (5) about medication; (6) about what people think; and (7) about daily life. Cronbach alpha for the Glasgow Epilepsy Outcome Scale - Client version (GEOS-C) was 0.92, and ranged from 0.64-0.81 for the sub-scales. Relatively weak associations (r <or= 0.40), between client and family carer, staff carer or clinician views, suggests that proxy reports are not good predictors of how people with epilepsy themselves are feeling. Preliminary validation suggests that the GEOS-C can discriminate on variables of clinical importance.

CONCLUSIONS

The GEOS-C complements existing GEOS measures, can be completed in 5-15 min depending upon the level of support required, and may provide a valuable clinical and research tool. Further validational work and appraisal of sensitivity are required.

Percutaneous coronary intervention: recommendations for good practice and training

Cardiologists undertaking percutaneous coronary intervention (PCI) are excited by the combination of patient and physician satisfaction and technological advance occurring on the background of the necessary manual dexterity. Progress and applicability of percutaneous techniques since their inception in 1977 have been remarkable; a sound evidence base coupled with the enthusiasm and ingenuity of the medical device industry has resulted in a sea change in the treatment of coronary heart disease (CHD), which continues to evolve at breakneck speed. This is the third set of guidelines produced by the British Cardiovascular Intervention Society and the British Cardiac Society. Following the last set of guidelines published in 2000, we have seen PCI activity in the UK increase from 33,652 to 62,780 (87% in four years) such that the PCI to coronary artery bypass grafting ratio has increased to 2.5:1. The impact of drug eluting stents has been profound, and the Department of Health is investigating the feasibility of primary PCI for acute myocardial infarction. Nevertheless, the changes in the structure of National Health Service funding are likely to focus our attention on cost effective treatments and will require physician engagement and sensitive handling if we are to continue the rapid and appropriate growth in our chosen field. It is important with this burgeoning development now occurring on a broad front (in both regional centres and district general hospitals) that we maintain our vigilance on audit and outcome measures so that standards are maintained for both operators and institutions alike. This set of guidelines includes new sections on training, informed consent, and a core evidence base, which we hope you will find useful and informative.

Analysis of enterococci using portable testing equipment for developing countries--variance of Azide NutriDisk medium under variable time and temperature

This report compares the enterococci count on samples obtained with Azide NutriDisk (AND) (sterile, dehydrated culture medium) and Slanetz and Bartley (SB) medium when exposed to a variable in incubation time and temperature. Three experiments were performed to examine the recovery of enterococci on AND and SB media using membrane filtration with respect to: (a) incubation time; (b) incubation temperature; and (c) a combination of the two. Presumptive counts were observed at 37, 41, 46 and 47 degrees C and at 20, 24, 28 and 48 h. These were compared to AWWA standard method 9230 C (44 degrees C, 44 h). Samples were confirmed using Kanamycin Aesculin Azide (KAA) agar. Friedman's ANOVA and Students t-test analysis indicated higher enumeration of enterococci when grown on AND (p = 0.45) than SB (p = < 0.001) at all temperatures with a survival threshold at 47 degrees C. Significant results for AND medium were noted at 20 h (p = 0.021), 24 h (p = 0.278) and 28 h (p = 0.543). The study concluded that the accuracy of the AND medium at a greater time and temperature range provided flexibility in incubator technology making it an appropriate alternative to SB medium for monitoring drinking water using field testing kits in developing countries.

Predicting faecal indicator fluxes using digital land use data in the UK's sentinel Water Framework Directive catchment: the Ribble study

The Ribble drainage basin is the single UK sentinel study area chosen for examining the implementation of the EU Water Framework Directive (WFD 20/60/EC). The study which has generated the data for this paper was initiated to quantify 'catchment-derived' fluxes of faecal indicators originating from both point and diffuse sources to inform the competent authorities on the potential for, and prioritization of, further options for reducing the faecal indicator loadings to this crucial coastal environment. It represents the first UK drainage basin-scale 'profile' of faecal indicator sources as recommended by WHO [1999. Health Based Monitoring of Recreational Waters: The Feasibility of a New Approach; the "Annapolis Protocol". World Health Organisation Geneva, Switzerland; 2003. Guidelines for Safe Recreational-Water Environments Volume 1: Coastal and Fresh-Waters. World Health Organisation Geneva, Switzerland] and incorporated into current drafts of the revised Bathing Water Directive [Anon, 2004. Council of the European Communities Amended proposal for a Directive of the European Parliament and of the Council concerning the management of bathing water quality. Brussels 23rd June]. This paper focuses on the relationships between land use and faecal indicator organism concentrations in surface waters within this very large drainage basin (1583 km2) containing some extensive urban areas. A geographical information system comprising readily available digital elevation, remotely sensed land cover and digital map data was used to generate the land use variables for subcatchments draining to 41 locations across the study area. Presumptive concentrations of coliforms, Escherichia coli and enterococci (colony forming unit (cfu) 100 ml(-1)) were measured at each location on at least 20 occasions over a 44-day period within the 2002 bathing season. The sampling programme targeted hydrograph events. Hydrometric records were used to allocate results as either base flow or high flow. At each site, geometric mean faecal indicator organism concentrations were significantly elevated at high flow compared to base flow. Stepwise regression modelling produced statistically significant models predicting geometric mean base and high-flow faecal indicator organism concentrations from land use variables (r2: 49.5-68.1%). The dominant predictor variable in each case was the proportion of built-up land in subcatchments, suggesting that this land use type, with associated sewage-related inputs, is a critical source of faecal indicator organisms in this drainage basin.

