Practical issues in the application of occlusion to measure visual demands imposed on drivers by in-vehicle tasks

Occlusion is a practical technique to measure the visual demand imposed by in-vehicle tasks and to assess whether a task can be resumed having been interrupted. This study describes a number of important factors and variables that need to be controlled to ensure reliability of results. Training of participants on in-vehicle tasks is found to help consistency and five training sessions are required for complex tasks. No significant differences in training with and without occlusion goggles are reported. The required sample size is dependent on the variability of the task; for those investigated an appropriate sample size is found to be 14. For in-vehicle systems that exhibit a delay in response to the user, consistency is improved when these delays are excluded from timing measurements. In terms of calculating the occlusion parameter R, the within-participant basis is most consistent by taking the ratio of the respective median total shutter open time and total task times across trial repetitions completed by one participant on each task under evaluation and, for the purposes of identifying interface designs that exhibit poor resumability, the 85th percentile value is identified as most suitable. Findings from the study are discussed in terms of future application of the occlusion technique to assess in-vehicle information systems (IVIS).

Subcutaneous scalp emphysema, pneumo-orbitis and pneumocephalus in a neonate on high humidity high flow nasal cannula

High humidity high flow nasal cannula has become a widely used alternative for nasal continuous positive airway pressure for the treatment of apnea of prematurity. We describe our experience of one incident of subcutaneous scalp emphysema, pneumo-orbitis and pneumocephalus with concomitant use of the high-flow nasal cannula.

Effect of accessibility of influenza vaccination on the rate of childcare staff vaccination

We assessed the impact of free on-site influenza vaccination on childcare staff vaccination prevalence using 2 before-and-after studies. Vaccination was offered during the 2003-2004 and 2006-2007 influenza seasons. Staff vaccination prevalence was higher in each intervention season compared to the prior, nonintervention season. No baseline characteristics were associated with receipt of vaccination.

Inequalities in access to education and healthcare

The burden of disease is borne by those who suffer as patients but also by society at large, including health service providers. That burden is felt most severely in parts of the world where there is no infrastructure, or foreseeable prospects of any, to change the status quo without external support. Poverty, disease and inequality pervade all the activities of daily living in low-income regions and are inextricably linked. External interventions may not be the most appropriate way to impact on this positively in all circumstances, but targeted programmes to build social capital, within and by countries, are more likely to be sustainable. By these means, basic oral healthcare, underpinned by the primary healthcare approach, can be delivered to more equitably address needs and demands. Education is fundamental to building knowledge-based economies but is often lacking in such regions even at primary and secondary level. Provision of private education at tertiary level may also introduce its own inequities. Access to distance learning and community-based practice opens opportunities and is more likely to encourage graduates to work in similar areas. Recruitment of faculty from minority groups provides role models for students from similar backgrounds but all faculty staff must be involved in supporting and mentoring students from marginalized groups to ensure their retention. The developed world has to act responsibly in two crucial areas: first, not to exacerbate the shortage of skilled educators and healthcare workers in emerging economies by recruiting their staff; second, they must offer educational opportunities at an economic rate. Governments need to lead on developing initiatives to attract, support and retain a competent workforce.

441. Renin angiotensin system polymorphisms are associated with pregnancy complications

Preeclampsia (PE), small for gestational age (SGA) and preterm birth (PTB) together affect 20% of first pregnancies. Currently there is no reliable way to identify women at risk. Polymorphims in genes in the renin angiotensin system (RAS) may be associated with impaired placentation and poor maternal response to pregnancy and hence predict risk for pregnancy complications. We aimed to determine if three functional polymorphisms in RAS genes, namely, AGT M235T, ACE (I/D) and AT1R A1166C are associated with pregnancy complications. Pregnancy trios were prospectively recruited from two public hospitals in Adelaide. Pregnancies were classified into normal (n = 110), PE (n = 26), SGA (n = 47), PE+SGA (n = 12), gestational hypertension (GH, n = 17), PTB (n = 20). PE, PE +SGA and GH were also grouped together as hypertension. Parental blood and maternal blood pressure was sampled or measured at 15 weeks gestation. Cord blood was sampled after delivery. DNA was extracted from buffy coats and genotyped using high resolution melt analyses. Maternal plasma [ACE] was measured by ELISA. Data were analysed by ANOVA and Fisher's exact test. Likelihood ratios (LR) were calculated where appropriate. Maternal ACE I/D was associated with hypertension (P = 0.001, LR = 14.8) and SGA (P = 0.019, LR = 10). Paternal AT1R A1166C was associated with PTB (P = 0.01, LR = 7.4). For ACE I/D, plasma [ACE] in women with DD was 33% and 62% higher than ID and II, respectively (both P < 0.001). Systolic blood pressure in women with DD was 6% higher than II (P = 0.04). Our data suggest that RAS polymorphisms are associated with pregnancy complications. Furthermore, maternal ACE genotype determines plasma [ACE] and affects blood pressure at 15 weeks gestation, well before symptoms manifest. Our data also suggest that paternal genotype may be important in determining risk for pregnancy complications, consistent with the role of paternity in their aetiology.

