Synthesis of diphenyl-(2-thienyl)phosphine, its chalcogenide derivatives and a series of novel complexes of lanthanide nitrates and triflates

A novel synthesis of diphenyl(2-thienyl)phosphine, along with its' oxide, sulfide and selenide derivatives, is reported here. These phosphines have been characterized by NMR, IR, MS and X-Ray crystallography. The phosphine oxide derivative was reacted with a selection of lanthanide(III) nitrates and triflates, LnX₃, to give the resultant metal-ligand complexes. These complexes have also been characterized by NMR, IR, MS and X-Ray crystallography. Single crystal X-Ray diffraction data shows a difference in metal-ligand complex stoichiometry and stereochemistry depending on the counteranion (nitrate vs. triflate). The [Ln(Ar₃PO)₃(NO₃)₃] ligand-nitrate complexes are nine-coordinate to the metal in the solid state (bidentate nitrate), featuring a 1 : 3 lanthanide-ligand ratio and bear an overall octahedral arrangement of the six, coordinated ligands. Our [Ln(Ar₃PO)₃(NO₃)₃] ligand-nitrate complexes gave three examples of fac-stereochemistry, where mer-stereochemistry is almost universally observed in the literature of highly related [Ln(Ar₃PO)₃(NO₃)₃] complexes. For the Tb complexes, two different arrangements of the ligands around the metal were observed in the solid state for [Tb(Ar₃PO)₃(NO₃)₃] and [Tb(Ar₃PO)₄(OTf)₂] [OTf]. [Tb(Ar₃PO)₃(NO₃)₃] is strictly nine-coordinate, ligand mer-stereochemistry in the solid state, and [Tb(Ar₃PO)₄(OTf)₂] [OTf] is strictly octahedral, six-coordinate, with a square-planar stereochemical arrangement of the phosphine oxide ligands around the metal.

Musculoskeletal consultations from childhood to adulthood: a longitudinal study

BACKGROUND

The Global Burden of Disease reports indicate that musculoskeletal conditions are important causes of disability worldwide. Such conditions may originate in childhood, but studies investigating changes longitudinally and from childhood to adulthood are infrequent.

METHODS

Nine birth cohorts of children (starting at ages 7-15 years) were followed. Participants were identified from Consultations in Primary Care Archive, an electronic health record database of 11 English general practices. Musculoskeletal consultation prevalence figures were calculated, and reasons for consultation evaluated.

RESULTS

Annual musculoskeletal consultation prevalence was similar across cohorts for each age. Prevalence increased from 6 to 16% between ages 7 and 22 and was higher in males until age 15, after which prevalence was higher in females. Pain was the most common reason for consultation. Back pain consultations increased from 1 consultation/1000 7 year olds to 84 consultations/1000 22 year olds. Lower limb pain consultations increased from 21 consultations/1000 7 year olds to 56 consultations/1000 22 year olds.

CONCLUSIONS

This study shows that from childhood, individuals are more likely to seek healthcare for musculoskeletal consultations as they age, but rates are not increasing over time. Changes in consultation rates by age, gender and pain region may inform studies on the development of chronic musculoskeletal pain over the life-course.

Stratified primary care versus non-stratified care for musculoskeletal pain: findings from the STarT MSK feasibility and pilot cluster randomized controlled trial

BACKGROUND

Musculoskeletal (MSK) pain from the five most common presentations to primary care (back, neck, shoulder, knee or multi-site pain), where the majority of patients are managed, is a costly global health challenge. At present, first-line decision-making is based on clinical reasoning and stratified models of care have only been tested in patients with low back pain. We therefore, examined the feasibility of; a) a future definitive cluster randomised controlled trial (RCT), and b) General Practitioners (GPs) providing stratified care at the point-of-consultation for these five most common MSK pain presentations.

