Evaluation of a hepatitis C clinical care coordination programme's effect on treatment initiation and cure: A surveillance-based propensity score matching approach

Hepatitis C (HCV) is a viral infection that if left untreated can severely damage the liver. Project INSPIRE was a 3 year HCV care coordination programme in New York City (NYC) that aimed to address barriers to treatment initiation and cure by providing patients with supportive services and health promotion. We examined whether enrolment in Project INSPIRE was associated with differences in HCV treatment and cure compared with a demographically similar group not enrolled in the programme. INSPIRE participants in 2015 were matched with a cohort of HCV-infected persons identified in the NYC surveillance registry, using full optimal matching on propensity scores and stratified by INSPIRE enrolment status. Conditional logistic regression was used to assess group differences in the two treatment outcomes. Two follow-up sensitivity analyses using individual pair-matched sets and the full unadjusted cohort were also conducted. Treatment was initiated by 72% (790/1130) of INSPIRE participants and 36% (11 960/32 819) of study-eligible controls. Among initiators, 65% (514/790) of INSPIRE participants compared with 47% (5641/11 960) of controls achieved cure. In the matched analysis, enrolment in INSPIRE increased the odds of treatment initiation (OR: 5.25, 95% CI: 4.47-6.17) and cure (OR: 2.52, 95% CI: 2.00-3.16). Results from the sensitivity analyses showed agreement with the results from the full optimal match. Participation in the HCV care coordination programme significantly increased the probability of treatment initiation and cure, demonstrating that care coordination for HCV-infected individuals improves treatment outcomes.

The role of web-based environmental information in urban planning--the environmental information system for planners

The Environmental Information System for Planners (EISP) is a proof of concept web-based system designed to support decision making within the UK planning framework by making information on environmental issues more widely accessible. It incorporates relevant outputs from the Natural Environment Research Council (NERC) Urban Regeneration and the Environment (URGENT) research programme and from research directly commissioned by the Office of the Deputy Prime Minister (ODPM). It supports three principal planning functions carried out by local authorities: pre-planning enquiries, development control decisions and strategic planning. Eleven environmental science themes are incorporated: Air quality, Shallow undermining, Landslide susceptibility, Groundwater protection, Flood risk, Drainage, Land contamination, Proximity to landfill, Biodiversity, Natural and Man-made heritage. Decision flow diagrams represent detailed analysis of workflow in each theme, taking account of best practice, regulatory responsibilities and planning guidance. Industry-standard web technologies integrate the flows and provide access to the system via secure web pages. Underpinning the system is an environmental geographical information system (GIS) containing up-to-date data, information and models relevant to each theme. The modular system design allows new legislation and local priorities and datasets to be easily incorporated. Web technology delivers information and research data that have hitherto been difficult for the non-specialist to access and have therefore been under-exploited. The study has demonstrated a successful application of the principles of e-Governance in an area where informed decisions commonly require specialist information. The system, if rolled out nationally, offers potential economic benefits and efficiency savings for both planners and developers.

The Scottish Perinatal Neuropathology Study-clinicopathological correlation in stillbirths

OBJECTIVE

To examine the neuropathology of fetuses dying before birth, to determine the timing of any brain damage seen and to ascertain clinical associations of pre-existing brain damage.

DESIGN

Population-based observational study.

SETTING

All 22 delivery units within Scotland, 1995-1998.

SAMPLE

All stillborn fetuses > or =24 weeks of gestation excluding those with chromosomal abnormality or central nervous system/cardiothoracic malformation.

METHODS

Clinical detail was collected on all stillborn fetuses. Requests for postmortem included separate request for detailed neuropathological examination. Stillborn fetuses were classified as full term antepartum (normal growth/growth restricted), preterm antepartum (normal growth/growth restricted), intrapartum (full term/preterm), multiple births and stillborn fetuses following abruptions. Clinicopathological correlation attempted to define the timing of brain insult. Placentas were examined for each case where available.

MAIN OUTCOME MEASURES

Presence of established and/or recent brain damage. RESULTS Clinical details were available for 471 stillborn fetuses, and detailed neuropathology was possible in 191 cases. Of these 191, 13 were multiple births, 9 died following abruption, 12 were intrapartum deaths and 157 were antepartum stillborn fetuses (99 preterm and 58 full term). Recent or established brain damage was seen in 66% of the entire cohort. Thirty-five percent of all cases showed well-established hypoxic damage predating the last evidence of fetal life, and this was more common in preterm fetuses (P = 0.015), those fetuses with evidence of recent damage (P < 0.001), in pregnancies complicated by pregnancy-induced hypertension (P = 0.044) and those in whom the placenta was <10th centile (P = 0.002).

CONCLUSIONS

Brain damage is commonly seen in stillborn infants, and in around one-third of cases, damage predates the period immediately before death. Factors suggesting suboptimal placental function are associated with such damage. Early identification of placental impairment may lead to improved pregnancy outcome.

