Socio-economic factors related to premature death from colorectal cancer in Santiago de Chile, 2014-2018: a cross-sectional study

OBJECTIVES

In Chile, colorectal cancer (CRC) is the fourth cause of death by cancer. Few studies have evaluated the role of contextual and individual socio-economic variables associated with premature death by CRC (<70 years). We analyzed the association between socio-economic factors (at individual and contextual levels) and premature death from CRC in Santiago de Chile.

STUDY DESIGN

This was a cross-sectional study.

METHODS

We analyzed deaths from CRC between 2014 and 2018 using data published by the Ministry of Health. Individual predictors were sex, marital status, and educational level. Contextual variable included the Social Priority Index (SPI) of the commune where the deceased lived. The association was assessed through multilevel logistic regression models.

RESULTS

During the period, 4762 deaths occurred (51.7% women); 39.3% were premature. At the individual level, male sex (odds ratio [OR] 1.36; 95% confidence interval [CI] 1.20-1.53) and single marital status (OR 1.45; 95% CI 1.24-1.68) were associated with premature death from CRC. Primary or lower education was a protective factor (OR 0.53; 95% CI 0.47-0.60). At the contextual level, communes with a higher SPI were three times more at risk than those with a lower SPI (OR 3.13; 95% CI 2.15-4.57).

CONCLUSIONS

This study showed that individual and contextual socio-economic variables are related to premature death from CRC. Residing in communes with greater socio-economic vulnerability was associated with greater risk. To reduce this gap, it is urgent to design and implement structural policies to reduce social inequities and improve access to health care.

Beam-Target Helicity Asymmetry for γ[over →]n[over →]→π^{-}p in the N^{*} Resonance Region

We report the first beam-target double-polarization asymmetries in the γ+n(p)→π^{-}+p(p) reaction spanning the nucleon resonance region from invariant mass W=1500 to 2300 MeV. Circularly polarized photons and longitudinally polarized deuterons in solid hydrogen deuteride (HD) have been used with the CEBAF Large Acceptance Spectrometer (CLAS) at Jefferson Lab. The exclusive final state has been extracted using three very different analyses that show excellent agreement, and these have been used to deduce the E polarization observable for an effective neutron target. These results have been incorporated into new partial wave analyses and have led to significant revisions for several γnN^{*} resonance photocouplings.

Use of the synergist piperonyl butoxide can slow the development of alpha-cypermethrin resistance in the whitefly Bemisia tabaci

The development of insecticide resistance in insect pests of crops is a growing threat to sustainable food production, and strategies that slow the development of resistance are therefore urgently required. The insecticide synergist piperonyl butoxide (PBO) inhibits certain insect detoxification systems and so may delay the evolution of metabolic resistance. In the current study we characterized resistance development in the silverleaf whitefly, Bemisia tabaci, after selection with either a neonicotinoid (thiacloprid) or pyrethroid (alpha-cypermethrin) insecticide alone or in combination with PBO. Resistance development was significantly suppressed (> 60%) in the line selected with alpha-cypermethrin + PBO compared to the line selected with alpha-cypermethrin alone. RNA sequencing (RNAseq) analyses revealed an increase in frequency of a knock-down resistance mutation but no differentially expressed genes were identified that could explain the sensitivity shift. No significant difference was observed in the level of resistance between the thiacloprid and thiacloprid + PBO selected lines, and RNA sequencing (RNAseq) analyses revealed that the cytochrome P450 monooxygenase CYP6CM1, known to metabolize neonicotinoids, was significantly upregulated (>10-fold) in both lines. The findings of this study demonstrate that PBO used in combination with certain insecticides can suppress the development of resistance in a laboratory setting; however, the mechanism by which PBO supresses resistance development remains unclear.

The 5-amino acid N-terminal extension of non-sulfated drosulfakinin II is a unique target to generate novel agonists

The ability to design agonists that target peptide signaling is a strategy to delineate underlying mechanisms and influence biology. A sequence that uniquely characterizes a peptide provides a distinct site to generate novel agonists. Drosophila melanogaster sulfakinin encodes non-sulfated drosulfakinin I (nsDSK I; FDDYGHMRF-NH2) and nsDSK II (GGDDQFDDYGHMRF-NH2). Drosulfakinin is typical of sulfakinin precursors, which are conserved throughout invertebrates. Non-sulfated DSK II is structurally related to DSK I, however, it contains a unique 5-residue N-terminal extension; drosulfakinins signal through G-protein coupled receptors, DSK-R1 and DSK-R2. Drosulfakinin II distinctly influences adult and larval gut motility and larval locomotion; yet, its structure-activity relationship was unreported. We hypothesized substitution of an N-terminal extension residue may alter nsDSK II activity. By targeting the extension we identified, not unexpectedly, analogs mimicking nsDSK II, yet, surprisingly, we also discovered novel agonists with increased (super) and opposite (protean) effects. We determined [A3] nsDSK II increased larval gut contractility rather than, like nsDSK II, decrease it. [N4] nsDSK II impacted larval locomotion, although nsDSK II was inactive. In adult gut, [A1] nsDSK II, [A2] nsDSKII, and [A3] nsDSK II mimicked nsDSK II, and [A4] nsDSK II and [A5] nsDSK II were more potent; [N3] nsDSK II and [N4] nsDSK II mimicked nsDSK II. This study reports nsDSK II signals through DSK-R2 to influence gut motility and locomotion, identifying a novel role for the N-terminal extension in sulfakinin biology and receptor activation; it also led to the discovery of nsDSK II structural analogs that act as super and protean agonists.

