Metal mixtures and oral health among children and adolescents in the National Health and Nutrition Examination Survey (NHANES), 2017-2020

INTRODUCTION

Dental caries is the most common non-communicable human disease, yet little is known about the role of environmental metals, despite teeth consisting of a hard matrix of trace elements. We conducted a cross-sectional study of associations between environmental metals and objective assessment of dental caries and subjective assessments of oral health among a representative sample of U.S. children and adolescents.

METHODS

Data were from the 2017-March 2020 pre-pandemic data file of the National Health and Nutrition Examination Survey (NHANES). To account for metal mixtures, we used weighted quantile sum (WQS) regression to estimate the joint impact of multiple trace elements assessed in blood and urine with oral disease outcomes.

RESULTS

The blood metal mixture index was associated with a 32% (95% CI: 1.11, 1.56) increased risk of decayed surfaces while the urine metal mixture index was associated with a 106%, RR (95% CI = 2.06 (1.58, 2.70) increased caries risk. For both blood and urine, Mercury (Hg) had the largest contribution to the mixture index followed by Lead (Pb). The WQS blood metal mixture index was also significantly associated with poorer self-rated oral health, although the magnitude of the association was not as strong as for the objective oral disease measures, RR (95% CI) = 1.04 (1.02, 1.07).

DISCUSSION

Increased exposure to a metal mixture was significantly related to poorer objective and subjective oral health outcomes among U.S. children and adolescents. These are among the first findings showing that metal mixtures are a significant contributor to poor oral health.

Peri-operative care of elective adult surgical patients with a learning disability

People with a learning disability can experience significant problems in accessing healthcare and this may be partly reflected in worse health outcomes compared with the general population, including a shorter life expectancy. The Equality Act (2010) requires that organisations and individuals make changes to the way services are provided for all disabled people to mitigate, as far as possible, any disadvantage they may face in accessing these services. These changes are termed 'reasonable adjustments'. This article describes the reasonable adjustments that can be made to facilitate the admission of an adult surgical patient with a learning disability, and therefore reduce health inequality. Each stage of a patient's journey through the hospital needs to be anticipated and planned for. Many of these changes are not only applicable to the wider care of people with a learning disability, but also to any person who lacks capacity and who is struggling to access healthcare. Key recommendations include the development of assessment tools, pathways and policies specific to the learning disabled patient; identification of key personnel including a learning disability lead, an acute liaison learning disability nurse, pre-assessment and operating theatre personnel and ward learning disability champions; regular multidisciplinary team meetings for planning and best interest assessments; and establishing an electronic alert on the patient administration system to identify learning disabled patients. The anaesthetist, operating theatre and learning disability teams play a pivotal role in ensuring individualised admission plans are made for patients with a learning disability to reduce these healthcare inequalities and improve peri-operative care.

Disrupted prevention: condom and contraception access and use among young adults during the initial months of the COVID-19 pandemic. An online survey

BACKGROUND

The initial response to COVID-19 in the UK involved a rapid contraction of face-to-face sexual and reproductive health (SRH) services and widespread use of remote workarounds. This study sought to illuminate young people's experiences of accessing and using condoms and contraception in the early months of the pandemic.

METHODS

We analysed data, including open-text responses, from an online survey conducted in June-July 2020 with a convenience sample of 2005 16-24-year-olds living in Scotland.

RESULTS

Among those who used condoms and contraception, one quarter reported that COVID-19 mitigation measures had made a difference to their access or use. Open-text responses revealed a landscape of disrupted prevention, including changes to sexual risk-taking and preventive practices, unwanted contraceptive pathways, unmet need for sexually transmitted infection (STI) testing, and switches from freely provided to commercially sold condoms and contraception. Pandemic-related barriers to accessing free condoms and contraception included: (1) uncertainty about the legitimacy of accessing SRH care and self-censorship of need; (2) confusion about differences between SRH care and advice received from healthcare professionals during the pandemic compared with routine practice; and (3) exacerbation of existing access barriers, alongside reduced social support and resources to navigate SRH care.