Decay of intestinal enterococci concentrations in high-energy estuarine and coastal waters: towards real-time T90 values for modelling faecal indicators in recreational waters

Intestinal enterococci are the principal 'health-evidence-based' parameter recommended by WHO for the assessment of marine recreational water compliance. Understanding the survival characteristics of these organisms in nearshore waters is central to public health protection using robust modelling to effect real-time prediction of water quality at recreation sites as recently suggested by WHO and the Commission of the European Communities Previous models have more often focused on the coliform parameters and assumed two static day-time and night-time T90 values to characterise the decay process. The principal driver for enterococci survival is the received dose of irradiance from sunlight. In the water column, transmission of irradiance is determined by turbidity produced by suspended material. This paper reports the results of irradiated microcosm experiments using simulated sunlight to investigate the decay of intestinal enterococci in relatively turbid estuarine and coastal waters collected from the Severn Estuary and Bristol Channel, UK. High-turbidity estuarine waters produced a T90 value of 39.5 h. Low-turbidity coastal waters produced a much shorter T90 value of 6.6 h. In experiments receiving no irradiation, high-turbidity estuarine waters also produced a longer T90 of 65.1 h compared with corresponding low-turbidity coastal waters, T90 24.8 h. Irradiated T90 values were correlated with salinity, turbidity and suspended solids (r>0.8, p<0.001). The results suggest that enterococci decay in irradiated experiments with turbidity >200 NTU is similar to decay observed under dark conditions. Most significantly, these results suggest that modelling turbidity and or suspended solids offers a potential means of predicting T90 values in 'real-time' for discrete cells of a hydrodynamic model.

Estimation of diffuse and point source microbial pollution in the ribble catchment discharging to bathing waters in the north west of England

Achieving compliance with the mandatory standards of the 1976 Bathing Water Directive (76/160/EEC) is required at all U.K. identified bathing waters. In recent years, the Fylde coast has been an area of significant investments in 'point source' control, which have not proven, in isolation, to satisfactorily achieve compliance with the mandatory, let alone the guide, levels of water quality in the Directive. The potential impact of riverine sources of pollution was first confirmed after a study in 1997. The completion of sewerage system enhancements offered the potential for the study of faecal indicator delivery from upstream sources comprising both point sources and diffuse agricultural sources. A research project to define these elements commenced in 2001. Initially, a desk study reported here, estimated the principal infrastructure contributions within the Ribble catchment. A second phase of this investigation has involved acquisition of empirical water quality and hydrological data from the catchment during the 2002 bathing season. These data have been used further to calibrate the 'budgets' and 'delivery' modelling and these data are still being analysed. This paper reports the initial desk study approach to faecal indicator budget estimation using available data from the sewerage infrastructure and catchment sources of faecal indicators.

Psychopathology in people with epilepsy and intellectual disability; an investigation of potential explanatory variables

OBJECTIVES

There are few studies on epilepsy and psychopathology in people with intellectual disability (mental retardation) despite epilepsy prevalence rates that are thirty times higher than in the general population. The aims of this study, therefore, were to identify reliable, epilepsy-specific predictors of psychiatric and behavioural disorder in these patients, and to investigate reliable predictors of carer stress.

METHODS

A database of 685 patients was compiled, from which 250 were randomly selected. Structured interviews were completed on 186 of these 250 patients (74%) (108 men, 78 women; mean age (SD) 35.5 (10.1)) comprising descriptive, clinical and functional components, and validated measures of psychopathology for which comparative data were available. Logistic and linear regression methods were used to identify predictors.

RESULTS

One-third of patients with epilepsy and intellectual disability met criteria for possible psychiatric disorder, particularly affective/neurotic disorder; twice the comparison rates for intellectual disability alone. Behavioural problem levels, however, were lower than population norms. Regression models explaining modest amounts of variance (R(2)< or =24%) suggested certain seizure phenomena (greater seizure severity, more seizures in past month, lesser tendency to loss of consciousness during seizures) as particular risk factors for psychiatric disorder. General disability factors such as level of intellectual, sensory or motor disability and side effects of medication, however, contributed more to explaining behavioural problems. Around half of the family carers reported significant stress, and one-third exhibited clinically significant anxiety symptoms. Younger carers were more stressed, and side effects from patients' medication also contributed to carer stress.

CONCLUSIONS

Although epilepsy in itself may be a risk factor for psychopathology in a minority of people with intellectual disability, some epilepsy-specific factors may predict psychiatric disorder. Behavioural problems need to be considered separately from psychiatric disorder because general factors, more closely associated with disability, are stronger predictors of their occurrence.