Induced thiacloprid insensitivity in honeybees (Apis mellifera L.) is associated with up-regulation of detoxification genes

Honey bees, Apis mellifera, are markedly less sensitive to neonicotinoid insecticides containing a cyanoimino pharmacophore than to those with a nitroimino group. Although previous work has suggested that this results from enhanced metabolism of the former by detoxification enzymes, the specific enzyme(s) involved remain to be characterized. In this work, a pretreatment of honey bees with a sublethal dose of thiacloprid resulted in induced insensitivity to the same compound immediately following thiacloprid feeding. A longer pretreatment time resulted in no, or increased, sensitivity. Transcriptome profiling, using microarrays, identified a number of genes encoding detoxification enzymes that were over-expressed significantly in insecticide-treated bees compared with untreated controls. These included five P450s, CYP6BE1, CYP305D1, CYP6AS5, CYP315A1, CYP301A1, and a carboxyl/cholinesterase (CCE) CCE8. Four of these P450s were functionally expressed in Escherichia coli and their ability to metabolize thiacloprid examined by liquid chromatography-mass spectrometry (LC-MS) analysis.

Factitious disorders and malingering in relation to functional neurologic disorders

Interest in malingering has grown in recent years, and is reflected in the exponential increase in academic publications since 1990. Although malingering is more commonly detected in medicolegal practice, it is not an all-or-nothing presentation and moreover can vary in the extent of presentation. As a nonmedical disorder, the challenge for clinical practice remains that malingering by definition is intentional and deliberate. As such, clinical skills alone are often insufficient to detect it and we describe psychometric tests such as symptom validity tests and relevant nonmedical investigations. Finally, we describe those areas of neurologic practice where symptom exaggeration and deception are more likely to occur, e.g., postconcussional syndrome, psychogenic nonepileptic seizures, motor weakness and movement disorders, and chronic pain. Factitious disorders are rare in clinical practice and their detection depends largely on the level of clinical suspicion supported by the systematic collection of relevant information from a variety of sources. In this chapter we challenge the accepted DSM-5 definition of factitious disorder and suggest that the traditional glossaries have neglected the extent to which a person's reported symptoms can be considered a product of intentional choice or selective psychopathology largely beyond the subject's voluntary control, or more likely, both. We present evidence to suggest that neurologists preferentially diagnose factitious presentations in healthcare workers as "hysterical," possibly to avoid the stigma of simulated illness.

Molecular cloning, characterisation and mRNA expression of the ryanodine receptor from the peach-potato aphid, Myzus persicae

The peach potato aphid, Myzus persicae, is one of the most important agricultural pests of temperate climates. It is mainly controlled through the judicious application of insecticides; however, over time, aphids have developed resistance to many insecticidal classes. The recent introduction of synthetic diamide insecticides, with a novel mode of action, potentially offers new tools to control aphid populations. These diamides act on the ryanodine receptor (RyR), a large endoplasmic calcium release channel. In this study we have cloned cDNAs encoding the complete open reading frame of the RyR from M. persicae. The open reading frame is 15,306 base pairs long and encodes a protein of 5101 amino acids. The aphid RyR shares many of the features of other insect and vertebrate RyRs, including a highly conserved transmembrane region. However, unlike the other RyRs characterised to date, the M. persicae channel does not display alternative splicing at any stage of its developmental cycle, so it cannot generate functional variants of the channel.

A de novo transcriptome of European pollen beetle populations and its analysis, with special reference to insecticide action and resistance

The pollen beetle Meligethes aeneus is the most important coleopteran pest in European oilseed rape cultivation, annually infesting millions of hectares and responsible for substantial yield losses if not kept under economic damage thresholds. This species is primarily controlled with insecticides but has recently developed high levels of resistance to the pyrethroid class. The aim of the present study was to provide a transcriptomic resource to investigate mechanisms of resistance. cDNA was sequenced on both Roche (Indianapolis, IN, USA) and Illumina (LGC Genomics, Berlin, Germany) platforms, resulting in a total of ∼53 m reads which assembled into 43 396 expressed sequence tags (ESTs). Manual annotation revealed good coverage of genes encoding insecticide target sites and detoxification enzymes. A total of 77 nonredundant cytochrome P450 genes were identified. Mapping of Illumina RNAseq sequences (from susceptible and pyrethroid-resistant strains) against the reference transcriptome identified a cytochrome P450 (CYP6BQ23) as highly overexpressed in pyrethroid resistance strains. Single-nucleotide polymorphism analysis confirmed the presence of a target-site resistance mutation (L1014F) in the voltage-gated sodium channel of one resistant strain. Our results provide new insights into the important genes associated with pyrethroid resistance in M. aeneus. Furthermore, a comprehensive EST resource is provided for future studies on insecticide modes of action and resistance mechanisms in pollen beetle.