Which parameters might predict complications after natural orifice endoluminal surgery (NOTES)? Results from a randomized comparison with open surgical access in pigs

BACKGROUND AND STUDY AIMS

Natural orifice transluminal endoscopic surgery (NOTES) is currently developed and assessed mainly in pig experiments. The vast majority of studies show a good outcome in short-term follow-up. The current study aims at comparing various parameters of postinterventional assessment and surveillance in relation to clinical behavior and autopsy results to find suitable control parameters and also to assess the pig as suitable model for NOTES compared with open surgery.

METHODS

Within the framework of a randomized prospective study of 20 pigs with iatrogenic colonic perforation comparing endoscopic with open surgical closure, clinical examination, including observation of behavior, food intake, and body temperature, was carried out daily. Laboratory parameters (white blood cells [WBC], granulocytes) were measured in 14 animals. Weight was measured preoperatively and on days 2 and 7 postoperatively. Results were matched with complications found during/after 2 weeks' survival. Pre-autopsy sterile cultures were taken from the peritoneal cavities to determine possible bacterial contamination.

RESULTS

Three animals from the surgical group were sacrificed on days 4, 8, and 12 because they became severely ill, with autopsy revealing intussusception from adhesions, peritoneal abscess, and peritonitis, in one pig each; another animal had culture positive for ESCHERICHIA COLI. Three minor complications (2 cough, 1 continuing fever with adhesions to the bladder found on autopsy) occurred in the endoscopic group without compromised recovery. WBC were measured in 14 animals, and found to be elevated (8 - 36 x 10 (9)/l) in six on day 2 including the two animals with severe complications. Between pre- and post-procedure, WBC increased about twofold in the uneventful cases but fourfold in the two animals with severe complications. Cultures from the abdominal cavity before autopsy were negative in all but one animal.

CONCLUSION

Animal behavior was a reliable indicator of severe complications. Fever, body weight, and the results of in vitro cultures of the peritoneal fluid did not indicate complications. WBC proved not to be specific but showed a larger increase in pigs with severe complications.

Efficacy and safety of antidepressants for treatment of depression in Alzheimer's disease: a metaanalysis

OBJECTIVE

Depression in patients with Alzheimer's disease (AD) is common (15% to 63%) and is associated with significant morbidity and increased mortality. Our objective was to quantitatively summarize the data on the efficacy and safety of antidepressant treatment for depression complicating AD.

METHOD

We performed a metaanalysis of randomized, double-blind, placebo-controlled trials of antidepressants with a database search of the English literature (up to 2006) and a manual search of references in the retrieved articles. We extracted the proportion of subjects who responded and remitted, experienced adverse events (AEs), discontinued treatment due to AEs, or discontinued treatment for any reason. Cognition scores were also extracted.

RESULTS

We included 5 studies, which involved 82 subjects treated with antidepressants and 83 subjects who received placebo treatment. Antidepressants were superior to placebo for both treatment response (odds ratio [OR] 2.32; 95% confidence interval [CI], 1.04 to 5.16) and remission of depression (OR 2.75; 95% CI, 1.13 to 6.65). There were no significant differences between the 2 groups for change in cognition (weighted mean difference -0.71, 95% CI, -3.20 to 1.79), overall dropouts (OR 0.70; 95% CI, 0.29 to 1.66) or dropout due to AEs (OR 1.41; 95% CI 0.36 to 5.54). The numbers needed to treat for one additional AD patient to respond to antidepressant treatment were 5 (95% CI, 3 to 59) and 5 (95% CI, 2 to 24) for remission of depression.

CONCLUSIONS

Antidepressant treatment for depression in AD is efficacious, with rates of discontinuation that are comparable to placebo. Nonetheless, clinicians must be vigilant regarding the potential side effects of antidepressants in this population.

The yield of head CT in syncope: a pilot study

Although head CT is often routinely performed in emergency department (ED) patients with syncope, few studies have assessed its value.

OBJECTIVES

To determine the yield of routine head CT in ED patients with syncope and analyse the factors associated with a positive CT.

METHODS

Prospective, observational, cohort study of consecutive patients presenting with syncope to an urban tertiary-care ED (48,000 annual visits).

INCLUSION CRITERIA

age >or=18 and loss of consciousness (LOC). Exclusion criteria included persistent altered mental status, drug-related or post-trauma LOC, seizure or hypoglycaemia. Primary outcome was abnormal head CT including subarachnoid, subdural or parenchymal haemorrhage, infarction, signs of acute stroke and newly diagnosed brain mass.

RESULTS

Of 293 eligible patients, 113 (39%) underwent head CT and comprise the study cohort. Ninety-five patients (84%) were admitted to the hospital. Five patients, 5% (95% CI=0.8%-8%), had an abnormal head CT: 2 subarachnoid haemorrhage, 2 cerebral haemorrhage and 1 stroke. Post hoc examination of patients with an abnormal head CT revealed focal neurologic findings in 2 and a new headache in 1. The remaining 2 patients had no new neurologic findings but physical findings of trauma (head lacerations with periorbital ecchymoses suggestive of orbital fractures). All patients with positive findings on CT were >65 years of age. Of the 108 remaining patients who had head CT, 45 (32%-51%) had signs or symptoms of neurologic disease including headache, trauma above the clavicles or took coumadin. Limiting head CT to this population would potentially reduce scans by 56% (47%-65%). If age >60 were an additional criteria, scans would be reduced by 24% (16%-32%). Of the patients who did not have head CT, none were found to have new neurologic disease during hospitalisation or 30-day follow-up.