CONCLUSIONS

Emerging barriers to STI and pregnancy prevention within the context of COVID-19 have the potential to undermine positive SRH practices, and widen inequalities, among young people. As SRH services are restored amid evolving pandemic restrictions, messaging to support navigation of condom and contraception services should be co-created with young people.

A comparison of mdma-assisted psychotherapy to non-assisted psychotherapy in treatment-resistant PTSD: A systematic review and meta-analysis

Introduction

Novel, evidence-based treatments are required for treatment-resistant post-traumatic stress disorder (PTSD). 3,4-Methylenedioxymethamphetamine (MDMA) has beneficially augmented psychotherapy in several small clinical trials.

Objectives

To review the use of MDMA-assisted psychotherapy in treatment-resistant PTSD.

Methods

Systematic searches of four databases were conducted from inception to February 2020. A meta-analysis was performed on trials which were double-blinded, randomised, and compared MDMA-assisted psychotherapy to psychotherapy and placebo. The primary outcomes were the differences in Clinician Administered PTSD Scale (CAPS-IV) score and Beck’s Depression Inventory (BDI). Secondary outcome measures included neurocognitive and physical adverse effects, at the time, and within seven days of intervention.

Results

Four randomised controlled trials (RCTs) met inclusion criteria. When compared to active placebo, intervention groups taking 75mg (MD -46.90; 95% CI -58.78, -35.02), 125mg (MD -20.98; 95% CI -34.35, -7.61) but not 100mg (MD -12.90; 95% CI -36.09, 10.29) of MDMA with psychotherapy, had significant decreases in CAPS-IV scores, as did the inactive placebo arm (MD -33.20; 95% CI -40.53, -25.87). A significant decrease in BDI when compared to active placebo (MD -10.80; 95% CI -20.39, -1.21) was only observed at 75mg. Compared to placebo, participants reported significantly more episodes of low mood, nausea and jaw-clenching during sessions and lack of appetite after seven days.

Conclusions

These results demonstrate potential therapeutic benefit with minimal physical and neurocognitive risk for the use of MDMA-assisted psychotherapy in TR-PTSD, despite little effect on Beck’s Depression Inventory. Better powered RCTs are required to investigate further.

Disclosure

James Rucker has attended trial related meetings paid for by Compass Pathways Ltd.

0778 Workplace Yoga Program Features and Associations With Shift Work and Sleep Among Nursing Staff

Introduction

Nursing staff are at risk for impaired sleep due to irregular schedules, long work hours, and other occupational stress. Yoga has demonstrated beneficial effects on sleep in healthy adults and patients with chronic diseases. However, yoga interventions are generally offered as 60-75-minute sessions; this long duration might not be suitable as a workplace program for nursing staff. The objective of this study is to examine workplace yoga program features and associations with shift work and sleep among nursing staff.

Methods

Online Qualtrics surveys were distributed among nurses and nursing assistants at a community hospital in the northeast U.S. Hypothetical workplace yoga program features were assessed including general interest, duration, frequency, timing with respect to work shift, and interest in home practice. Sleep duration and disturbances were assessed.

Results

Among the 541 participants (94% female; age 43±13y), over a third reported sleep ≤6hrs/day (38%) and sleep disturbances (38%), and 79% reported interest in workplace yoga. Among those reporting interest, after work (61%), 30min/session (73%), 3 sessions/week (56%), and interests in home practice (64%) were yoga features endorsed by nursing staff. Night or ≥12hr shift was associated with less interest in workplace yoga. Evening or ≥12hr shift was associated with less interest in yoga after work, while day or night shift was associated with less interest in yoga before work. Mild sleep disturbances were associated with more interest while severe disturbances were associated with less interest in yoga after work. Nursing staff with sleep≤6hrs/day reported less interest in yoga before work, but more interest in home yoga practice.

Conclusion

Nursing staff reported a high prevalence of short and disturbed sleep and interest in workplace yoga. Workplace yoga programs need to be designed according to nursing staff’s interest while considering the effect of shift work and sleep problems reported by nursing staff.

Support

Drs. Yuan Zhang and Jeanne F. Duffy were supported by NIH grant R01 AG044416.

