Long-Term Ingestion of Paracetamol and Liver Disease1

Of 45 patients with chronic active hepatitis, 17 had taken paracetamol before the onset of symptoms. There were no significant differences, however, between the two groups in abnormalities of liver function tests, nor in ease of control after paracetamol withdrawal and institution of immunosuppressive therapy. The patient who had taken more than 5 g/week was studied in greater detail, but after a challenge dose of 1 g paracetamol there was no rise in serum aminotransferases and the pattern of excretion of paracetamol metabolites was normal. A critical review of the previously published reports failed to uncover any convincing evidence that paracetamol is an initiating factor in the development of chronic active hepatitis, although it may, at therapeutic levels, cause a toxic hepatitis in those individuals at risk.

Improving access to better care for people with knee and/or hip pain: service evaluation of allied health professional-led primary care

INTRODUCTION

Chronic knee and hip pain is prevalent, impairing mobility, function and quality of life. Allied health professions (AHPs) are better trained and have more time than general practitioners in primary care to advise and support people to adopt healthier lifestyles (maintain healthy weight, increase physical activity) that reduce joint pain. We evaluated whether AHP-led primary care delivering person-centred, practical lifestyle coaching was a feasible, effective way to manage chronic knee and/or hip pain.

METHODS

At initial assessment the 'Joint Pain Advisor' assessed pain, function, quality of life, physical activity, waist circumference and body mass, taught simple self-management strategies and used behaviour change techniques (motivational interviewing, goal setting, action/coping planning) to alter participants' lifestyles. Participants were invited for 6-week and 6-month reviews, when the Advisor reassessed clinical outcomes, fed back progress and reinforced health messages. Feasibility and effectiveness of the service was evaluated using quantitative and qualitative methods.

RESULTS

Uptake of the service was good: 498 people used the service. Between initial assessment and reviews, participants' pain, function, quality of life, weight, waist circumference and physical activity improved (p < 0.005). Service user satisfaction was high; they reported easier access to advice and support tailored to their needs that translated into clinical benefits and a more efficient pathway reducing unnecessary consultations and investigations. Relatively few people returned for a 6-month review as they considered they had received sufficient advice.

CONCLUSIONS

AHP-led care is a popular, effective, efficient and sustainable way to manage joint pain, without compromising safety or quality of care.

Evaluation of the BioLogic-DT sorbent-suspension dialyser in patients with fulminant hepatic failure

The BioLogic-DT sorbent suspension dialyser was developed to remove toxic substances from the blood of patients with liver failure. In the present study a randomised controlled trial was carried out in 10 patients with fulminant hepatic failure who had developed grade 4 encephalopathy to evaluate the safety and biocompatibility of the dialyser in such severely ill patients. A total of 18 treatments were performed in 5 patients. Haemodynamic stability was maintained throughout. There was a significant loss of platelets (163 ± 34 to 101 ± 13 x 109/l) and decrease in plasma fibrinogen (0.53 ± 0.09 to 0.31 ± 0.08 g/l) with a rise in blood activated clotting time (190 ± 17 to 223 ± 22 sec) — not seen in the controls —, which was a result of the dialysis being carried out without the use of heparin as anticoagulant. Removal of metabolites by treatment was limited, with no significant effect on blood ammonia level and further developments of the system will be needed for this very sick group of patients.

Effect of ELAD Liver Support on Plasma HGF and TGF–β1 in Acute Liver Failure

The aim of this study was to investigate the effects of treatment with the extracorporeal liver assist device (ELAD) in patients with acute liver failure (ALF) on plasma hepatocyte growth factor (HGF), the most potent growth factor, and transforming growth factor-β1 (TGF-β1), an inhibitory factor for liver regeneration. Initial plasma HGF, measured by ELISA, was significantly increased in the ALF patients (7.86 ± SEM 1.76 ng/ml) compared with normal subjects (0.10 ± 0.02 ng/ml, p<0.001). After 6 hours of ELAD haemoperfusion, plasma HGF increased further (30.5 ± 6.19 ng/ml, p<0.001), with a subsequent decrease towards the initial value by 48 hours. Initial plasma levels of TGF-β1 determined by ELISA were significantly increased in the ALF patients (43.4 ± 5.9 ng/ml) compared with normal subjects (25.1 ± 2.3 ng/ml, p<0.01), but there was no change in plasma TGF-β1 during the study period in either the ELAD or control ALF group. As HGF is a heparin-binding growth factor and similar changes in HGF were observed during CVVHD, one possible explanation is that heparin administered as anticoagulant for extracorporeal circulation is involved in the effects observed on HGF.

Clinician Versus Computer in the Choice of 11 Differential Diagnoses of Jaundice Based on Formalised Data

The information on 20 jaundiced patients available within 48 hours of their admission to general hospitals in the London area was presented, firstly to a computer-assisted model for the diagnosis of jaundice, and secondly to each of 5 clinicians. When the diagnoses produced by each were compared with the final diagnoses on each patient the computer was correct in 70% of cases and the clinicians in between 45 and 65%. When second and third choices were taken into account the clinicians’ scores rose more than that of the computer. When the clinicians’ choices of diagnosis were compared with those of the computer, irrespective of the accuracy of either, a good correlation with the computer was obtained by 2 clinicians and a poorer one by the other 3. When the items of information most helpful to the clinicians in reaching their diagnoses were compared with those items most helpful to the computer, the correlation between clinician and computer was poor in all cases.