CONCLUSIONS

Our data suggest that the derivation of a prospectively derived decision rule has the potential to decrease the routine use of head CT in patients presenting to the ED with syncope.

Non-normal path analysis in the presence of measurement error and missing data: a Bayesian analysis of nursing homes' structure and outcomes

Path analytic models are useful tools in quantitative nursing research. They allow researchers to hypothesize causal inferential paths and test the significance of these paths both directly and indirectly through a mediating variable. A standard statistical method in the path analysis literature is to treat the variables as having a normal distribution and to estimate paths using several least squares regression equations. The parameters corresponding to the direct paths have point and interval estimates based on normal distribution theory. Indirect paths are a product of the direct path from the independent variable to the mediating variable and the direct path of the mediating variable to the dependent variable. However, in the case of non-normal distributions, the point and interval estimates of the indirect path become much more difficult to estimate. We address the issue of calculating indirect point and interval estimates in the case of non-normally distributed data. Our substantive application is a nursing home research problem in which the variables in the path analysis of interest involve variables with normal, Bernoulli, or Poisson distributions. Additionally, one of the Poisson variables is observed with error. This paper addresses estimating point and interval estimation of indirect paths for variables with non-normal distributions in the presence of missing data and measurement error. We handle these difficulties from a fully Bayesian point of view. We present our substantive path analysis motivated from a nursing home structure, process, and outcomes model. Our results focus on the impact job turnover in the nursing homes has on nursing home outcomes.

A randomized controlled trial of an interactive Web-based intervention for reducing alcohol consumption

In an uncontrolled pilot study of an interactive, Web-based treatment programme for people with alcohol problems, the mean number of units consumed decreased from 33 per week to 23. A two-arm online randomized controlled trial will be conducted to determine the effectiveness of an interactive Web-based intervention for reducing alcohol consumption. Participants will be randomized to intervention (access to an interactive Web-based intervention plus information) or control (access to an information Web-site only) groups, and followed up for six months. The primary outcome measure will be reduction in units of alcohol consumed in the previous seven days; secondary outcome measures will determine effects on alcohol dependence, alcohol-related harm and social disruption and quality of life. Recruitment, consent, randomization, intervention and follow-up will all be delivered on-line.

DKA, CVL and DVT. Increased risk of deep venous thrombosis in children with diabetic ketoacidosis and femoral central venous lines

Incidence of type 1 diabetes mellitus is continuing to rise in children. The presentation of diabetic ketoacidosis (DKA) in children with newly diagnosed diabetes is significantly higher in those less than 5 years old. Critically ill patients admitted to Paediatric Intensive Care Units (PICU), would have a central venous line (CVL) inserted as part of their ongoing management. There are associations linking with the development of deep venous thrombosis (DVT) in DKA/CVL patients. An 18-month-old boy presented with a short history of polydypsia, polyuria and weight loss. The initial blood sugar was 27.0 mmol/L and a venous blood gas showed severe metabolic acidosis. He was diagnosed and treated for DKA. He was transferred to the regional PICU for further management. There, a central venous line (CVL) was inserted in his left femoral vein. This was removed on Day 4. Subsequently, he developed a swelling on his left leg, with significant discrepancy in leg circumference. Doppler ultrasound confirmed a deep venous thrombosis. Conclusion Diabetes has a propensity for hypercoagulability and DKA promotes a prothrombotic state. Retrospective studies have shown younger patients with DKA and a femoral CVL are at higher risk of developing DVT. A central femoral line should avoided in such patients. DVT prophylaxis and Doppler follow up should also be considered.

Reliability of the Nursing Home Survey Process: A Simultaneous Survey Approach

PURPOSE

We designed this study to examine the reliability of the nursing home survey process in the state of Kansas using regular and simultaneous survey teams. In particular, the study examined how two survey teams exposed to the same information at the same time differed in their interpretations.

DESIGN AND METHODS

The protocol for simultaneous surveys consists of having one in-region and one out-of-region team survey a facility together.

RESULTS

The regular and simultaneous survey teams generally agreed about the number of deficiencies. The intraclass correlation coefficient was 0.87 for total deficiencies and 0.76 for deficiencies with scores of G or higher. But in a substantial number of instances the teams did not agree about the scope and severity of the deficiency or about what regulation the nursing home had breached.

IMPLICATIONS

The survey process is reliable when assessing aggregate results, but it is only moderately reliable when examining individual citations. Stakeholders (i.e., consumers, policy makers, nursing home administrators) should be aware of the limitations of the survey process. It needs to be modified to reduce variability.