0409 The Efficacy of Afternoon-Evening Sleep Following Night Shifts on Sleep and Alertness in Nurses with Rotating Shift Work Schedule: Real World Data

Introduction

The aim of this study was to investigate the efficacy of changing sleep timing to afternoon-evening following nightshifts in hospital nurses with three rapid rotating shift schedules.

Methods

Hospital nurses with three rotating shift schedules were enrolled for a 1-month pre-intervention and a 1-month intervention study. During the Intervention, sleep timing following nightshifts was directed to afternoon-evening sleep for 8h time-in-bed (TIB) after 1 PM, and ad-lib sleep schedule for other shifts. Baseline and follow-up evaluation included sleep schedule, sleep duration, Epworth sleepiness scale (ESS), insomnia severity index (ISI) for each shift, Beck depression inventory (BDI), and Beck anxiety inventory (BAI). Sleep was assessed by sleep diary and actigraphy. Alertness during the night shift was evaluated using the Karolinska sleepiness scale (KSS) in the beginning and at the end of the shift by texts sent to their cell phones. The participants were asked to give feedback and a willingness to continue this intervention.

Results

A total of 26 subjects (30.7±8.5years, 25 female) finished the study among 29 nurses who participated in the study. The shift work was 6.5±8.0years. The mean morningness-eveningness scale was 42.1±8.0(31-62). TIB following nightshifts were 379.9±91.2 and 478.4±48.7 min for preintervention and intervention, respectively (p=0.001). Total sleep time (TST) was 328.0±91.0 vs. 361.0±70.4min, respectively following nightshifts (p=0.187, Cohen’s drm = 0.467). BDI, BAI, ESS, and ISI were significantly improved after the intervention. 60.7% and 49% of the participants reported improved alertness, and work efficiency during the nightshift. 17.9% and 42.9% of the participants reported increased sleep duration, and improved sleep quality after nightshift, respectively. Only eight participants were willing to continue the afternoon-evening sleep schedule following night shifts. KSS was not different between pre-intervention and intervention.

Conclusion

The afternoon-evening sleep schedule modestly increased total sleep time following nightshift. The overall mood, sleepiness and insomnia scale improved after the intervention although the alertness assessed by KSS failed to show the difference. The individual difference should be considered for applying afternoon-evening sleep for rapid rotating shift schedules.

Support

2018 Research award grants from the Korean sleep research society and NRF-2019R1A2C1090643 funded by the Korean national research foundation

1024 Associations Of Low Back Pain And Sleep Among Nursing Staff

Introduction

Nursing is one of the top occupations suffering musculoskeletal disorders, especially low back pain (LBP). Nursing staff also experience short and disturbed sleep. Although there is a known relationship between pain and sleep, the specific associations between different aspects of LBP (e.g., duration, frequency, intensity) and sleep have not been studied. The objective of this study is to examine different aspects of LBP and their cross-sectional associations with sleep among nursing staff.

Methods

Online Qualtrics surveys were distributed among nurses and nursing assistants at a community hospital in the northeast U.S. LBP was assessed in terms of duration, frequency, intensity, and intensity change from before to after the work shift. Sleep duration and disturbances were assessed with validated scales.

Results

Among the 541 participants (94% female; age 43±13y), more than a third reported short sleep duration (≤6hrs/day; 38%) or sleep disturbances (38%), and more than half (60%) reported LBP in the past 6 months. Among those with LBP, 82% had ongoing pain for at least 6 months; 44% had ongoing pain for at least half the days in the past 6 months; 39% had LBP intensity ≥4 out of 10; and 79% reported post-shift LBP intensity increased of at least 1 level. Short sleep duration was associated with ongoing LBP for at least half the days in the past 6 months, intensity ≥4, and post-shift LBP intensity increase. Sleep disturbances were associated with prevalent LBP and intensity ≥4.

Conclusion

Nursing staff reported a high prevalence of LBP as well as short and disturbed sleep. Overall, poor sleep was associated with higher LBP prevalence, frequency, intensity, and post-shift increase. Future longitudinal studies are needed to clarify the causal directions of these relationships. Workplace interventions should address the widespread problems of LBP and sleep deficiency of nursing staff.