The distribution of apolipoprotein E alleles in Scottish perinatal deaths

BACKGROUND

The apolipoprotein E (ApoE) polymorphism has been well studied in the adult human population, in part because the e4 allele is a known risk factor for Alzheimer's disease. Little is known of the distribution of ApoE alleles in newborns, and their association with perinatal brain damage has not been investigated.

METHODS

ApoE genotyping was undertaken in a Scottish cohort of perinatal deaths (n = 261), some of whom had prenatal brain damage. The distribution of ApoE alleles in perinatal deaths was compared with that in healthy liveborn infants and in adults in Scotland.

RESULTS

ApoE e2 was over-represented in 251 perinatal deaths (13% v 8% in healthy newborns, odds ratio (OR) = 1.63, 95% confidence interval (CI) 1.13 to 2.36 and 13% v 8% in adults, OR = 1.67, 95% CI 1.16 to 2.41), both in liveborn and stillborn perinatal deaths. In contrast, the prevalence of ApoE e4 was raised in healthy liveborn infants (19%) compared with stillbirths (13%, OR = 1.59, 95% CI 1.11 to 2.26) and with adults (15%, OR = 1.35, 95% CI 1.04 to 1.76). However, no correlation was found between ApoE genotype and the presence or absence of perinatal brain damage.

CONCLUSIONS

This study shows a shift in ApoE allelic distribution in early life compared with adults. The raised prevalence of ApoE e2 associated with perinatal death suggests that this allele is detrimental to pregnancy outcome, whereas ApoE e4 may be less so. However, ApoE genotype did not appear to influence the vulnerability for perinatal hypoxic/ischaemic brain damage, in agreement with findings in adult brains and in animal models.

Brain damage and axonal injury in a Scottish cohort of neonatal deaths

Despite the clinical and medicolegal significance attached to perinatal asphyxia, the neuropathological basis of this condition remains obscure. There are very few studies in the literature which correlate the pathological findings in neonatal brains with detailed epidemiological data, and none which are population based. In a Scotland-wide study of neonatal deaths, 70 brains have been examined. On the basis of glial and macrophage reactions, we previously identified infants with putative antepartum brain damage in this cohort and have related these reactions to signs of birth asphyxia. The present study explores the extent of neuronal/axonal injury in these infants since this is likely to be the basis for neurological deficits in surviving infants. We have also investigated these brains for beta-amyloid precursor protein (betaAPP) positivity to determine whether this is a useful marker of neuronal injury in neonates. Neuronal eosinophilia and karyorrhexes were detected in 43% and 27% of the cohort, respectively; maximally in the subiculum and ventral pons, but often present elsewhere. White matter damage was detected in 24% of cases but without classic cystic lesions of periventricular leucomalacia. betaAPP positivity was present in neuronal soma in 52% of cases and, in axons, in 27% of cases, and was seen from as early as 25-weeks gestation. Axonal bulbs were clearly delineated by betaAPP positivity and were usually located in the cerebral white matter and internal capsule, and infrequently in the brain stem. Although white matter damage and betaAPP axonal positivity were often detected in the same cases (P = 0.034), these features also occurred independently of each other. Both neuronal karyorrhexes and white matter betaAPP positivity were significantly correlated with the features of birth asphyxia, particularly a history of seizures. Immunocytochemistry for both betaAPP and glial fibrillary acidic protein proved useful in detecting neuropathological features which escaped detection on routine examination, particularly in preterm infants. The presence together of recent and older damage in individual brains suggests that there is an ongoing neuronal response to cerebral insults. We find that betaAPP is a useful marker of white matter damage in the neonatal brain. Immunopositivity for betaAPP in these circumstances is not attributable to inflicted or accidental trauma. While birth-related trauma cannot be ruled out, hypoxia/ischaemia is a likely cause in these infants. However, the exact pathogenesis of neuronal/axonal injury in the neonatal brain remains unclear.

The Scottish perinatal neuropathology study: clinicopathological correlation in early neonatal deaths

BACKGROUND

A proportion of neonatal deaths from asphyxia have been shown to be associated with pre-existing brain injury.

OBJECTIVES

(a) To compare the epidemiology of infants displaying signs of birth asphyxia with those not showing signs; (b) to examine the neuropathology and determine if possible the timing of brain insult comparing asphyxiated with non-asphyxiated infants; (c) to compare the clinical features of those born with birth asphyxia with and without pre-labour damage.

METHODS

Over a two year period, all 22 Scottish delivery units collected clinical details on early neonatal deaths. Requests for post mortem included separate requests for detailed neuropathological examination of the brain. Infants were classified into two groups: birth asphyxia and non-birth asphyxia. Clinicopathological correlation was used to attempt to define the time of brain insult.