The hyper-CVAD-rituximab chemotherapy programme followed by high-dose busulfan, melphalan and autologous stem cell transplantation produces excellent event-free survival in patients with previously untreated mantle cell lymphoma

The hyper-CVAD + rituximab (R) programme consists of fractionated cyclophosphamide, vincristine, doxorubicin and dexamethasone + R alternating with high-dose methotrexate + cytarabine (HD MTX/ARA-C) + R. This regimen, when used as initial therapy for patients under 65 years of age with previously untreated mantle cell lymphoma (MCL), results in remission rates of > 85% with a median event-free survival (EFS) of > 50 months, but with a pattern of continuous relapse out to 60 months. We performed a study of hyper-CVAD + R, followed by consolidative peripheral blood progenitor cells autograft [autologous stem cell transplant (AuSCT)] with high-dose busulfan and melphalan (Bu/Mel) conditioning, in patients with responsive disease. Thirteen patients with a median age of 54 (range = 33-61) were treated. Complete remission (CR) was achieved in 12 patients (92%) after hyper-CVAD + R and 12 completed AuSCT after Bu/Mel conditioning. One patient died during the autograft and another declined AuSCT after achieving a CR with hyper-CVAD + R. With a median follow-up from diagnosis of 36 months (range = 16-53 months), the observed 36 months overall survival and EFS are both 92% for the whole cohort. These data confirm the excellent CR rates achieved by the use of hyper-CVAD + R in patients with MCL and suggest that consolidation with Bu/Mel and AuSCT may improve durable disease control when compared to published outcomes of hyper-CVAD + R alone.

Sedation in Wales: a questionnaire

AIM

To identify the current provision of sedation in primary dental care in Wales.

DESIGN

Postal questionnaire survey.

SETTING

Wales 2003.

SUBJECTS AND MATERIALS

Questionnaires were sent to all dentists appearing on the Dentists Register with addresses in Wales (n = 1374). The questionnaires sought details on personal status, use of and training in conscious sedation techniques.

RESULTS

In total 951 (69%) questionnaires were returned, 720 (90%) respondents worked in a primary dental care setting. Only 87 (12.1%) primary care dentists offered some form of sedation.

CONCLUSIONS

The provision of conscious sedation services in primary dental care in Wales is poor.

Inter-rater reliability of nursing home surveys: a Bayesian latent class approach

In the U.S., federal and state governments perform routine inspections of nursing homes. Results of the inspections allow government to generate fines for findings of non-compliance as well as allow consumers to rank facilities. The purpose of this study is to investigate the inter-rater reliability of the nursing home survey process. In general, the survey data involves 191 binary deficiency variables interpreted as 'deficient' or 'non-deficient'. To reduce the dimensionality of the problem, our proposed method involves two steps. First, we reduce the deficiency categories to sub-categories using previous nursing home studies. Second, looking at the State of Kansas specifically, we take the deficiency data from 1 year, and use Bayesian latent class analysis (LCA) to collapse the sub-categories to a binary variable. We evaluate inter-rater agreement using deficiency data from two separate survey teams on one facility, a matched-pair design. We evaluate the agreement of the two raters on binary data using the weights from the LCA. This allows a two-by-two contingency analysis using a Bayesian beta-binomial model. We elicit informative prior distributions from the nursing home providers. Together, with the experimental data, this provides a posterior distribution of the kappa agreement of the raters for nursing home deficiency citation data.

Postzygotic mutation and germline mosaicism in the otopalatodigital syndrome spectrum disorders

The otopalatodigital syndrome (OPD) spectrum disorders are a heterogeneous group of skeletal dysplasias caused by mutations in the X-linked gene, FLNA. All OPD spectrum disorders (otopalatodigital syndromes types 1 and 2, frontometaphyseal dysplasia and Melnick-Needles syndrome) exhibit significant interfamilial variability in their expressivity, especially in female subjects. Factors contributing to this may include allelic heterogeneity, variation in the degree of skewing of X inactivation or, conceivably, mosaicism for the underlying causative mutation. We report here monozygotic twin sisters who are discordant for the severe phenotype, Melnick-Needles syndrome, associated with the heterozygous mutation, 3596C>T. We also describe two brothers with otopalatodigital syndrome type 1 due to the FLNA mutation 620G>A. The mutation is not detectable in the blood leucocytes of their clinically unaffected mother, indicating that she is a germline mosaic for the condition. The description of somatic mutations and germline mosaicism in FLNA has implications for clinical and molecular diagnosis, phenotypic expression and genetic counseling of families with these disorders.

Scarlet fever outbreak in two nurseries in southwest England

Fifty cases of scarlet fever were reported in a county in southwest England between 1 January and 28 February 2006

A history of total mercury in edible muscle of fish from lakes in northern Canada

Subsistence fishing has been an important source of food for Native People in northern Canada since prehistoric time. Measurements of the levels of mercury in edible muscle of northern fish have been undertaken for over three decades in efforts to evaluate the risks of consuming northern fish. This report summarizes the data obtained from 7974 fish of 25 species from sites distributed from the Yukon to Labrador. The most abundant species were lake trout, lake whitefish, arctic char, walleye, northern pike and burbot. The question being asked was essentially "Are the fish safe to eat?" The results were used to support decisions on fishing and consumption of fish. They were sorted in several ways, into concentration ranges corresponding to human consumption guidelines, into political jurisdictions and into types of bedrock geology. Overall walleye, northern pike and lake trout, usually exceeded the subsistence consumption guideline of 0.2 microg g-1 total mercury and often exceeded the higher guideline of 0.5 microg g-1 total mercury for commercial sales of fish. Mercury in burbot, another facultative predator, was often lower but several still exceeding a guideline. Arctic char collections were mostly from anadromous populations and these had very low levels of mercury, presumably reflecting marine food sources. Lake whitefish were among the cleanest fish examined with 69 of 81 collections falling in the lowest range. Most collections were from sites in sedimentary rock. However a few sites were in metamorphic, intrusive or volcanic rocks and these, taken together, tended to have a higher proportion of sites in the higher ranges of mercury. These results indicate a widespread problem with mercury in subsistence fisheries for predator species of fish with the problem being most problematic for Nunavut.