Support

Drs. Yuan Zhang and Jeanne F. Duffy were supported by NIH grant R01 AG044416.

Use of progression criteria to support monitoring and commissioning decision making of public health services: lessons from Better Start Bradford

BACKGROUND

Commissioning and monitoring of community-based interventions is a challenge due to the complex nature of the environment and the lack of any explicit cut-offs to guide decision making. At what point, for example, is participant enrolment to interventions, course completion or satisfaction deemed to be acceptable or sufficient for continued funding? We aimed to identify and quantify key progression criteria for fourteen early years interventions by (1) agreeing the top three criteria for monitoring of successful implementation and progress; and (2) agreeing boundaries to categorise interventions as 'meeting anticipated target' (green); 'falling short of targets' (amber) and 'targets not being met' (red).

METHODS

We ran three workshops in partnership with the UK's Big Lottery Fund commissioned programme 'Better Start Bradford' (implementing more than 20 interventions to improve the health, wellbeing and development of children aged 0-3) to support decision making by agreeing progression criteria for the interventions being delivered. Workshops included 72 participants, representing a range of professional groups including intervention delivery teams, commissioners, intervention-monitoring teams, academics and community representatives. After discussion and activities, final decisions were submitted using electronic voting devices. All participants were invited to reconsider their responses via a post-workshop questionnaire.

RESULTS

Three key progression criteria were assigned to each of the 14 interventions. Overall, criteria that participants most commonly voted for were recruitment, implementation and reach, but these differed according to each intervention. Cut-off values used to indicate when an intervention moved to 'red' varied by criteria; the lowest being for recruitment, where participants agreed that meeting less than 65% of the targeted recruitment would be deemed as 'red' (falling short of target).

CONCLUSIONS

Our methodology for monitoring the progression of interventions has resulted in a clear pathway which will support commissioners and intervention teams in local decision making within the Better Start Bradford programme and beyond. This work can support others wishing to implement a formal system for monitoring the progression of public health interventions.

Vitamin D and tuberculosis: review and association in three rural provinces of Afghanistan

OBJECTIVES

1) To update the 2006 systematic review and meta-analysis by Nnoaham & Clarke exploring the association between serum vitamin D and risk of active tuberculosis (TB) following discrepant evidence; and 2) to identify whether TB and vitamin D are associated in rural Afghanistan.

METHODS

Systematic review and meta-analysis of studies published between January 1980 and June 2014 using Nnoaham & Clarke's methodology. For this case-control study, 90 age- and sex-matched pairs were recruited from rural provinces, and blood 25-hydroxyvitamin D concentrations were measured using enzyme-linked immunosorbent assay.

RESULTS

Sixteen studies were eligible for review. Eleven showed differences between vitamin D levels in TB patients and controls, two showed partial differences and three showed none. Studies on African and European populations show lower vitamin D levels in TB patients, but results from Asia vary. No significant differences were found in vitamin D levels in our rural Afghan population. Controls had a higher body mass index (BMI) (mean control BMI 21.50 kg/m(2), mean case BMI 18.86 kg/m(2), P < 0.001), and were more likely to have been employed (40% of controls, 15.6% of cases, P = 0.002).

CONCLUSION

Genetic differences may account for the differences among study results in the systematic review. Vitamin D levels are not associated with TB among Afghans living in these rural provinces.

Pediatric health-related quality of life after intestinal transplantation

As outcomes after ITx improve, greater emphasis is needed on HRQOL. The primary aims of this study were to (i) assess the feasibility of measuring HRQOL in pediatric ITx recipients, (ii) measure HRQOL using validated instruments, and (iii) compare HRQOL in ITx recipients to healthy normal (NL) children. The CHQ and Pediatric Quality of Life (PedsQL4.0) instruments were administered to both patients and parents at outpatient visits. All 24 eligible patients were enrolled. The median age at study enrollment was 6.0 yr (range: 2-18 yr), and the median time from transplant to study enrollment was 2.8 yr (range: 0.5-11.8 yr). The majority of subjects were male (58%), Latino (58%), and liver-inclusive (92%) recipients. For CHQ and PedsQL4.0, parental responses were significantly lower in multiple categories including physical health and social functioning compared to healthy norms. Patient responses were not different from NL using CHQ but using PedsQL4.0 were significantly lower in the school functioning subcategory and psychosocial health summary score. HRQOL as reported by children and families after ITx is significantly lower in multiple categories compared to NL.