Conserved residues in RF-NH₂ receptor models identify predicted contact sites in ligand-receptor binding

Peptides in the RF-NH2 family are grouped together based on an amidated dipeptide C terminus and signal through G-protein coupled receptors (GPCRs) to influence diverse physiological functions. By determining the mechanisms underlying RF-NH2 signaling targets can be identified to modulate physiological activity; yet, how RF-NH2 peptides interact with GPCRs is relatively unexplored. We predicted conserved residues played a role in Drosophila melanogaster RF-NH2 ligand-receptor interactions. In this study D. melanogaster rhodopsin-like family A peptide GPCRs alignments identified eight conserved residues unique to RF-NH2 receptors. Three of these residues were in extra-cellular loops of modeled RF-NH2 receptors and four in transmembrane helices oriented into a ligand binding pocket to allow contact with a peptide. The eighth residue was unavailable for interaction; yet its conservation suggested it played another role. A novel hydrophobic region representative of RF-NH2 receptors was also discovered. The presence of rhodopsin-like family A GPCR structural motifs including a toggle switch indicated RF-NH2s signal classically; however, some features of the DMS receptors were distinct from other RF-NH2 GPCRs. Additionally, differences in RF-NH2 receptor structures which bind the same peptide explained ligand specificity. Our novel results predicted conserved residues as RF-NH2 ligand-receptor contact sites and identified unique and classic structural features. These discoveries will aid antagonist design to modulate RF-NH2 signaling.

Transcriptome profiling of the whitefly Bemisia tabaci reveals stage-specific gene expression signatures for thiamethoxam resistance

Bemisia tabaci has developed high levels of resistance to many insecticides including the neonicotinoids and there is strong evidence that for some compounds resistance is stage-specific. To investigate the molecular basis of B. tabaci resistance to the neonicotinoid thiamethoxam we used a custom whitefly microarray to compare gene expression in the egg, nymph and adult stages of a thiamethoxam-resistant strain (TH-R) with a susceptible strain (TH-S). Gene ontology and bioinformatic analyses revealed that in all life stages many of the differentially expressed transcripts encoded enzymes involved in metabolic processes and/or metabolism of xenobiotics. Several of these are candidate resistance genes and include the cytochrome P450 CYP6CM1, which has been shown to confer resistance to several neonicotinoids previously, a P450 belonging to the Cytochrome P450s 4 family and a glutathione S-transferase (GST) belonging to the sigma class. Finally several ATP-binding cassette transporters of the ABCG subfamily were highly over-expressed in the adult stage of the TH-R strain and may play a role in resistance by active efflux. Here, we evaluated both common and stage-specific gene expression signatures and identified several candidate resistance genes that may underlie B. tabaci resistance to thiamethoxam.

Neuropeptide F peptides act through unique signaling pathways to affect cardiac activity

Elucidating how neuropeptides affect physiology may result in delineating peptidergic mechanisms and identifying antagonists for application in basic and translational science. Human neuropeptide Y (NPY) regulates cardiac activity; frequently invertebrates contain orthologs of vertebrate peptides. We report invertebrate NPY-like neuropeptide F (NPF) arrested the signal frequency of the slow phase of the cardiac cycle (EC50 = 1 pM); however, signal frequency of the fast phase was affected only minimally. Neuropeptide F decreased the duration of the slow phase by ~70% (EC50 = 0.6 pM), but increased the duration of the fast phase by ~57% (EC50 = 10nM). Short NPF-1 (sNPF-1) decreased the signal frequency of the slow phase by ~70% (EC50 = 9 nM); yet, signal frequency of the fast phase was unaffected. Short NPF-1 decreased the duration of the slow phase ~55% (EC50 ~50 nM), but increased the duration of the fast phase ~20% without dose dependency. Neuropeptide F and sNPF-1 increased isoelectric period duration. This novel report demonstrated NPY-like peptides are cardioactive but functionally unique. These data contribute to understanding how invertebrate orthologs affect cardiovascular activity. Dipteran fast and slow phases may be generated from separate pacemakers in the abdominal heart and in the anterior thoracocephalic aorta, respectively. Thus, our research suggests NPF and sNPF-1 act through different mechanisms to regulate cardiac activity. Invertebrate NPY-like peptides act in olfaction and feeding yet mechanisms which are associated with their cardioactive effects remain unknown; our work may provide evidence linking their roles in sensory response and cardiac activity.

Overexpression of a cytochrome P450 monooxygenase, CYP6ER1, is associated with resistance to imidacloprid in the brown planthopper, Nilaparvata lugens

The brown planthopper, Nilaparvata lugens, is an economically significant pest of rice throughout Asia and has evolved resistance to many insecticides including the neonicotinoid imidacloprid. The resistance of field populations of N. lugens to imidacloprid has been attributed to enhanced detoxification by cytochrome P450 monooxygenases (P450s), although, to date, the causative P450(s) has (have) not been identified. In the present study, biochemical assays using the model substrate 7-ethoxycoumarin showed enhanced P450 activity in several resistant N. lugens field strains when compared with a susceptible reference strain. Thirty three cDNA sequences encoding tentative unique P450s were identified from two recent sequencing projects and by degenerate PCR. The mRNA expression level of 32 of these was examined in susceptible, moderately resistant and highly resistant N. lugens strains using quantitative real-time PCR. A single P450 gene (CYP6ER1) was highly overexpressed in all resistant strains (up to 40-fold) and the level of expression observed in the different N. lugens strains was significantly correlated with the resistance phenotype. These results provide strong evidence for a role of CYP6ER1 in the resistance of N. lugens to imidacloprid.