Aeolian processes at the Mars Exploration Rover Meridiani Planum landing site

The martian surface is a natural laboratory for testing our understanding of the physics of aeolian (wind-related) processes in an environment different from that of Earth. Martian surface markings and atmospheric opacity are time-variable, indicating that fine particles at the surface are mobilized regularly by wind. Regolith (unconsolidated surface material) at the Mars Exploration Rover Opportunity's landing site has been affected greatly by wind, which has created and reoriented bedforms, sorted grains, and eroded bedrock. Aeolian features here preserve a unique record of changing wind direction and wind strength. Here we present an in situ examination of a martian bright wind streak, which provides evidence consistent with a previously proposed formational model for such features. We also show that a widely used criterion for distinguishing between aeolian saltation- and suspension-dominated grain behaviour is different on Mars, and that estimated wind friction speeds between 2 and 3 m s(-1), most recently from the northwest, are associated with recent global dust storms, providing ground truth for climate model predictions.

A controlled trial of smart infusion pumps to improve medication safety in critically ill patients

OBJECTIVE

Intravenous medications are vital during inpatient management. Errors associated with the administration of medications through intravenous infusion pumps to critically ill patients can result in adverse drug events. We sought to assess the impact of smart pumps with integrated decision support software on the incidence and nature of medication errors and adverse drug events.

DESIGN

We performed a prospective, randomized time-series trial and compared the serious medication error rate between intervention (decision support on) and control (decision support off) periods. Serious medication errors included both near-misses and preventable adverse drug events. Pump software produced log reports to help identify potential events. Events were presented to physicians for rating of event type, preventability, and severity.

SETTING

Cardiac surgical intensive care and step-down units between February and December 2002.

PATIENTS

Pump data were available for 744 cardiac surgery admissions.

INTERVENTIONS

Decision support during medication administration provided feedback including alerts, reminders, and unit-specific drug rate limits.

MEASUREMENTS AND MAIN RESULTS

We found a total of 180 serious medication errors, including 14 and 11 preventable adverse drug events and 73 and 82 nonintercepted potential adverse drug events in the control and intervention periods, respectively. The serious medication error rates in the control and intervention periods were 2.03 and 2.41 per 100 patient-pump-days, respectively (p = .124). We also found numerous opportunities for safety improvement. Violations of infusion practice during the intervention periods included 571 (25%) bypasses of the drug library. Medications were also frequently administered without documentation of physician orders in both periods (n = 823; 7.7%).

CONCLUSION

Intravenous medication errors and adverse drug events were frequent and could be detected using smart pumps. We found no measurable impact on the serious medication error rate, likely in part due to poor compliance. Although smart pumps have great promise, technological and nursing behavioral factors must be addressed if these pumps are to achieve their potential for improving medication safety.

Encephalopathy in pediatric patients after allogeneic hematopoietic stem cell transplantation is associated with a poor prognosis

Encephalopathy is a poorly characterized complication of hematopoietic stem cell transplantation (HSCT). No comprehensive report of encephalopathy exists for children, and the literature contains only a few for adults. We analyzed a large cohort of 405 pediatric patients who underwent allogeneic HSCT during a 10-year period and identified 26 patients (6.4%) who experienced encephalopathy. Identifiable causes of encephalopathy included infection (n=5), single or multiorgan failure (n=4), medication-related complications (n=3), nonconvulsive seizures (n=4), acute disseminated encephalomyelitis (n=2), thrombotic thrombocytopenic purpura (n=2), and stroke (n=1). We were unable to identify the etiology of encephalopathy in five (19%) patients. The prognosis for pediatric patients with encephalopathy was poor: only four (15%) experienced complete neurologic recovery, and 10 (38%) patients experienced partial recovery with residual neurologic deficits. Nine (35%) patients with complete or partial recovery survive long term. A total of 17 patients died; one died of progressive encephalopathy, and 16 died of either relapse of primary disease or toxicity. MRI, CSF analysis including molecular testing for infectious pathogens, and brain biopsy were helpful in obtaining a diagnosis in most of our patients. However, a standardized approach to accurate and timely diagnosis and treatment is needed to improve outcome in these patients.