METHODS

The design was a pragmatic pilot, two parallel-arm (stratified versus non-stratified care), cluster RCT and the setting was 8 UK GP practices (4 intervention, 4 control) with randomisation (stratified by practice size) and blinding of trial statistician and outcome data-collectors. Participants were adult consulters with MSK pain without indicators of serious pathologies, urgent medical needs, or vulnerabilities. Potential participant records were tagged and individuals sent postal invitations using a GP point-of-consultation electronic medical record (EMR) template. The intervention was supported by the EMR template housing the Keele STarT MSK Tool (to stratify into low, medium and high-risk prognostic subgroups of persistent pain and disability) and recommended matched treatment options. Feasibility outcomes included exploration of recruitment and follow-up rates, selection bias, and GP intervention fidelity. To capture recommended outcomes including pain and function, participants completed an initial questionnaire, brief monthly questionnaire (postal or SMS), and 6-month follow-up questionnaire. An anonymised EMR audit described GP decision-making.

RESULTS

GPs screened 3063 patients (intervention = 1591, control = 1472), completed the EMR template with 1237 eligible patients (intervention = 513, control = 724) and 524 participants (42%) consented to data collection (intervention = 231, control = 293). Recruitment took 28 weeks (target 12 weeks) with > 90% follow-up retention (target > 75%). We detected no selection bias of concern and no harms identified. GP stratification tool fidelity failed to achieve a-priori success criteria, whilst fidelity to the matched treatments achieved "complete success".

CONCLUSIONS

A future definitive cluster RCT of stratified care for MSK pain is feasible and is underway, following key amendments including a clinician-completed version of the stratification tool and refinements to recommended matched treatments.

TRIAL REGISTRATION

Name of the registry: ISRCTN.

TRIAL REGISTRATION NUMBER

15366334. Date of registration: 06/04/2016.

Back pain, mental health and substance use are associated in adolescents

BACKGROUND

During adolescence, prevalence of pain and health risk factors such as smoking, alcohol use and poor mental health all rise sharply. The aim of this study was to describe the relationship between back pain and health risk factors in adolescents.

METHODS

Cross-sectional data from the Healthy Schools Healthy Futures study, and the Australian Child Wellbeing Project was used, mean age: 14-15 years. Children were stratified according to back pain frequency. Within each strata, the proportion of children that reported drinking alcohol or smoking or that experienced feelings of anxiety or depression was reported. Test-for-trend analyses assessed whether increasing frequency of pain was associated with health risk factors.

RESULTS

Data was collected from ~2500 and 3900 children. Larger proportions of children smoked or drank alcohol within each strata of increasing pain frequency. The trend with anxiety and depression was less clear, although there was a marked difference between the children that reported no pain, and pain more frequently.

CONCLUSION

Two large, independent samples show adolescents that experience back pain more frequently are also more likely to smoke, drink alcohol and report feelings of anxiety and depression. Pain appears to be part of the picture of general health risk in adolescents.

Brief pain re-assessment provided more accurate prognosis than baseline information for low-back or shoulder pain

Background

Research investigating prognosis in musculoskeletal pain conditions has only been moderately successful in predicting which patients are unlikely to recover. Clinical decision making could potentially be improved by combining information taken at baseline and re-consultation.

Methods

Data from four prospective clinical cohorts of adults presenting to UK and Dutch primary care with low-back or shoulder pain was analysed, assessing long-term disability at 6 or 12 months and including baseline and 4–6 week assessments of pain. Baseline versus short-term assessments of pain, and previously validated multivariable prediction models versus repeat assessment, were compared to assess predictive performance of long-term disability outcome. A hypothetical clinical scenario was explored which made efficient use of both baseline and repeated assessment to identify patients likely to have a poor prognosis and decide on further treatment.

Results

Short-term repeat assessment of pain was better than short-term change or baseline score at predicting long-term disability improvement across all cohorts. Short-term repeat assessment of pain was only slightly more predictive of long-term recovery (c-statistics 0.78, 95% CI 0.74 to 0.83 and 0.75, 95% CI 0.69 to 0.82) than a multivariable baseline prognostic model in the two cohorts presenting such a model (c-statistics 0.71, 95% CI 0.67 to 0.76 and 0.72, 95% CI 0.66 to 0.78). Combining optimal prediction at baseline using a multivariable prognostic model with short-term repeat assessment of pain in those with uncertain prognosis in a hypothetical clinical scenario resulted in reduction in the number of patients with an uncertain probability of recovery, thereby reducing the instances where patients may be inappropriately referred or reassured.