Distribution of pyrethroid and DDT resistance and the L1014F kdr mutation in Anopheles gambiae s.l. from Burkina Faso (West Africa)

This study reports on the distribution of pyrethroid and DDT resistance and the L1014F knockdown resistance (kdr) mutation in Anopheles gambiae s.l. populations from 21 localities in three different climatic zones of Burkina Faso from August to October 2006. The susceptibility of these populations was assessed by bioassay using DDT (4%), permethrin (1%) and deltamethrin (0.05%). Anophelesgambiae were resistant to both permethrin and DDT in the Sudanian regions but were susceptible in the central and sahelian areas and susceptible to deltamethrin at all sites except Orodara, although mortality values in some populations were close to the resistance threshold. The kdr frequency varied from 0.4 to 0.97 in populations from the Sudanian region and was lower in populations from the Sudano-sahelian and sahelian areas (0.047 to 0.54). Compared to the last survey of kdr in An. gambiae populations conducted in 2000, the kdr frequency did not differ in the S form but had increased in the M form (0.6), with an extended distribution into the Sudano-sahelian region. The frequency of kdr was also found to have increased in An. arabiensis populations (0.28), where it was formerly reported in only a single specimen. These results have practical significance for malaria vector control programs.

Distribution of insensitive acetylcholinesterase (ace-1R) in Anopheles gambiae s.l. populations from Burkina Faso (West Africa)

OBJECTIVE

To investigate through countrywide sampling at 20 localities across the three different agro-climatic zones of Burkina Faso, the distribution of the acetylcholinesterase insensitive mutation ace-1(R), which confers resistance to organophosphates (OP) and carbamates (CM) insecticides in An. gambiae s.l.

METHODS

Adult mosquitoes were collected by indoor aerosol spraying from August to October 2006. Specimens were identified to species by polymerase chain reaction (PCR) assay and characterized for the ace-1(R) mutation using a PCR-restriction fragment length polymorphism diagnostic.

RESULTS

Collected mosquitoes were a mixture of An. gambiae s.s. and An. arabiensis across the Sudan (98.3%vs. 1.7%), Sudan-sahelian (78.6%vs. 21.4%) and the Sahel (91.5%vs. 8.5%) ecotypes. The An. gambiae S-form predominated in the Sudan sites from the West (69%vs. 31% for the M form) but was not found in the Sahel (100% M form). The ace-1(R) mutation was dispersed throughout the Sudan and Sudan-sahelian localities at moderate frequency (<50%) but was absent in the Sahel. It was far more prevalent in S form than M form mosquitoes (0.32 for the S form vs. 0.036 for the M form). No An. arabiensis was detected carrying the mutation. The geographic distribution of ace-1(R) in the Sudan and Sudan-sahelian correlated with the cotton growing areas dispersed throughout the two climatic zones.

CONCLUSIONS

These results have special significance as OP and CM insecticides have been proposed as alternatives or additions to pyrethroids which are currently used exclusively in many vector control programmes.

Reduced susceptibility to DDT in field populations of Anopheles quadriannulatus and Anopheles arabiensis in Malawi: evidence for larval selection

Bioassays for insecticide resistance in adult mosquitoes were conducted on samples of Anopheles gambiae Giles s.l. (Diptera: Culicidae) species collected as larvae from breeding sites in the lower Shire Valley, Malawi. The results indicate full susceptibility to permethrin, deltamethrin and malathion, but reduced susceptibility to DDT in one sample from Thom (LT(50) of 8.39 min for females and 25.09 min for males). Polymerase chain reaction-based species identification of the mosquitoes assayed revealed a mixture of Anopheles arabiensis Patton and Anopheles quadriannulatus (Theobold). The LT(50) did not differ significantly between species. Genotyping of the L1014F and L1014S kdr alleles showed all mosquito specimens to be homozygous wild type; thus the reduced susceptibility detected is not attributable to target site insensitivity and instead is likely to be metabolic in nature. Anopheles quadriannulatus is characteristically zoophagic and exophilic. Indeed, of 82 Anopheles collected through knockdown collections within dwellings, only one was An. quadriannulatus and the rest were An. arabiensis. They are unlikely, therefore, to have been exposed to selection pressure arising from insecticide-treated net usage or to DDT indoor residual spraying. Therefore, it is suggested that this example of reduced susceptibility to DDT in An. quadriannulatus reflects selection in the larval stages.

Comparison of biochemical and molecular methods for the identification of bacterial isolates associated with failed loggerhead sea turtle eggs

AIMS

Comparison of biochemical vs molecular methods for identification of microbial populations associated with failed loggerhead turtle eggs.