Serum inflammatory markers in relation to prostate cancer severity and death in the Swedish AMORIS study

Inflammation is a well-documented driver of cancer development and progression. However, little is known about its role in prostate carcinogenesis. Thus, we examined the association of C-reactive protein (CRP), haptoglobin, albumin and white blood cells (WBC) with prostate cancer (PCa) severity (defined by PCa risk category and clinicopathological characteristics) and progression (defined by PCa death). We selected 8,471 Swedish men with newly diagnosed PCa who had exposure measurements taken approximately 14 years prior to diagnosis. We calculated odds ratio (OR) and 95% confidence interval (CI) for the associations between the inflammatory markers and PCa severity using logistic regression, while Cox proportional hazard regression was used for the associations with overall and PCa death. Serum CRP levels were associated with increased odds of high risk and metastatic PCa, and high PSA levels (≥20 µg/L) (OR: 1.29; 95% CI: 1.06-1.56, 1.32; 1.05-1.65 and 1.51; 1.26-1.81, respectively). Similarly, higher haptoglobin levels were associated with increased odds of metastatic PCa, high PSA level and possibly high grade PCa (1.38; 1.10-1.74, 1.50; 1.17-1.93 and 1.25; 1.00-1.56, respectively). Albumin was positively associated with Gleason 4 + 3 tumour (1.38; 1.02-1.86) and overall death (HR_{unit increase in log} : 1.60; 95% CI: 1.11-2.30), but inversely associated with high risk PCa and high PSA levels (≥20 µg/L) (0.71; 0.56-0.89 and 0.72; 0.5 9-0.90). WBC was associated with increased odds of T3-T4 PCa. Except for albumin, none of these markers were associated with PCa death or overall death. Systemic inflammation as early as 14 years prior to diagnosis may influence prostate cancer severity.

IMPACT: A Generic Tool for Modelling and Simulating Public Health Policy

Background: Populations are under-served by local health policies and management of resources. This partly reflects a lack of realistically complex models to enable appraisal of a wide range of potential options. Rising computing power coupled with advances in machine learning and healthcare information now enables such models to be constructed and executed. However, such models are not generally accessible to public health practitioners who often lack the requisite technical knowledge or skills.

Objectives: To design and develop a system for creating, executing and analysing the results of simulated public health and health-care policy interventions, in ways that are accessible and usable by modellers and policy-makers.

Methods: The system requirements were captured and analysed in parallel with the statistical method development for the simulation engine. From the resulting software requirement specification the system architecture was designed, implemented and tested. A model for Coronary Heart Disease (CHD) was created and validated against empirical data.

Results: The system was successfully used to create and validate the CHD model. The initial validation results show concordance between the simulation results and the empirical data.

Conclusions: We have demonstrated the ability to connect health policy-modellers and policy-makers in a unified system, thereby making population health models easier to share, maintain, reuse and deploy.

International validation of the European Organisation for Research and Treatment of Cancer QLQ-BRECON23 quality-of-life questionnaire for women undergoing breast reconstruction

Background

The aim was to carry out phase 4 international field-testing of the European Organisation for Research and Treatment of Cancer (EORTC) breast reconstruction (BRECON) module. The primary objective was finalization of its scale structure. Secondary objectives were evaluation of its reliability, validity, responsiveness, acceptability and interpretability in patients with breast cancer undergoing mastectomy and reconstruction.

Methods

The EORTC module development guidelines were followed. Patients were recruited from 28 centres in seven countries. A prospective cohort completed the QLQ-BRECON15 before mastectomy and the QLQ-BRECON24 at 4–8 months after reconstruction. The cross-sectional cohort completed the QLQ-BRECON24 at 1–5 years after reconstruction, and repeated this 2–8 weeks later (test–retest reliability). All participants completed debriefing questionnaires.

Results

A total of 438 patients were recruited, 234 in the prospective cohort and 204 in the cross-sectional cohort. A total of 414 reconstructions were immediate, with a comparable number of implants (176) and donor-site flaps (166). Control groups comprised patients who underwent two-stage implant procedures (72, 75 per cent) or delayed reconstruction (24, 25 per cent). Psychometric scale validity was supported by moderate to high item-own scale and item-total correlations (over 0·5). Questionnaire validity was confirmed by good scale-to-sample targeting, and computable scale scores exceeding 50 per cent, except nipple cosmesis (over 40 per cent). In known-group comparisons, QLQ-BRECON24 scales and items differentiated between patient groups defined by clinical criteria, such as type and timing of reconstruction, postmastectomy radiotherapy and surgical complications, with moderate effect sizes. Prospectively, sexuality and surgical side-effects scales showed significant responsiveness over time (P &lt; 0·001). Scale reliability was supported by high Cronbach's α coefficients (over 0·7) and test–retest (intraclass correlation more than 0·8). One item (finding a well fitting bra) was excluded based on high floor/ceiling effects, poor test–retest and weak correlations in factor analysis (below 0·3), thus generating the QLQ-BRECON23 questionnaire.