The benefits and risks associated with cholinesterase inhibitor therapy in Alzheimer’s disease

The 'second-generation' cholinesterase inhibitors (ChEIs), donepezil, galantamine and rivastigmine, are a class of medications that are currently approved for the treatment of mild-to-moderate Alzheimer's disease (AD). These medications have proven efficacy in improving cognition, behaviour, activities of daily living, and global functioning in mild-to-moderate AD. They have also been shown to reduce caregiver stress and to delay time to nursing home placement. Two separate meta-analyses have indicated that ChEIs confer a modest but significant therapeutic benefit in the treatment of AD, despite higher rates of treatment discontinuation and side effects than placebo. There is growing evidence to support their efficacy in treating moderate-to-severe AD. ChEIs are generally well-tolerated, with side effects that tend to be dose-related and are most problematic during dose titration. The most common adverse effects, related to cholinergic stimulation in the brain and peripheral tissues, include gastrointestinal, cardiorespiratory, extrapyramidal, genitourinary, and musculoskeletal symptoms, as well as sleep disturbances. Few clinically significant drug-drug interactions with ChEIs have been identified. Three head-to-head trials of ChEIs in the treatment of AD have been published to date, but are limited due to their open-label design, rates of titration, and the drug dosage levels utilised. Further study is needed to examine other indications for ChEIs, as well as their combination with newer treatments, such as memantine.

Virtual outreach: a randomised controlled trial and economic evaluation of joint teleconferenced medical consultations

OBJECTIVES

To test the hypotheses that virtual outreach would reduce offers of hospital follow-up appointments and reduce numbers of medical interventions and investigations, reduce numbers of contacts with the health care system, have a positive impact on patient satisfaction and enablement, and lead to improvements in patient health status. To perform an economic evaluation of virtual outreach.

DESIGN

A randomised controlled trial comparing joint teleconsultations between GPs, specialists and patients with standard outpatient referral. It was accompanied by an economic evaluation.

SETTING

The trial was centred on the Royal Free Hampstead NHS Trust, London, and the Royal Shrewsbury Hospital Trust in Shropshire. The project teams recruited and trained a total of 134 GPs from 29 practices and 20 consultant specialists.

PARTICIPANTS

In total, 3170 patients were referred, of whom 2094 consented to participate in the study and were eligible for inclusion. In all, 1051 patients were randomised to the virtual outreach group and 1043 to standard outpatient appointments. The patients were followed 6 months after their index consultation.

INTERVENTIONS

Patients randomised to virtual outreach underwent a joint teleconsultation, in which they attended the general practice surgery where they and their GP consulted with a hospital specialist via a videolink between the hospital and the practice.

MAIN OUTCOME MEASURES

Outcome measures included offers of follow-up outpatient appointments, numbers of tests, investigations, procedures, treatments and contacts with primary and secondary care, patient satisfaction (Ware Specific Visit Questionnaire), enablement (Patient Enablement Instrument) and quality of life (Short Form-12 and Child Health Questionnaire). An economic evaluation of the costs and consequences of the intervention was undertaken. Sensitivity analysis was used to test the robustness of the results.

RESULTS

Patients in the virtual outreach group were more likely to be offered a follow-up appointment. Significant differences in effects were observed between the two sites and across different specialities. Virtual outreach increased the offers of follow-up appointments more in Shrewsbury than in London, and more in ENT and orthopaedics than in the other specialities. Fewer tests and investigations were ordered in the virtual outreach group, by an average of 0.79 per patient. In the 6-month period following the index consultation, there were no significant differences overall in number of contacts with general practice, outpatient visits, accident and emergency contacts, inpatient stays, day surgery and inpatient procedures or prescriptions between the randomised groups. Tests of interaction indicated that virtual outreach decreased the number of tests and investigations, particularly in patients referred to gastroenterology, and increased the number of outpatient visits, particularly in those referred to orthopaedics. Patient satisfaction was greater after a virtual outreach consultation than after a standard outpatient consultation, with no heterogeneity between specialities or sites. However, patient enablement after the index consultation, and the physical and psychological scores of the Short Form-12 for adults and the scores on the Child Health Questionnaire for children under 16, did not differ between the randomised groups at 6 months' follow-up. NHS costs over 6 months were greater for the virtual outreach consultations than for conventional outpatients, pound 724 and pound 625 per patient, respectively. The index consultation accounted for this excess. Cost and time savings to patients were found. Estimated productivity losses were also less in the virtual outreach group.

CONCLUSIONS

Virtual outreach consultations result in significantly higher levels of patient satisfaction than standard outpatient appointments and lead to substantial reductions in numbers of tests and investigations, but they are variably associated with increased rates of offer of follow-up according to speciality and site. Changes in costs and technological advances may improve the relative position of virtual consultations in future. The extent to which virtual outreach is implemented will probably be dependent on factors such as patient demand, costs, and the attitudes of staff working in general practice and hospital settings. Further research could involve long-term follow-up of patients in the virtual outreach trial to determine downstream outcomes and costs; further study into the effectiveness and costs of virtual outreach used for follow-up appointments, rather than first-time referrals; and whether the costs of virtual outreach could be substantially reduced without adversely affecting the quality of the consultation if nurses or other members of the primary care team were to undertake the hosting of the joint teleconsultations in place of the GP. Qualitative work into the attitudes of the patients, GPs and hospital specialists would also be valuable.