METHODS AND RESULTS

Two biochemical (API and Microgen) and one molecular methods (16s rRNA analysis) were compared in the areas of cost, identification, corroboration of data with other methods, ease of use, resources and software. The molecular method was costly and identified only 66% of the isolates tested compared with 74% for API. A 74% discrepancy in identifications occurred between API and 16s rRNA analysis. The two biochemical methods were comparable in cost, but Microgen was easier to use and yielded the lowest discrepancy among identifications (29%) when compared with both API 20 enteric (API 20E) and API 20 nonenteric (API 20NE) combined. A comparison of API 20E and API 20NE indicated an 83% discrepancy between the two methods.

CONCLUSIONS

The Microgen identification system appears to be better suited than API or 16s rRNA analysis for identification of environmental isolates associated with failed loggerhead eggs.

SIGNIFICANCE AND IMPACT OF THE STUDY

Most identification methods are not intended for use with environmental isolates. A comparison of identification systems would provide better options for identifying environmental bacteria for ecological studies.

The Sbm1 locus conferring resistance to Soil-borne cereal mosaic virus maps to a gene-rich region on 5DL in wheat

A mosaic disease caused by Soil-borne cereal mosaic virus (SBCMV) is becoming increasingly important, particularly in winter wheat in Europe. As there are currently no effective cultural practices or practical environmentally friendly chemicals for disease control, host plant resistance is an important objective in breeding programs. However, development of resistant cultivars is slow owing to difficulties in germplasm screening for resistance. Therefore, there is a need to identify molecular markers linked to SBCMV-resistance gene(s), so that quick and accurate laboratory-based marker-assisted selection rather than prolonged field-based screens for resistance can be used in developing resistant cultivars. We previously demonstrated that resistance to SBCMV in Triticum aestivum ‘Cadenza’ is controlled by a single locus. In this work, we used AFLP and microsatellite technology to map this resistance locus, with the proposed name Sbm1, to the distal end of chromosome 5DL. Interestingly, several expressed disease-resistance gene analogues also map to this gene-rich region on 5DL. Closely linked (~17 cM interval) markers, BARC110 and WMC765, RRES01 and BARC144, that flank Sbm1 will be very useful in breeding for selection of germplasm carrying Sbm1.

Single blind, randomised, comparative study of the Bug Buster kit and over the counter pediculicide treatments against head lice in the United Kingdom

OBJECTIVE

To compare the effectiveness of the Bug Buster kit with a single treatment of over the counter pediculicides for eliminating head lice.

DESIGN

Single blind, multicentre, randomised, comparative clinical study.

SETTING

Four counties in England and one county in Scotland.

PARTICIPANTS

133 young people aged 2-15 years with head louse infestation: 56 were allocated to the Bug Buster kit and 70 to pediculicide treatment.

INTERVENTIONS

Home use of proprietary pediculicides (organophosphate or pyrethroid) or the Bug Buster kit.

MAIN OUTCOME MEASURE

Presence of head lice 2-4 days after end of treatment: day 5 for the pediculicides and day 15 for the Bug Buster kit.

RESULTS

The cure rate using the Bug Buster kit was significantly greater than that for the pediculicides (57% v 13%; relative risk 4.4, 95% confidence interval 2.3 to 8.5). Number needed to treat for the Bug Buster kit compared with the pediculicides was 2.26.

CONCLUSION

The Bug Buster kit was the most effective over the counter treatment for head louse infestation in the community when compared with pediculicides.

Somatization among older primary care attenders

BACKGROUND

The importance of somatization among older primary care attenders is unclear. We aimed to establish the prevalence, persistence and associations of somatization among older primary care attenders, and the associations of frequent attendance.

METHOD

One hundred and forty primary care attenders over 65 years were rated twice, 10 months apart, on measures of somatization, psychiatric status, physical health and attendance.

RESULTS

The syndrome of GMS hypochondriacal neurosis had a prevalence of 5% but was transient. Somatized symptoms and attributions were persistent and associated with depression, physical illness and perceived poor social support. Frequent attenders (top third) had higher rates of depression, physical illness and somatic symptoms, and lower perceived support.

CONCLUSION

Somatization is common among older primary care attenders and has similar correlates to younger primary care somatizers. Psychological distress among older primary care attenders is associated with frequent attendance. Improved recognition should result in benefits to patients and services.

Characteristics of patients with persistent severe disability and medically unexplained neurological symptoms: a pilot study

This study audited 25 patients (21 female) from Oxfordshire who had been referred to either the liaison psychiatry or the neurological disability service between 1992 and 1998, reported a Barthel activities of daily living index score < 20 or a global assessment of functioning score of < or = 30, and had no pathology to explain their neurological disability. Levels of motor impairment, disability, mood, and cognitive status were assessed using standardised scales, and all patients were assigned a psychiatric diagnosis according to the International classification of diseases, 10th revision. Of the 25 patients, 13 had a motor conversion disorder, 8 had diverse somatoform disorders, and 3 had chronic fatigue syndrome. Nine had extensive previous contact with psychiatric services and 11 had experienced physical or sexual abuse. In 6 patients cessation of repeated self harm was closely associated with the onset of wheelchair use. Seven were receiving treatment for depression. The commonest putative diagnoses were multiple sclerosis (6) and epilepsy (5). Twelve were unable to walk and 20 owned a wheelchair but only 3 had formal care packages. The mean (SD) Barthel score was 14.1 (3.3) and the mean (SD) Frenchay activity index score was 12.9 (7.5). All were unemployed and receiving a disability living allowance, and some had benefits of up to pound 1815 a month. This small but significant group of disabled patients had a variety of psychiatric and neurological diagnoses and used considerable health care resources.