Conclusions

Incorporating short-term repeat assessment of pain into prognostic models could potentially optimise the clinical usefulness of prognostic information.

Electronic supplementary material

The online version of this article (doi:10.1186/s12891-017-1502-8) contains supplementary material, which is available to authorized users.

Does a modified STarT Back Tool predict outcome with a broader group of musculoskeletal patients than back pain? A secondary analysis of cohort data

OBJECTIVES

The STarT Back Tool has good predictive performance for non-specific low back pain in primary care. We therefore aimed to investigate whether a modified STarT Back Tool predicted outcome with a broader group of musculoskeletal patients, and assessed the consequences of using existing risk-group cut-points across different pain regions.

SETTING

Secondary analysis of prospective data from 2 cohorts: (1) outpatient musculoskeletal physiotherapy services (PhysioDirect trial n=1887) and (2) musculoskeletal primary-secondary care interface services (SAMBA study n=1082).

PARTICIPANTS

Patients with back, neck, upper limb, lower limb or multisite pain with a completed modified STarT Back Tool (baseline) and 6-month physical health outcome (Short Form 36 (SF-36)).

OUTCOMES

Area under the receiving operator curve (AUCs) tested discriminative abilities of the tool's baseline score for identifying poor 6-month outcome (SF-36 lower tertile Physical Component Score). Risk-group cut-points were tested using sensitivity and specificity for identifying poor outcome using (1) Youden's J statistic and (2) a clinically determined rule that specificity should not fall below 0.7 (false-positive rate <30%).

RESULTS

In PhysioDirect and SAMBA, poor 6-month physical health was 18.5% and 28.2%, respectively. Modified STarT Back Tool score AUCs for predicting outcome in back pain were 0.72 and 0.79, neck 0.82 and 0.88, upper limb 0.79 and 0.86, lower limb 0.77 and 0.83, and multisite pain 0.83 and 0.82 in PhysioDirect and SAMBA, respectively. Differences between pain region AUCs were non-significant. Optimal cut-points to discriminate low-risk and medium-risk/high-risk groups depended on pain region and clinical services.

CONCLUSIONS

A modified STarT Back Tool similarly predicts 6-month physical health outcome across 5 musculoskeletal pain regions. However, the use of consistent risk-group cut-points was not possible and resulted in poor sensitivity (too many with long-term disability being missed) or specificity (too many with good outcome inaccurately classified as 'at risk') for some pain regions. The draft tool is now being refined and validated within a new programme of research for a broader musculoskeletal population.

TRIAL REGISTRATION NUMBER

ISRCTN55666618; Post results.

In sickness and in health: A cross-sectional analysis of concordance for musculoskeletal pain in 13,507 couples

Background

Musculoskeletal pain conditions are common and create substantial burden for the individual and society. While research has shown concordance between couples for risk of some diseases, e.g. heart disease or diabetes, little information is available on such effects for musculoskeletal pain conditions. Our aims were to investigate the presence of concordance between couples for consultations about pain, and to examine theoretical influences on such concordance.

Methods

This was a 1‐year cross‐sectional study of musculoskeletal pain consultations in a UK primary care database. In total 27,014 patients (13,507 couples) aged between 30 and 74 years were included. The main outcome measure was the presence of a musculoskeletal morbidity read code indicating a consultation for musculoskeletal conditions (any, back, neck, knee, shoulder, foot, osteoarthritis). Logistic regression was used to test associations with odds ratios (OR) and 95% confidence intervals (95% CI).

Results

Patients whose partner had a musculoskeletal pain consultation were also more likely to consult for a musculoskeletal condition (OR 1.22, 95% CI 1.12–1.32). This association was found to be strongest for shoulder disorders (OR 1.91, 95% CI 1.06–3.47). No significant associations were found for other pain conditions.