Atmospheric imaging results from the Mars exploration rovers: Spirit and Opportunity

A visible atmospheric optical depth of 0.9 was measured by the Spirit rover at Gusev crater and by the Opportunity rover at Meridiani Planum. Optical depth decreased by about 0.6 to 0.7% per sol through both 90-sol primary missions. The vertical distribution of atmospheric dust at Gusev crater was consistent with uniform mixing, with a measured scale height of 11.56 +/- 0.62 kilometers. The dust's cross section weighted mean radius was 1.47 +/- 0.21 micrometers (mm) at Gusev and 1.52 +/- 0.18 mm at Meridiani. Comparison of visible optical depths with 9-mm optical depths shows a visible-to-infrared optical depth ratio of 2.0 +/- 0.2 for comparison with previous monitoring of infrared optical depths.

Evidence from Opportunity's Microscopic Imager for water on Meridiani Planum

The Microscopic Imager on the Opportunity rover analyzed textures of soils and rocks at Meridiani Planum at a scale of 31 micrometers per pixel. The uppermost millimeter of some soils is weakly cemented, whereas other soils show little evidence of cohesion. Rock outcrops are laminated on a millimeter scale; image mosaics of cross-stratification suggest that some sediments were deposited by flowing water. Vugs in some outcrop faces are probably molds formed by dissolution of relatively soluble minerals during diagenesis. Microscopic images support the hypothesis that hematite-rich spherules observed in outcrops and soils also formed diagenetically as concretions.

The wear and fracture behaviour of ultra high molecular weight polyethylene subjected to gamma-irradiation in an atmosphere of acetylene

The wear and mechanical properties of GUR 1020 (Perplas IMP 2000-2) Ultra High Molecular Weight Polyethylene (UHMWPE) subjected to gamma-irradiation in an atmosphere of acetylene, were evaluated for a range of processing conditions of irradiation, annealing and ageing. The results were compared with those obtained for the virgin UHMWPE material and material processed using conventional gamma-irradiation in nitrogen. Cross-linking produced by irradiation in acetylene, followed by subsequent annealing was found to be significantly more effective in improving the mechanical and wear properties of UHMWPE compared to when the material was irradiated in nitrogen. Gel fraction analysis on its own, while being able to detect the degree of cross-linking, was found to be insufficient in determining the effectiveness of the cross-links and the resulting mechanical properties of the UHMWPE material. The results suggest that gamma-irradiation in an atmosphere of acetylene may provide significant advantages over conventional UHMWPE processing and irradiation cross-linking techniques.

Clinical risk management in obstetrics: eclampsia drills

PROBLEM

Infrequent presentation of patients with eclampsia, leading to staff inexperienced in the condition and untested emergency systems.

DESIGN

"Fire drill" programme using on-site simulation of patients with eclampsia.

SETTING

Tertiary referral obstetric unit.

KEY MEASURES FOR IMPROVEMENT

Successful implementation of measures to optimise management of eclampsia.

STRATEGIES FOR CHANGE

Rapid activation of emergency team after one call, development and dissemination of evidence based protocol for eclampsia, strategically placed "eclampsia boxes," individual staff feedback and education.

EFFECTS OF CHANGE

Efficient and appropriate management of subsequent simulated patients.

LESSONS LEARNT

On-site simulation can identify and correct potential deficiencies in the care of patients with eclampsia.

Clinical risk management in obstetrics: eclampsia drills

PROBLEM

Infrequent presentation of patients with eclampsia, leading to staff inexperienced in the condition and untested emergency systems.

DESIGN

"Fire drill" programme using on-site simulation of patients with eclampsia.

SETTING

Tertiary referral obstetric unit.

KEY MEASURES FOR IMPROVEMENT

Successful implementation of measures to optimise management of eclampsia.

STRATEGIES FOR CHANGE

Rapid activation of emergency team after one call, development and dissemination of evidence based protocol for eclampsia, strategically placed "eclampsia boxes," individual staff feedback and education.

EFFECTS OF CHANGE

Efficient and appropriate management of subsequent simulated patients.

LESSONS LEARNT

On-site simulation can identify and correct potential deficiencies in the care of patients with eclampsia.

Non-HLA gene polymorphisms in juvenile rheumatoid arthritis

A substantial amount of work has gone into elucidating the non-HLA genetic associations in JRA. In this paper, we attempt to provide an overview of this body of knowledge. Direct comparison of the different studies is difficult. Different ethnic populations, different JRA/JIA subgroups, and different systems of nomenclature and classification all impose various limitations. Adding to the complexity is the polygenic nature of chronic childhood arthritis. Family based studies will be necessary to overcome ethnicity related issues. A candidate gene approach complemented by genome wide screen data will hopefully advance our knowledge of the genetics of JRA.

Cost-effectiveness of brief cognitive behaviour therapy versus treatment as usual in recurrent deliberate self-harm: a decision-making approach

BACKGROUND

Deliberate self-harm can be costly, in terms of treatment and subsequent suicide. Any intervention that reduces episodes of self-harm might therefore have a major impact on the costs incurred by service providers and the productivity losses due to illness or premature death.