Referrals to a liaison psychiatry out-patient clinic in a UK general hospital: a report on 900 cases

OBJECTIVE

To describe the demographic and clinical characteristics of consecutive referrals to an out-patient liaison psychiatry clinic in a large university hospital in the UK.

METHOD

We studied 900 patients using a standardized proforma. Assessments of functional capacity were made using the Global Assessment of Functioning (GAF) scale, and each patient was assigned a psychiatric diagnosis using ICD-10 criteria.

RESULTS

Four of five of all referrals presented with somatic complaints, and 41% had a concurrent physical illness. The most common psychiatric diagnoses were somatoform disorders (55%) and neurasthenia (11%). Although more than half (59%) had no previous psychiatric history, a surprisingly high number (35%) had significant functional impairment (scores of < 50 on the GAF scale). The lack of adequate psychological treatment services often provided a barrier to optimal management of some of the more disabled patients.

CONCLUSION

The general hospital liaison psychiatry clinic provides an acceptable setting in which to assess and manage patients referred from non-psychiatric colleagues.

Cognitive behavioral therapy for chronic fatigue syndrome in a general hospital--feasible and effective

Cognitive behavior therapy (CBT) has been shown to be effective in recent randomized controlled trials for chronic fatigue syndrome (CFS). We examined the effectiveness of CBT in a general hospital setting in a retrospective questionnaire follow-up study of 94 patients offered CBT by liaison psychiatry services. The questionnaire response rate was 61%. Eighteen percent had returned to normal functioning at follow-up. For the group as a whole, there was a significant improvement in the functional and social impairment and the number of frequently experienced symptoms. Those in work or study at follow-up was 53% (29% pretreatment), and 65% of patients mentioned occupational stress as a contributory factor in their illness. There was a significant reduction in the frequency of attendance at primary care in the year after the end of CBT. We conclude that cognitive behavioral therapy is an acceptable treatment for most patients and can be used in a general hospital outpatient setting by a variety of trained therapists. However, a proportion of patients do not benefit and remain significantly disabled by the condition.

Fast-tracking pulmonary resections

OBJECTIVE

We streamlined our care after pulmonary resection for quality and cost-effectiveness.

METHODS

A single surgeon performed 500 consecutive pulmonary resections through a thoracotomy over a 2(3/4)-year period in a university setting. Patients were extubated in the operating room and sent directly to their hospital room. Chest tubes were placed to water seal and removed on postoperative day 2 if there was no air leak and drainage was less then 400 mL/d. Epidural catheters were used and removed by postoperative day 2. The plan for each day and discharge on postoperative day 3 or 4 was reviewed with the patients and families daily during rounds. The patient went home the day the last chest tube was removed. Persistent air leaks were treated with Heimlich valves.

RESULTS

There were 500 patients (338 men), with a median age of 58 years (range, 3-87 years). Of these patients, 293 had pre-existing conditions. Seventy-three (15%) patients had been denied operations by at least one other surgeon. Four hundred nineteen (84%) patients had successful placement of a functioning preoperative epidural catheter. Pneumonectomy was performed in 32 (6%) patients, segmentectomy was performed in 16 (3%) patients, and lobectomy, sleeve lobectomy, and/or bilobectomy was performed in 194 (39%) patients. Nonanatomic resections were performed for metastasectomy. This included a single wedge resection in 161 (32%) patients and multiple wedge resections in 97 (19%) patients. A total of 482 (96%) patients were extubated in the operating room, and 380 (76%) patients were sent to their hospital room. The remaining 120 patients went to the intensive care unit for a median of 1 day (range, 1-41 days). Complications occurred in 107 (21%) patients, and operative mortality was 2.0%. Median day of discharge was postoperative day 4 (range, 2-119 days). A total of 327 (65%) patients left the hospital on postoperative day 4 or sooner. By survey, 97% of patients had excellent or good satisfaction with their care at hospital discharge, and 91% were extremely happy or satisfied at the 2-week follow-up contact.

CONCLUSIONS

Most patients who undergo elective pulmonary resection can be extubated immediately after the operation, go directly to their room and avoid the intensive care unit, be discharged on postoperative day 3 or 4, and have minimal morbidity and mortality with high satisfaction both at discharge and at the 2-week follow-up contact. Techniques that seem to accomplish this include the following: the use of a water seal, removal of epidural catheters on postoperative day 2, early chest tube management, treatment of persistent air leaks with Heimlich valves, and daily reinforcement of the planned events for each day, as well as on the date of discharge with the patients and their families.

Somatoform disorders: severe psychiatric illnesses neglected by psychiatrists

BACKGROUND

Somatoform disorders have few peers in terms of personal morbidity and cost to the health service, yet many psychiatrists train without any experience of them.