Conclusion

Results show that partner concordance is present for consultations for some musculoskeletal conditions but not others. Possible explanations for concordance include the shared health behaviours between couples leading to potential heightened awareness of symptoms. Given the high prevalence of musculoskeletal pain within populations, it may be worth considering further the mechanisms that explain partner concordance.

The effectiveness of national guidance in changing analgesic prescribing in primary care from 2002 to 2009: an observational database study

Background

Numerous national guidelines have been issued to assist general practitioners’ safe analgesic prescribing. Their effectiveness is unclear. The objective of this study was to examine trends in general practitioners’ prescribing behaviour in relation to national guidelines.

Methods

This was a retrospective observational database study of registered adult patients prescribed an analgesic (2002–2009) from the Consultations in Primary Care Archive – 12 North Staffordshire general practices. Prescribing guidance from the UK Medicines Regulatory Health Authority (MHRA) regarding non-steroidal anti-inflammatory drugs (NSAIDs) and co-proxamol, and the National Institute for Health and Clinical Excellence (NICE) osteoarthritis (OA) management guidelines were considered. Analgesic prescribing rates were examined, arranged according to a classification of six equipotent medication groups: (1) basic analgesics; (2)–(5) increasingly potent opioids and (6) NSAIDs. In each quarter from 2002 to 2009, the number of patients per 10,000 registered population receiving a prescription for the first time from each group was determined. Quarters associated with significant changes in the underlying prescribing trend were determined using joinpoint regression.

Results

A significant decrease in incident co-proxamol and Cox-2 prescribing occurred around the time of the first MHRA advice to stop using them and were rarely prescribed thereafter. The new prescribing of weak analgesics (e.g., co-codamol 8/500) increased at this same time. Initiating topical NSAIDs significantly increased around the time of the NICE OA guidelines.

Conclusions

Significant prescribing changes occurred when national advice and guidelines were issued. The effectiveness of this advice may vary depending upon the content and method of dissemination. Further evaluation of the optimal methods for delivering prescribing guidance is required.

Intermediate-conductance calcium-activated potassium channels participate in neurovascular coupling

BACKGROUND AND PURPOSE

Controlling vascular tone involves K(+) efflux through endothelial cell small- and intermediate-conductance calcium-activated potassium channels (K(Ca)2.3 and K(Ca)3.1, respectively). We investigated the expression of these channels in astrocytes and the possibility that, by a similar mechanism, they might contribute to neurovascular coupling.

EXPERIMENTAL APPROACH

Transgenic mice expressing enhanced green fluorescent protein (eGFP) in astrocytes were used to assess K(Ca)2.3 and K(Ca)3.1 expression by immunohistochemistry and RT-PCR. K(Ca) currents in eGFP-positive astrocytes were determined in situ using whole-cell patch clamp electrophysiology. The contribution of K(Ca)3.1 to neurovascular coupling was investigated in pharmacological experiments using electrical field stimulation (EFS) to evoke parenchymal arteriole dilatation in FVB/NJ mouse brain slices and whisker stimulation to evoke changes in cerebral blood flow in vivo, measured by laser Doppler flowmetry.

KEY RESULTS

K(Ca)3.1 immunoreactivity was restricted to astrocyte processes and endfeet and RT-PCR confirmed astrocytic K(Ca)2.3 and K(Ca)3.1 mRNA expression. With 200 nM [Ca(2+)](i) , the K(Ca)2.1-2.3/K(Ca)3.1 opener NS309 increased whole-cell currents. CyPPA, a K(Ca)2.2/K(Ca)2.3 opener, was without effect. With 1 µM [Ca(2+)](i) , the K(Ca)3.1 inhibitor TRAM-34 reduced currents whereas apamin (K(Ca)2.1-2.3 blocker) had no effect. CyPPA also inhibited currents evoked by NS309 in HEK293 cells expressing K(Ca)3.1. EFS-evoked Fluo-4 fluorescence confirmed astrocyte endfoot recruitment into neurovascular coupling. TRAM-34 inhibited EFS-evoked arteriolar dilatation by 50% whereas charybdotoxin, a blocker of K(Ca)3.1 and the large-conductance K(Ca) channel, K(Ca)1.1, inhibited dilatation by 82%. TRAM-34 reduced the cortical hyperaemic response to whisker stimulation by 40%.