Prevalence of genital chlamydial infection among a community sample of young international backpackers in Sydney, Australia

We conducted a chlamydia prevalence study from January to June 2009 among a community sample of young international backpackers by recruiting at hostels in Sydney, Australia. Participants completed a questionnaire; men provided a urine sample and women provided a self-collected vaginal swab, which were tested for Chlamydia trachomatis DNA by strand displacement amplification. We recruited 225 men (median age 24 years) and 207 women (median age 23 years). Most (87%) of the travellers came from Europe. A new sexual partner during travel was reported by 67%, and 51% had more than one new sexual partner. Of those reporting a new sexual partner, 40% always used condoms. Prevalence of chlamydia was 3.5% (3.1% in men, 3.9% in women). Previous testing for chlamydia was reported by 40%. Drinking alcohol at hazardous levels was reported by 58% of men and 29% of women. Despite the reporting of new sexual partners and inconsistent condom use, the prevalence of chlamydia in these backpackers was not higher than that found in more general populations, and may relate to good health-care seeking behaviour. Young travellers need education about sexual risks and promotion of condom use prior to travel, and access to public sexual health services.

Extended criteria donor and severe intraoperative glucose variability: association with reoperation for hemorrhage in liver transplantation

Reoperations for hemorrhage following liver transplantation (OLT) are commonly associated with increased morbidity and mortality. We sought to determine the incidence and risk factors for reoperation for hemorrhage among adult liver transplantations. We retrospectively analyzed 668 patients transplanted between January 2004 and November 2007. Within 30 days following transplantation one hundred eleven patients (16.6%) underwent 156 reoperations for hemorrhage, averaging 1.4 reoperations per patient. More than half of the reoperations occurred during the first 2 postoperative days. One-third of patients required 2 or more reoperations. Multivariate logistic regression analysis showed 4 independent risk factors: grafts from donors with multiple extended criteria, severe intraoperative glucose variability, intraoperative use of vasopressors, and red blood cell transfusion requirement. In conclusion, we identified several independent risk factors for reoperation due to hemorrhage following OLT. Avoidance of severe intraoperative glucose variability and careful evaluation of the benefits and risks of utilizing extended criteria donors must be considered before transplantation.

Pain relief in hysterosalpingography

BACKGROUND

Hysterosalpingography (HSG) is a method of testing for tubal patency. Various pharmacological strategies are available that may reduce the pain during the procedure.

OBJECTIVES

To compare the effectiveness of different types of pharmacological interventions for pain relief in women undergoing hysterosalpingography (HSG) for investigation of subfertility.

SEARCH STRATEGY

This review has drawn on the search strategy developed for the Menstrual Disorders and Subfertility Group. In addition MEDLINE and EMBASE were searched up to July 2006.

SELECTION CRITERIA

All randomised controlled trials investigating the pharmacological interventions for pain relief during HSG were investigated.

DATA COLLECTION AND ANALYSIS

Data were extracted independently by the first two authors. Differences of opinion were registered and resolved by the third author. Results for each study were expressed as mean pain score and standard error of the mean with 95% confidence intervals.

MAIN RESULTS

The included eight trials reported on 570 women undergoing HSG.Overall, there was no evidence of benefit of using any analgesia compared with placebo for pain relief during the procedure (standard mean difference (SMD) of -0.05 (95%CI -0.25 to 0.14) or up to 29 minutes after HSG SMD 0.17, (95%CI -1.00 to 1.34)). Four RCTs involving 219 women found evidence of benefit with any analgesia in comparison to placebo for pain relief more than 30 minutes after HSG, with the SMD of -0.82(95%CI-1.18 to -0.45). One RCT involving 91 women compared the effectiveness of opioid analgesics versus non-opioid analgesics and reported no evidence of difference in pain relief at any stage of the procedure. One RCT involving 20 women compared the use of topical analgesia with a paracervical block, with analysis demonstrating more benefit to be gained from using topical analgesia during HSG, with the SMD of -2.03 (95%Cl-3.16 to -0.91).