AIMS

To review the prevalence, disability and economic burden of somatoform disorders, and to explore the reasons why they are neglected by psychiatrists.

METHOD

A selective review of the key literature.

RESULTS

Psychiatrists' current preoccupation with so-called 'serious mental illness' gives somatoform disorders low priority. Some health planners have erroneously equated severity with diagnosis rather than level of need and disability. As a consequence the development of psychiatric services has been neglected.

CONCLUSIONS

Greater recognition of the importance of somatoform disorders will only occur if high quality research and teaching receive priority, and if the Royal Colleges continue to press for increasing public awareness of their importance. Services should be driven by clinical need rather than diagnosis.

Prospective randomized trial compares suction versus water seal for air leaks

BACKGROUND

Surgeons treat air leaks differently. Our goal was to evaluate whether it is better to place chest tubes on suction or water seal for stopping air leaks after pulmonary surgery. A second goal was to evaluate a new classification system for air leaks that we developed.

METHODS

Patients were prospectively randomized before surgery to receive suction or water seal to their chest tubes on postoperative day (POD) #2. Air leaks were described and quantified daily by a classification system and a leak meter. The air-leak meter scored leaks from 1 (least) to 7 (greatest). The group randomized to water seal stayed on water seal unless a pneumothorax developed.

RESULTS

On POD #2, 33 of 140 patients had an air leak. Eighteen patients had been preoperatively randomized to water seal and 15 to suction. Air leaks resolved in 12 (67%) of the water seal patients by the morning of POD #3. All 6 patients whose air leak did not stop had a leak that was 4/7 or greater (p < 0.0001) on the leak meter. Of the 15 patients randomized to suction, only 1 patient's air leak (7%) resolved by the morning of POD #3. The randomization aspect of the trial was ended and statistical analysis showed water seal was superior (p = 0.001). The remaining 14 patients were then placed to water seal and by the morning of POD #4, 13 patients' leaks had stopped. Of the 32 total patients placed to seal, 7 (22%) developed a pneumothorax and 6 of these 7 patients had leaks that were 4/7 or greater (p = 0.001).

CONCLUSIONS

Placing chest tubes on water seal seems superior to wall suction for stopping air leaks after pulmonary resection. However, water seal does not stop expiratory leaks that are 4/7 or greater. Pneumothorax may occur when chest tubes are placed on seal with leaks this large.

A survey of frequent attenders at a gastroenterology clinic

OBJECTIVE

To examine a group of patients satisfying criteria for "frequent attending" as part of an audit of an outpatient gastroenterology service, and to note the prevalence of those with no conspicuous organic disease to account for their symptomatology.

METHODS

We used the hospital computer (Oxford Patient Administration System, OXPAS) to identify 2530 consecutive patients who were given an appointment to attend the gastroenterology clinic during an 11-month period. Patients designated "frequent attenders" had their notes flagged before the clinic attendance and were examined in more detail. A frequent attender was defined as a patient who had attended any hospital outpatient clinic in the three Oxford general hospitals on four or more occasions in the previous 12 months. The gastroenterologist then interviewed the patients satisfying these criteria and indicated whether he/she was satisfied that there was no relevant organic disease to account for the symptoms.

RESULTS

Of the total 2530 patients, 762 (30%) satisfied our criteria for frequent attendance (FA). Of these, 452 (59%) had organic disease, 128 (17%) either did not attend or cancelled and 159 (21%) had no relevant organic disease. The diagnosis was uncertain in 23 patients (3%). Of patients satisfying our criteria for frequent attending, approximately 20-25% had no established gastroenterological disease.

CONCLUSIONS

Frequent attenders present formidable management problems for the gastroenterologist. If they can be identified by computer before the outpatient visit then assessment and management might be more appropriately supervised in designated clinics by more experienced gastroenterology staff.

Older patients referred to a consultation-liaison psychiatry clinic

BACKGROUND

Little is known about the psychiatric disorders which are associated with somatic presentations of psychological distress in older people.

METHOD

A study of patients aged 65 years and over referred to an adult consultation-liaison psychiatry clinic in a general hospital.

RESULTS

Of 900 patients referred over a 7-year period, 45 (5%) were aged 65 years and over. The most frequent ICD-10 diagnostic category was somatoform disorder (N=30) followed by depressive disorder (N=6). The age of onset of the physical symptoms was significantly earlier in those with somatoform disorders (mean 49 years; SD 3.1 years) compared with patients with depressive disorders (mean 74 years; SD 3.1 years) (p<0.05). All diagnoses were equally associated with moderate functional impairment.

CONCLUSION

Medically unexplained physical symptoms may occur as part of a range of psychiatric disorders in older people and diagnostic groups are distinct in a number of ways. The usefulness of the ICD-10 classification of disorders in relation to these patients is considered. Implications for the delivery of old age psychiatry services are discussed.

Chronic idiopathic constipation: a psychological enquiry

BACKGROUND

Intractable idiopathic constipation in women is often associated with psychosocial problems.

AIMS

To determine the past and current psychological factors associated with slow and normal transit constipation.