CONCLUSION AND IMPLICATIONS

Astrocytes express functional K(Ca)3.1 channels, and these contribute to neurovascular coupling.

Intermediate-conductance calcium-activated potassium channels participate in neurovascular coupling

BACKGROUND AND PURPOSE

Controlling vascular tone involves K(+) efflux through endothelial cell small- and intermediate-conductance calcium-activated potassium channels (K(Ca)2.3 and K(Ca)3.1, respectively). We investigated the expression of these channels in astrocytes and the possibility that, by a similar mechanism, they might contribute to neurovascular coupling.

EXPERIMENTAL APPROACH

Transgenic mice expressing enhanced green fluorescent protein (eGFP) in astrocytes were used to assess K(Ca)2.3 and K(Ca)3.1 expression by immunohistochemistry and RT-PCR. K(Ca) currents in eGFP-positive astrocytes were determined in situ using whole-cell patch clamp electrophysiology. The contribution of K(Ca)3.1 to neurovascular coupling was investigated in pharmacological experiments using electrical field stimulation (EFS) to evoke parenchymal arteriole dilatation in FVB/NJ mouse brain slices and whisker stimulation to evoke changes in cerebral blood flow in vivo, measured by laser Doppler flowmetry.

KEY RESULTS

K(Ca)3.1 immunoreactivity was restricted to astrocyte processes and endfeet and RT-PCR confirmed astrocytic K(Ca)2.3 and K(Ca)3.1 mRNA expression. With 200 nM [Ca(2+)](i) , the K(Ca)2.1-2.3/K(Ca)3.1 opener NS309 increased whole-cell currents. CyPPA, a K(Ca)2.2/K(Ca)2.3 opener, was without effect. With 1 µM [Ca(2+)](i) , the K(Ca)3.1 inhibitor TRAM-34 reduced currents whereas apamin (K(Ca)2.1-2.3 blocker) had no effect. CyPPA also inhibited currents evoked by NS309 in HEK293 cells expressing K(Ca)3.1. EFS-evoked Fluo-4 fluorescence confirmed astrocyte endfoot recruitment into neurovascular coupling. TRAM-34 inhibited EFS-evoked arteriolar dilatation by 50% whereas charybdotoxin, a blocker of K(Ca)3.1 and the large-conductance K(Ca) channel, K(Ca)1.1, inhibited dilatation by 82%. TRAM-34 reduced the cortical hyperaemic response to whisker stimulation by 40%.

CONCLUSION AND IMPLICATIONS

Astrocytes express functional K(Ca)3.1 channels, and these contribute to neurovascular coupling.

Sickness certification and the GP: what really happens in practice?

BACKGROUND

GPs typically sanction absence from work by issuing sickness certificates. There has been some debate recently about changing the way sickness certificates are issued and by whom. However, without understanding GPs' certification practices, their requirements in terms of training and education and how they feel the certification process should or should not be changed, measures aimed at improving the system are unlikely to succeed.

OBJECTIVE

To investigate and describe British GPs' sickness certification practices.

METHODS

A cross-sectional nationwide postal survey of 2154 UK GPs was conducted. GPs were asked about perceived certification practices, training in sickness certification, their opinions about the certification process and potential to improve the system.

RESULTS

Adjusted response was 42% (n = 878). GPs do ask about a patient's work situation but lack training in sickness certification. GPs would like to maintain their role in sickness certification but felt there was scope for other health professionals to issue some sickness certificates. GPs report more frequent sickness certification for mental health and musculoskeletal conditions compared to any other condition.