AUTHORS' CONCLUSIONS

There is little evidence of benefit in terms of pain relief of any of the interventions considered in this study during or immediately after HSG. However, there is limited evidence of pain reduction 30 minutes after the procedure. Further RCTs should consider the role of non steroidal antiinflammatories (NSAIDs) and intrauterine anaesthetic during HSG.

Effects of elevated temperature and nickel pollution on the immune status of Japanese medaka

Changes in a host's environment (i.e. physical or chemical) can alter normal immune function. In aquatic organisms, exposure to stress can result in significant changes in innate immunity. In the natural environment, fish are exposed to multiple stressors simultaneously. Temperature change and/or chemical exposure as individual environmental stressors have been shown in various fish species to alter all aspects of the immune response. These same stressors have also been shown to alter plasma steroid levels in exposed fish. For this study, the effects of elevated temperature and nickel pollution on specific immune parameters of Japanese medaka (Oryzias latipes) were determined. Fish were exposed for 1, 7 or 14d to either: waterborne nickel (Ni) at the nominal concentration of 125ppb; a 5 degrees C (+/-0.5 degrees C) rapid increase in water temperature; or, both potential stressors in combination. Medaka maintained at room temperature (25 degrees C+/-1 degrees C) served as the controls. Altered function of the innate and adaptive arms of the immune response was evaluated by assessing kidney macrophage-mediated superoxide (O(2)(-)) production and splenic T-cell proliferation, respectively. Plasma cortisol levels were analysed in the same fish as a marker of the physiological stress response. While kidney cell number was unaffected by exposure of fish to either stressor alone or both factors in combination, spleen cellularity was decreased (compared to control fish) in medaka exposed for 1d to thermal stress in combination with Ni, and to a lesser extent to thermal stress alone. T-lymphocyte proliferation by medaka splenocytes was not affected by any exposure paradigm. Unstimulated intracellular O(2)(-) production by kidney phagocytes was significantly elevated (compared to control) in medaka exposed for 1d to either thermal stress alone or temperature change in combination with Ni; by 7d, only the stressor combination significantly increased baseline O(2)(-) production. Resting levels of extracellular O(2)(-) production was significantly reduced in fish maintained for 1d at the elevated temperature. Effects on phorbol 12-myristate 13 acetate (PMA)-stimulated intracellular and extracellular O(2)(-) production were less dramatic than those observed for resting phagocytes. Exposure of medaka to elevated temperature for 14d tended (p<0.06) to reduce PMA-stimulated intracellular O(2)(-) production (compared to the time-matched control). Although exposure of fish for 14d to elevated temperature only slightly reduced stimulated extracellular O(2)(-) production, exposure for the same duration to Ni alone significantly depressed oxyradical production by kidney phagocytes (compared to the time-matched controls). Decreased plasma cortisol levels were observed in fish exposed for 7d to either an elevated water temperature or Ni (compared to the time-matched control); by 14d of exposure, no significant treatment-induced effects on cortisol levels were observed. These findings add to the growing body of literature seeking to determine what effects, if any, exposure to multiple aquatic pollution-induced effects have upon fish health and the health of impacted ecosystems.

Severe pulmonary disease due to multisystemic eosinophilic epitheliotropic disease in a horse

Multisystemic eosinophilic epitheliotropic disease was diagnosed histologically in a 17-year-old Quarter Horse intact mare that was presented with a chronic history of respiratory distress. At necropsy, the lungs were poorly collapsed and the pulmonary parenchyma contained innumerable, discrete, spherical nodules in a miliary pattern. A few similar nodules were scattered in the liver and the renal lymph nodes. Histologically, these nodules consisted of fibrosing eosinophilic granulomas. Based on histologic findings and the absence of an etiologic agent, a diagnosis of multisystemic eosinophilic epitheliotropic disease was made.