Conclusion

The QLQ-BRECON23 is an internationally validated tool to be used alongside the EORTC QLQ-C30 (cancer) and QLQ-BR23 (breast cancer) questionnaires for evaluating quality of life and satisfaction after breast reconstruction.

An evaluation of a school-based dental sealant programme

OBJECTIVES

To evaluate the effectiveness of Bengal Smiles, a school-based dental sealant programme and assess outcomes related to the U.S. Healthy People 2020 oral health objectives.

METHODS

A needs assessment identified high caries prevalence in Idaho children and supported the need for a school-based dental sealant programme at a local Title 1 school. Children (n=54) ages 6-12 were screened by dental hygiene students for suspected dental caries, sealant placement and need for referral for dental treatment. Sealant retention and sealant caries rates were computed at 12 months (n=32) using descriptive statistics. Caries rates were analysed with a t test for paired samples, while a chi-square test was used to determine a difference in referral treatment rates before and after the intervention of administrative staff who contacted parents of children in need of dental treatment.

RESULTS

Bengal Smiles participants had a 16% decrease in suspected dental caries; however, there was no statistically significant difference in caries rates (P=.21) at baseline and 12 months. Sealant prevalence increased 370%. Sealant retention outcomes were 74% fully retained with 0% caries, 13% partially retained with 25% caries and 13% no retention with 25% caries. At 12 months, 50% of participants referred for dental treatment accessed care. The intervention of contacting parents had no statistically significant effect on increasing dental treatments (P=.75).

CONCLUSIONS

School-based sealant programmes eliminate disparities in accessing oral health care and contribute to attaining U.S. Healthy People 2020 oral health objectives.

Social and ethical aspects of forensic genetics: A critical review

This review describes the social and ethical responses to the history of innovations in forensic genetics and their application to criminal investigations. Following an outline of the three recurrent social perspectives that have informed these responses (crime management, due process, and genetic surveillance), it goes on to introduce the repertoire of ethical considerations by describing a series of key reports that have shaped subsequent commentaries on forensic DNA profiling and databasing. Four major ethical concerns form the focus of the remainder of the paper (dignity, privacy, justice, and social solidarity), and key features of forensic genetic practice are examined in the light of these concerns. The paper concludes with a discussion of the concept of "proportionality" as a resource for balancing the social and ethical risks and benefits of the use of forensic genetics in support of criminal justice.

Conditions of the external and middle ear: an overview of presentation, management and associated complications

Ear, nose and throat (ENT) presentations to primary care are common and frequently affect military patients. Many patients can be managed in primary care with appropriate treatment, but some presentations require appropriate, timely, and occasionally emergency onward referral for hospital management. This paper discusses the management of common otological presentations including otitis externa (OE), acute otitis media, chronic suppurative otitis media (including cholesteatoma), tympanic membrane (TM) perforations and pinna haematoma.

Mortality in people with intellectual disabilities in England

BACKGROUND

People with intellectual disabilities (IDs) die at younger ages than the general population, but nationally representative and internationally comparable mortality data about people with ID, quantifying the extent and pattern of the excess, have not previously been reported for England.

METHOD

We used data from the Clinical Practice Research Datalink database for April 2010 to March 2014 (CPRD GOLD September 2015). This source covered several hundred participating general practices comprising roughly 5% of the population of England in the period studied. General practitioner (GP) records identified people diagnosed by their GP as having ID. Linked national death certification data allowed us to derive corresponding mortality data for people with and without ID, overall and by cause.

RESULTS

Mortality rates for people with ID were significantly higher than for those without. Their all-cause standardised mortality ratio was 3.18. Their life expectancy at birth was 19.7 years lower than for people without ID. Circulatory and respiratory diseases and neoplasms were the three most common causes of death for them. Cerebrovascular disease, thrombophlebitis and pulmonary embolism all had standardised mortality ratios greater than 3 in people with ID. This has not been described before. Other potentially avoidable causes included epilepsy (3.9% of deaths), aspiration pneumonitis (3.6%) and colorectal cancer (2.4%). Avoidable mortality analysis showed a higher proportion of deaths from causes classified as amenable to good medical care but a lower proportion from preventable causes compared with people without ID. International comparison to areas for which data have been published in sufficient detail for calculation of directly standardised rates suggest England may have higher death rates for people with ID than areas in Canada and Finland, and lower death rates than Ireland or the State of Massachusetts in the USA.

CONCLUSIONS

National data about mortality in people with ID provides a basis for public health interventions. Linked data using GP records to identify people with ID could provide comprehensive population-based monitoring in England, unbiased by the circumstances of illnesses or death; to date information governance constraints have prevented this. However, GPs in England currently identify only around 0.5% of the population as having ID, suggesting that individuals with mild, non-syndromic ID are largely missed. Notably common causes of death suggest control of cardiovascular risk factors, epilepsy and dysphagia, management of thrombotic risks and colorectal screening are important areas for health promotion initiatives.