CONCLUSIONS

This study has highlighted the main issues that GPs face during a consultation where sickness certification is a possible outcome. Lack of training in certification was a recurrent theme. However, GPs felt there was scope to improve training and recommendations were made as to how this might be achieved. The survey has highlighted that GPs feel there are opportunities to improve the system and that other health professionals may play a role in the certification process.

Epidemiology and natural history of low back pain

Low back pain is a common problem affecting most adults at some point during their lifetime. At any one time, around 1 in 5 adults will report symptoms of low back pain, rising to 40% when asked if they have experienced symptoms during the previous month. The majority of people who experience an episode of low back pain will improve over time. However a sizeable proportion experience repeated episodes or recurrences, and some report continuous symptoms for many years. A wide range of factors are linked to both the onset and persistence of low back pain. Some studies have related age and gender to low back pain, but the link overall is equivocal. Work-related factors such as heavy lifting, and socio-demographic factors such as smoking and obesity have been linked with the onset of low back pain. High levels of functional impairment and the presence of pain radiating to the leg have been cited as factors associated with a poor prognosis among primary care consulters with low back pain. Other characteristics associated with both the development and the persistence of low back pain include psychological factors such as depression and anxiety and workplace factors such as job satisfaction. Low back pain places large demands on health, social and welfare systems. Further research is needed to identify practical interventions to reduce this burden from low back pain.

Personalizing retrieval of journal articles for patient care

We present a system for patient-specific searches on a database of medical journal articles which uses natural language techniques to match search results against patient records. We performed an information retrieval experiment comparing the performance of this system to two strategies, one of which uses extensive medical knowledge, while the other uses the same patient information our system has. The results show that our system is useful in improving recall over the strategy simulating a human specialist, and clearly outperforms the strategy of using the patient record content without intelligent processing.

Satisfaction in the sex life of a general population sample

A questionnaire asking about satisfaction and problems in the sex lives of respondents and their partners was sent to 4,000 adults registered with general practices in England. A quarter of respondents said that they were dissatisfied with their sex lives, men more so than women, particularly with the frequency of intercourse. Respondents were more likely to be dissatisfied with their sex life if they perceived their partner to have a sexual problem. Respondents who were dissatisfied were more likely to report that their partner was dissatisfied with their sex life. The benefits of treating sexual problems have wide implications for both partners in a relationship.

Has endometrial ablation replaced hysterectomy for the treatment of dysfunctional uterine bleeding? National figures

OBJECTIVES

To describe trends in the use of endometrial ablation and hysterectomy for the treatment of dysfunctional uterine bleeding.

DESIGN

Analysis of hospital admissions data.

SETTING

National Health Service Hospitals in England.

POPULATION

Women who underwent a hysterectomy or endometrial ablation for dysfunctional uterine bleeding between 1989 and 1996.

MAIN OUTCOME MEASURES

Annual operation rates and standardised operation ratios for England and for the National Health Service Regions within it, and proportion of operations for dysfunctional uterine bleeding that were endometrial ablations or hysterectomies.

RESULTS

There was an initial rise in operation rates for endometrial ablation until 1992/3, since when the rates have fallen. Hysterectomy rates have remained relatively steady since the introduction of endometrial ablation. The total operation rates for dysfunctional uterine bleeding initially increased but have tended to fall since 1992/3. The ratio of hysterectomy to endometrial ablation for dysfunctional uterine bleeding troughed at 3:1 in 1992/3, but by 1995/6 had increased to 4:1.

CONCLUSIONS

Rather than replacing hysterectomy in the treatment of dysfunctional uterine bleeding, endometrial ablation appears to have added an alternative operative technique. This led to an increase in the total number of operations for this condition, perhaps by lowering the threshold for intervention.

Interventions for treating calcaneal fractures

BACKGROUND

Fracture of the calcaneus (os calcis or heel bone) comprises one to two per cent of all fractures.

OBJECTIVES

To identify and evaluate randomised trials of treatments for calcaneal fractures.