Predictors of operative death after oesophagectomy for carcinoma

BACKGROUND

Oesophagectomy for carcinoma provides a chance of cure but carries significant risk. This study defined risk factors for death after oesophageal resection for malignant disease.

METHODS

Between 1990 and 2003, 773 oesophagectomies for oesophageal cancer were performed. Continuous variables were categorized into quartiles for analysis. Predictors of operative mortality were identified by univariate and multiple logistic regression analysis.

RESULTS

The operative mortality rate was 4.8 per cent (37 of 773). In univariate analysis, advanced age, reduced forced expiratory volume in 1 s (FEV1), reduced forced vital capacity, presence of diabetes and tumour located in the upper third of the oesophagus were associated with a higher mortality rate. Multivariate analysis identified age (highest relative to lowest quartile, odds ratio (OR) 4.87 (95 per cent confidence interval (c.i.) 1.35 to 17.55); P = 0.009), tumour position (upper third relative to other locations, OR 4.23 (95 per cent c.i. 1.06 to 16.86); P = 0.041) and FEV1 (lowest relative to highest quartile, OR 4.72 (95 per cent c.i. 1.01 to 21.99); P = 0.018) as independent predictors of death.

CONCLUSION

Advanced age, impaired preoperative respiratory function and a tumour high in the oesophagus are associated with a significantly increased risk of death after oesophagectomy for carcinoma.

New approaches to enhance the accuracy of the diagnosis of reflux disease

The accuracy of symptoms in diagnosing gastro-oesophageal reflux disease (GORD) is complicated by the lack of a gold standard test. Statistical techniques such as latent class and Bayesian analyses can estimate accuracy of symptoms without a gold standard. Both techniques require three independent diagnostic tests. Latent class analysis makes no assumptions about the performance of the tests. Bayesian analysis is useful when the accuracy of the other tests is known. These statistical techniques should be used in the future to validate GORD symptom questionnaires comparing them with endoscopy, oesophageal pH monitoring, and response to proton pump inhibitor therapy. Studies that evaluate GORD symptoms are usually done in secondary care. The prevalence of GORD in primary care will be lower and this reduces the positive predictive value of symptoms. There will be some bias in the type of patient referred for diagnosis and this usually decreases the specificity of symptom diagnosis.

Progressive nonfluent aphasia and subsequent aphasic dementia associated with atypical progressive supranuclear palsy pathology

We describe a right-handed man who developed progressive nonfluent aphasia and apraxia of speech beginning at age 71. By age 74 he had behavioral changes, aphasic dementia, as well as mild parkinsonism; extraocular movements were normal except for mild limitation of upgaze. Serial neuropsychometric testing and single photon emission computed tomography (SPECT) scans showed progressive changes reflecting left>right cerebral hemisphere dysfunction. Neuropathologic examination revealed findings characteristic of progressive supranuclear palsy (PSP) except that the cortical pathology was more widespread than is typical of PSP. We conclude that the clinical manifestations in this case were more similar to the syndrome of progressive nonfluent aphasia with subsequent aphasic dementia and mild parkinsonism, rather than those of PSP. Hence, PSP can present clinically as an atypical dementing syndrome dominated by progressive aphasia/apraxia of speech.

Concurrent opioid dependence and mental health problems: a review of the issues for general practice

The literature is reviewed on the issue of concurrent opioid dependence and mental health problems within the general practice setting. People with such problems have poorer personal, clinical and social outcomes than people with either mental health or drug and alcohol (D&A) problems alone. Mental health and drug services operate from different policy systems and are generally not co-ordinated with each other, leaving the onus on the patient to move effectively through health systems. The common statement that GPs are ideal health professionals to manage concurrent problems is contrasted with the evident barriers in general practice such as lack of time, knowledge, skills and confidence. Models for managing concurrent problems tend towards shared care. However, these models either have received mixed evidence (e.g. consultant-liaison psychiatry) or are amenable to development but remain untested (e.g. co-ordinated care, community health centre programs). The Enhanced Primary Care items introduced in 1999/2000 may provide an incentive for GPs to participate in shared care arrangements with other health professionals. However, there is a need for mechanisms to increase the links between GPs and other health services.