PATIENTS

Twenty-eight consecutive patients referred for biofeedback treatment were interviewed before the procedure. All were women. Transit studies revealed that 12 had slow transit constipation (STC) and 16 had normal transit constipation (NTC).

METHODS

Patients were assessed for evidence of previous and current psychiatric diagnoses using a standardized diagnostic interview schedule. A full family and social history was noted. Self-rating scales were used to measure psychological distress, abnormal attitudes to eating and current psychosocial functioning.

RESULTS

The mean age of the 28 patients was 38.2 years (SD = 10.8) with a mean duration of symptoms of 17.5 years (SD = 16.9). Seventeen (61%) had a current psychiatric disorder and 18 (64%) a previous episode of psychiatric illness. The mean age of the 16 NTC patients was 38.4 years (SD = 10.1) with a mean duration of symptoms of 12.4 years (SD = 15.9). By contrast, the 12 STC patients had a much longer mean duration of constipation (24.3 years; SD = 16.4), a mean age of 37.9 years (SD = 12.1), with half having an onset in childhood. The STC patients reported more psychosocial distress on the rating scales than those with NTC, and only one did not experience some form of adverse life event or gynaecological procedure in the 6 months before the onset of constipation. Eleven (39%) of the 28 women had had a hysterectomy at a mean age of 36 years, but only four (14%) reported a history of sexual abuse. Of the nine (32%) patients who reported markedly distorted attitudes to food, six had NTC and three had STC.

CONCLUSIONS

Of consecutive patients undergoing psychological assessment for intractable constipation, three fifths had evidence of current, and two thirds a previous, affective disorder. One third reported distorted attitudes to food. Although STC is a chronic disorder accompanied by high rates of psychological distress, it does not appear to be associated with gross functional impairment. We suggest that patients who present to surgical departments with chronic intractable constipation should routinely have a psychological assessment.

Can clinical assessment of chest pain be made more therapeutic?

We describe the referral and management of consecutive patients attending a cardiac service with the presenting complaint of chest pain. Of 610 consecutive new referrals to five Oxford cardiac clinics over 12 weeks, 202 had chest pain as the presenting complaint: 91 (45%) angina, 101 (50%) non-cardiac chest pain, 8 (4%) both and 2 (1%) uncertain diagnosis. Information in clinic letters was sometimes ambiguous and contradictory and suggested a lack of precise information to patients. Patients with non-cardiac chest pain often had long histories, including considerable previous use of services and specialist investigations. There were delays in referral and assessment of patients. There are opportunities for simple changes in assessment procedures which might have substantial advantages for outcome and resource: (i) more detailed referral information from general practitioners, with an explicit statement of the reasons for referral; (ii) minor modifications to augment the assessment by provision of unambiguous information to patients and primary care at discharge.

"Wheelchair" patients with nonorganic disease: a psychological inquiry

We studied ten patients referred from the neurology service with severe disability associated with the use of a wheelchair, but with no organic disorder to account for their disabilities. All patients were assessed using rating scales as well as a standardized psychiatric interview (SCID), and all medical and psychiatric case notes were examined. We also interviewed key carers for their views on the information and assistance the patients had received. All but two of the ten patients were women, and the mean age was 45.4 years (SD=5.4). All had current diagnoses of conversion or somatoform disorders and six had previous episodes of major depression. Most patients expressed beliefs about their illness that were not consistent with the medical facts, and only two of the carers were satisfied with explanations they had been given by doctors. The results suggest that requests for psychiatric help once patients have become grossly disabled are unlikely to lead to recovery. The psychiatrist, however, can help the primary care doctor to formulate a plan of management aimed at preventing further deterioration.

Frequent attenders without organic disease in a gastroenterology clinic. Patient characteristics and health care use

We used a hospital computer to identify 50 patients (35 women, 15 men) satisfying research criteria for "frequent attenders" at a gastroenterology outpatient clinic (four or more visits to a general hospital clinic in the previous 12 months). Their mean duration of symptoms was 5 years, and 80% reported fatigue as a significant complaint. Thirteen (37%) of the women were also consulting a gynecologist, and in nine of these their status was normal. Seven (21%) of the 35 women who were interviewed had a history of childhood sexual abuse, and these patients reported significantly more lifetime somatic symptoms (9.7, SD = 3.8) than those without such a history (5.4, SD = 3.5, p = < 0.01). The 50 patients reported high levels of disability and psychological distress, and were more likely to rate the probability of their symptoms as being due to "bowel disease" than to "stress" or "other problems." Forty-five patients had at least one current psychiatric diagnosis and 24 at least two, with somatoform disorders being the most common. Nineteen (38%) reported infrequent panic attacks, but only three had somatization disorder. The mean number of lifetime somatic symptoms was 5.9 (SD = 3.6; range 1-14). Seventeen patients (35%) also satisfied criteria for frequent attending in primary care (> 12 visits over the previous 12 months), and the patients reported a mean number of 5.7 (SD = 2.1) specialist appointments in the previous year. There may be a case for using the hospital computer to identify frequent attenders proactively at an earlier stage of their hospital visits so that appropriate management can be instituted. If such patients can be identified in this way, their assessment and management might be more appropriately supervised in designated clinics by more experienced gastroenterology staff.