SEARCH STRATEGY

MEDLINE, EMBASE, CINAHL, the Cochrane Controlled Trials Register, and the Cochrane Musculoskeletal Injuries Group Trials Register were searched. We checked reference lists of relevant articles and contacted trialists and experts in the field. Date of the most recent search: October 1998.

SELECTION CRITERIA

Randomised and quasi-randomised trials comparing interventions for treating patients with calcaneal fractures.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial quality, using a 12 item scale, and extracted data. Wherever appropriate and possible, results were pooled.

MAIN RESULTS

Of the six relevant randomised trials identified, four were included, one excluded and one is ongoing. All four included trials had methodological flaws. Three trials, involving 134 patients, compared open reduction and internal fixation with non-operative management of displaced intra-articular fractures. Pooled results showed no apparent difference in residual pain (24/40 versus 24/42; Peto odds ratio 0.90, 95% confidence interval 0.34 to 2.36), but a lower proportion of the operative group was unable to return to the same work (11/45 versus 23/45; Peto odds ratio 0.30, 95% confidence interval 0.13 to 0.71), and was unable to wear the same shoes as before (12/52 versus 24/54; Peto odds ratio 0.37, 95% confidence interval 0.17 to 0.84). One trial, involving 23 patients, evaluated impulse compression therapy. At one year there was a mean difference of 1.40 pain units on a visual analogue score (scale 0-10) (95% confidence interval 0.02 to 2.82) in favour of the treated group. The impulse compression group had greater subtalar movement (mean difference 14.0 degrees, 95% confidence interval 3.2 to 24.6) at three months. On average, patients in the impulse compression group returned to work three months earlier than those in the control group.

REVIEWER'S CONCLUSIONS

Randomised trials of management of calcaneal fractures are few, small and generally of poor quality. Even where there is some evidence of benefit of operative compared with non-operative treatment, it remains unclear whether the possible advantages of surgery are worth its risks. Given this it seems best to wait for the results of one large ongoing trial on open reduction and internal fixation against conservative treatment. One very small trial suggests that impulse compression therapy for intra-articular calcaneal fractures may be beneficial. More large-scale, high quality randomised controlled trials are needed to confirm these results, and to test other interventions in the treatment of calcaneal fractures.

Surgery for obstructive sleep apnoea

BACKGROUND

Obstructive sleep apnoea is the periodic reduction (hypopnoea) or cessation (apnoea) of airflow during sleep. The syndrome is associated with loud snoring, disrupted sleep and observed apnoeas. Beside conservative treatments there are a range of 8 broad categories of operative treatments for this condition. Surgical treatments aim to relieve the obstruction by either increasing the surface area

OBJECTIVES

Surgery for obstructive sleep apnoea aims to relieve the obstruction by increasing the surface area of the airway, bypassing the pharyngeal airways or removing a lesion. The objective of this review was to assess the effects of any type of surgery for the treatment of obstructive sleep apnoea.

SEARCH STRATEGY

We searched the Cochrane Airways Group trials register and reference lists of articles. We contacted experts in the field, research dissemination bodies and other Cochrane Review Groups.

SELECTION CRITERIA

Randomised and quasi-randomised trials comparing any surgical intervention for obstructive sleep apnoea with other surgical or non-surgical interventions for obstructive sleep apnoea or no intervention.

DATA COLLECTION AND ANALYSIS

No completed trials were identified.

MAIN RESULTS

No studies fulfilled the inclusion criteria.

REVIEWER'S CONCLUSIONS

There is an urgent need for high quality randomised controlled trials to be carried out in the field of surgery for obstructive sleep apnoea. More research should also be undertaken to identify and standardise techniques to determine the site of airways obstructions.

Association of sexual problems with social, psychological, and physical problems in men and women: a cross sectional population survey

STUDY OBJECTIVE

To investigate the association of sexual problems with social, physical, and psychological problems.

DESIGN

An anonymous postal questionnaire survey.

SETTING

Four general practices in England.