METHOD

Four hundred and eighty patients with a history of recurrent deliberate self-harm were randomized to manual-assisted cognitive behaviour therapy (MACT) or treatment as usual. Economic data were collected from patients at baseline, 6 and 12 months, and these data were complete for 397 patients. Incremental cost-effectiveness was explored using the primary outcome measure, proportion of patients having a repeat episode of deliberate self-harm, and quality of life. The uncertainty surrounding costs and effects was represented using cost-effectiveness acceptability curves.

RESULTS

Differences in total cost per patient were statistically significant at 6 months in favour of MACT (pounds sterling -897, 95 % CI -1747 to -48, P=0.04), but these differences did not remain significant at 12 months (pounds sterling -838, 95% CI -2142 to 466, P=0.21). Nevertheless, exploration of the uncertainty surrounding these estimates suggests there is >90% probability that MACT is a more cost-effective strategy for reducing the recurrence of deliberate self-harm in this population over 1 year than treatment as usual. The results for quality of life were not conclusive.

CONCLUSION

Cost-effectiveness acceptability curves demonstrate that, based on the evidence currently available, to reject MACT on traditional grounds of statistical significance and to continue funding current practice has <10% chance of being the correct decision in terms of cost-effectiveness.

Randomized controlled trial of brief cognitive behaviour therapy versus treatment as usual in recurrent deliberate self-harm: the POPMACT study

BACKGROUND

We carried out a large randomized trial of a brief form of cognitive therapy, manual-assisted cognitive behaviour therapy (MACT) versus treatment as usual (TAU) for deliberate self-harm.

METHOD

Patients presenting with recurrent deliberate self-harm in five centres were randomized to either MACT or (TAU) and followed up over 1 year. MACT patients received a booklet based on cognitive behaviour therapy (CBT) principles and were offered up to five plus two booster sessions of CBT from a therapist in the first 3 months of the study. Ratings of parasuicide risk, anxiety, depression, social functioning and global function, positive and negative thinking, and quality of life were measured at baseline and after 6 and 12 months.

RESULTS

Four hundred and eighty patients were randomized. Sixty per cent of the MACT group had both the booklet and CBT sessions. There were seven suicides, five in the TAU group. The main outcome measure, the proportion of those repeating deliberate self-harm in the 12 months of the study, showed no significant difference between those treated with MACT (39%) and treatment as usual (46%) (OR 0.78, 95% CI 0.53 to 1.14, P=0.20).

CONCLUSION

Brief cognitive behaviour therapy is of limited efficacy in reducing self-harm repetition, but the findings taken in conjunctin with the economic evaluation (Byford et al. 2003) indicate superiority of MACT over TAU in terms of cost and effectiveness combined.

Melanopsin and rod-cone photoreceptive systems account for all major accessory visual functions in mice

In the mammalian retina, besides the conventional rod-cone system, a melanopsin-associated photoreceptive system exists that conveys photic information for accessory visual functions such as pupillary light reflex and circadian photo-entrainment. On ablation of the melanopsin gene, retinal ganglion cells that normally express melanopsin are no longer intrinsically photosensitive. Furthermore, pupil reflex, light-induced phase delays of the circadian clock and period lengthening of the circadian rhythm in constant light are all partially impaired. Here, we investigated whether additional photoreceptive systems participate in these responses. Using mice lacking rods and cones, we measured the action spectrum for phase-shifting the circadian rhythm of locomotor behaviour. This spectrum matches that for the pupillary light reflex in mice of the same genotype, and that for the intrinsic photosensitivity of the melanopsin-expressing retinal ganglion cells. We have also generated mice lacking melanopsin coupled with disabled rod and cone phototransduction mechanisms. These animals have an intact retina but fail to show any significant pupil reflex, to entrain to light/dark cycles, and to show any masking response to light. Thus, the rod-cone and melanopsin systems together seem to provide all of the photic input for these accessory visual functions.

Perioperative corticosteroid supplementation and dento-alveolar surgery

Patients are referred to hospital for dento-alveolar surgical procedures requiring supplemental corticosteroid administration. However, it has been reported that medically compromised patients who require routine dental treatment are being referred unnecessarily. This article reports a retrospective study undertaken at a Regional Maxillofacial Unit over a 24-month period, which reveals the referral pattern and management of patients specifically referred for outpatient dental treatment with corticosteroid supplementation. The paper highlights the dilemma confronting practitioners when reviewing the literature on corticosteroid supplementation and the confusion that still exists in both the primary and secondary care settings as to which patients should be prescribed supplemental corticosteroids. A simplified guide is proposed for the clinical management of these patients.

Intelligent intravenous infusion pumps to improve medication administration safety

Intravenous (IV) medications are vital in the management of hospitalized patients. Inpatients frequently receive several IV medications concurrently, and these are commonly delivered with infusion pump systems. In particular, critically ill patients receive potent "high-alert" IV drugs, many with narrow safety margins requiring careful nursing titration. However, while intravenous medications have important benefits, errors associated with IV medication administration can result in severe or life-threatening adverse drug events (ADEs). Although errors in prescribing are often intercepted, administration errors do not get caught with most current systems While several safety improvements in IV infusion pump design have reduced mechanical complications, errors with IV drug administration such as incorrect programming persist. Intelligent IV infusion pumps have integrated software to provide point of care decision support (DS). This software includes drug library profiles configured for specific patient care units and includes programming of safety limits for drug/dose calculations.