RESULTS

Detailed clinical data were available on 137 of 174 early neonatal deaths that met the inclusion criteria. Seventy of 88 parents who had agreed to post mortem examination consented to a detailed examination of additional samples from the brain; in 53 of these cases the infant was born in an asphyxiated condition. All asphyxiated and encephalopathic infants, 38% of mature and 52% of preterm infants with features of birth asphyxia but without encephalopathy, and only one of 12 infants without any signs of birth asphyxia showed damage consistent with onset before the start of labour.

CONCLUSIONS

In a large proportion of neonatal deaths, brain injury predates the onset of labour. This is more common in infants born in an asphyxiated condition.

The prognostic influence of bcl-2 in malignant glioma

The bcl-2 gene is one of a complex group of genes which control programmed cell death. Bcl-2 acts to extend cell survival by blocking apoptosis, and thereby may influence tumour prognosis. This study of 187 high grade gliomas reviews clinicopathological prognostic features and the relationship to bcl-2 expression. Bcl-2 immunostaining was assessed in 159 specimens from these patients, by scoring systems of 0 to 3 for intensity of scoring and proportion of cells staining. Age, histology, pre- and post-operative performance status were found to be strongly predictive of survival (log rank test P<0.0001). The type of surgery performed did not influence survival in this group of patients. The expression of bcl-2 had a significant relationship with survival (univariate Cox model P=0.0302, hazard ratio 0.8, 95% confidence interval 0.65-0.98), with increased staining associated with improved survival. Multivariate analysis showed performance status, histology and proportion of cells staining for bcl-2 to be independently predictive of survival. Bcl-2 staining was not related to histological grade of tumours.

MIRABEL: models for integrated review and assessment of biodiversity in European landscapes

In this paper, we present the methodology and some results from the application of an integrating conceptual framework, MIRABEL, to analyze the consequences of environmental change for biodiversity. For 28 European countries, MIRABEL tabulates changes in the status of threatened habitats predicted to result from 10 environmental pressures. Regional variations in the severity of the pressures and impacts are taken into account by compiling separate impact tables for each of 13 Ecological Regions. Results suggest that agricultural intensification is one of the main threats, however, differences recorded by MIRABEL in the intensity of the pressures, their rate of change and their past and expected impacts on biodiversity in the various Ecological Regions is telling evidence of Europe's biogeographical variety, and of the need to take this into consideration when assessing environmental change.

MIRABEL: models for integrated review and assessment of biodiversity in European landscapes

In this paper, we present the methodology and some results from the application of an integrating conceptual framework, MIRABEL, to analyze the consequences of environmental change for biodiversity. For 28 European countries, MIRABEL tabulates changes in the status of threatened habitats predicted to result from 10 environmental pressures. Regional variations in the severity of the pressures and impacts are taken into account by compiling separate impact tables for each of 13 Ecological Regions. Results suggest that agricultural intensification is one of the main threats, however, differences recorded by MIRABEL in the intensity of the pressures, their rate of change and their past and expected impacts on biodiversity in the various Ecological Regions is telling evidence of Europe's biogeographical variety, and of the need to take this into consideration when assessing environmental change.

Preoperative evaluation and workup of the cataract and intraocular lens implant patient

1. Cataract and intraocular lens (IOL) implant surgery is the most common operation in ophthalmology. Much of the success of cataract and implant surgery depends on thorough and accurate preoperative patient counseling, testing, and biometric measurements. 2. The preoperative workup of cataract and implant surgery should include a complete ocular history and physical examination, patient education, preoperative testing, and informed consent. 3. Essential preoperative testing includes keratometric readings, ultrasound axial length of the eye (A-scan), and a calculation of implant power requirements using a modern implant formula. 4. In some circumstances, corneal endothelial cell counts, corneal pachymetry, and B-scan ultrasonographic scanning of the posterior segment will be needed. Optional testing also might include potential visual acuity (PVA) testing, ophthalmic photography, and corneal topographic scanning.

Serum oestradiol in women with and without breast disease

It has been suggested that the percentage of non-protein-bound or free oestradiol (E2) is abnormally high in patients with breast cancer. In this study, the serum oestradiol profiles of a large group of women were analysed to determine whether a significant correlation could be found between serum oestradiol and various breast diseases. In addition oestradiol levels were measured in relation to sex hormone binding globulin (SHBG), albumin levels, oestrogen receptor status and family history of breast cancer. Serum samples were taken from a total of 300 women who had either no breast disease, benign breast disease or breast cancer. The percentage of free oestradiol was found to be highest in women with breast cancer, lowest in the control group and intermediate for the women with benign breast disease. These differences were most marked in post-menopausal women. The absolute values for total and free oestradiol were not statistically different in the three groups studied. There did not appear to be a correlation between oestrogen receptor (ER) concentration in breast cancer tissue and free E2 percentage levels. Women who had a family history of breast cancer did not appear to have higher percentage levels of free E2 than those with no such history. The presence of elevated proportions of free oestradiol in the serum of women with breast cancer may be significant in regard to understanding the aetiology of breast neoplasia. There also may be important implications for the use of this measurement in the earlier diagnosis and detection of breast cancer.