PARTICIPANTS

789 men and 979 women responding to a questionnaire sent to a stratified random sample of the adult general population (n = 4000).

MAIN RESULTS

Strong physical, social, and psychological associations were found with sexual problems. In men, erectile problems and premature ejaculation were associated with increasing age. Erectile problems were most strongly associated with prostate trouble, with an age adjusted odds ratio of 2.6 (95% confidence intervals 1.4, 4.7), but hypertension and diabetes were also associated. Premature ejaculation was predominantly associated with anxiety (age adjusted odds ratio 3.1 (95% confidence intervals 1.7, 5.6)). In women, the predominant association with arousal, orgasmic, and enjoyment problems was martial difficulties, all with odds ratios greater than five. All female sexual problems were associated with anxiety and depression. Vaginal dryness was found to increase with age, whereas dyspareunia decreased with age.

CONCLUSIONS

This study indicates that sexual problems cluster with self reported physical problems in men, and with psychological and social problems in women. This has potentially important consequences for the planning of treatment for sexual problems, and implies that effective therapy could have a broad impact on health in the adult population.

An integrated algal sulphate reducing high rate ponding process for the treatment of acid mine drainage wastewaters

Acid mine drainage pollution may be associated with large water volume flows and exceptionally long periods of time over which the drainage may require treatment. While the use and role of sulphate reducing bacteria has been demonstrated in active treatment systems for acid mine drainage remediation, reactor size requirement and the cost and availability of the carbon and electron donor source are factors which constrain process development. Little attention has focussed on the use of waste stabilisation ponding processes for acid mine drainage treatment. Wastewater ponding is a mature technology for the treatment of large water volumes and its use as a basis for appropriate reactor design for acid mine drainage treatment is described including high rates of sulphate reduction and the precipitation of metal sulphides. Together with the co-disposal of organic wastes, algal biomass is generated as an independent carbon source for SRB production. Treatment of tannery effluent in a custom-designed high rate algal ponding process, and its use as a carbon source in the generation and precipitation of metal sulphides, has been demonstrated through piloting to the implementation of a full-scale process. The treatment of both mine drainage and zinc refinery wastewaters are reported. A complementary role for microalgal production in the generation of alkalinity and bioadsorptive removal of metals has been utilised and an Integrated 'Algal Sulphate Reducing Ponding Process for the Treatment of Acidic and Metal Wastewaters' (ASPAM) has been described.

Sexual problems: a study of the prevalence and need for health care in the general population

BACKGROUND

There has been little research carried out on the prevalence and types of sexual dysfunction in the general population, although the indications are that such problems are relatively common. Most common sexual problems are potentially treatable. However GPs have estimated the prevalence of sexual problems to be far lower than survey estimates.

OBJECTIVE

To provide an estimate of the prevalence of sexual problems in the general population, and assess the use of and need for professional help for such problems.

METHODS

We used an anonymous postal questionnaire survey. The study was set in four general practices in England*, and the study population was a stratified random sample of the adult general population (n = 4000). The subjects were 789 men and 979 women who responded to the questionnaire. The main outcome measures were the presence and type of current sexual problems in men and women, and the provision and use of treatments for sexual problems.

RESULTS

A response rate of 44% was obtained. The median age of the responders was 50 years. A third of men (34%) and two-fifths of women (41 %) reported having a current sexual problem. The most common problems were erectile dysfunction (n = 170) and premature ejaculation (n = 88) in men; in women the most widely reported problems were vaginal dryness (n = 186) and infrequent orgasm (n = 166). In men, the proportion of responders reporting sexual problems increased with age, but there was no similar trend in women. Of those responders who reported a sexual problem, 52% said that they would like to receive professional help for this problem, but only one in ten of these people (n = 50) had received such help.

CONCLUSION

Among responders there was a high level of reported sexual problems. The most frequently reported problems (vaginal dryness, erectile problems) may be amenable to physical treatment in practice, and yet few had sought or received help. However, many said that they would like to receive help. These figures suggest that there may be an important burden of potentially reversible sexual problems in the general population.