Achievement of Target Gain Larger than Unity in an Inertial Fusion Experiment

On December 5, 2022, an indirect drive fusion implosion on the National Ignition Facility (NIF) achieved a target gain G_{target} of 1.5. This is the first laboratory demonstration of exceeding "scientific breakeven" (or G_{target}>1) where 2.05 MJ of 351 nm laser light produced 3.1 MJ of total fusion yield, a result which significantly exceeds the Lawson criterion for fusion ignition as reported in a previous NIF implosion [H. Abu-Shawareb et al. (Indirect Drive ICF Collaboration), Phys. Rev. Lett. 129, 075001 (2022)PRLTAO0031-900710.1103/PhysRevLett.129.075001]. This achievement is the culmination of more than five decades of research and gives proof that laboratory fusion, based on fundamental physics principles, is possible. This Letter reports on the target, laser, design, and experimental advancements that led to this result.

Multiorgan MRI findings after hospitalisation with COVID-19 in the UK (C-MORE): a prospective, multicentre, observational cohort study

INTRODUCTION

The multiorgan impact of moderate to severe coronavirus infections in the post-acute phase is still poorly understood. We aimed to evaluate the excess burden of multiorgan abnormalities after hospitalisation with COVID-19, evaluate their determinants, and explore associations with patient-related outcome measures.

METHODS

In a prospective, UK-wide, multicentre MRI follow-up study (C-MORE), adults (aged ≥18 years) discharged from hospital following COVID-19 who were included in Tier 2 of the Post-hospitalisation COVID-19 study (PHOSP-COVID) and contemporary controls with no evidence of previous COVID-19 (SARS-CoV-2 nucleocapsid antibody negative) underwent multiorgan MRI (lungs, heart, brain, liver, and kidneys) with quantitative and qualitative assessment of images and clinical adjudication when relevant. Individuals with end-stage renal failure or contraindications to MRI were excluded. Participants also underwent detailed recording of symptoms, and physiological and biochemical tests. The primary outcome was the excess burden of multiorgan abnormalities (two or more organs) relative to controls, with further adjustments for potential confounders. The C-MORE study is ongoing and is registered with ClinicalTrials.gov, NCT04510025.

FINDINGS

Of 2710 participants in Tier 2 of PHOSP-COVID, 531 were recruited across 13 UK-wide C-MORE sites. After exclusions, 259 C-MORE patients (mean age 57 years [SD 12]; 158 [61%] male and 101 [39%] female) who were discharged from hospital with PCR-confirmed or clinically diagnosed COVID-19 between March 1, 2020, and Nov 1, 2021, and 52 non-COVID-19 controls from the community (mean age 49 years [SD 14]; 30 [58%] male and 22 [42%] female) were included in the analysis. Patients were assessed at a median of 5·0 months (IQR 4·2-6·3) after hospital discharge. Compared with non-COVID-19 controls, patients were older, living with more obesity, and had more comorbidities. Multiorgan abnormalities on MRI were more frequent in patients than in controls (157 [61%] of 259 vs 14 [27%] of 52; p<0·0001) and independently associated with COVID-19 status (odds ratio [OR] 2·9 [95% CI 1·5-5·8]; padjusted=0·0023) after adjusting for relevant confounders. Compared with controls, patients were more likely to have MRI evidence of lung abnormalities (p=0·0001; parenchymal abnormalities), brain abnormalities (p<0·0001; more white matter hyperintensities and regional brain volume reduction), and kidney abnormalities (p=0·014; lower medullary T1 and loss of corticomedullary differentiation), whereas cardiac and liver MRI abnormalities were similar between patients and controls. Patients with multiorgan abnormalities were older (difference in mean age 7 years [95% CI 4-10]; mean age of 59·8 years [SD 11·7] with multiorgan abnormalities vs mean age of 52·8 years [11·9] without multiorgan abnormalities; p<0·0001), more likely to have three or more comorbidities (OR 2·47 [1·32-4·82]; padjusted=0·0059), and more likely to have a more severe acute infection (acute CRP >5mg/L, OR 3·55 [1·23-11·88]; padjusted=0·025) than those without multiorgan abnormalities. Presence of lung MRI abnormalities was associated with a two-fold higher risk of chest tightness, and multiorgan MRI abnormalities were associated with severe and very severe persistent physical and mental health impairment (PHOSP-COVID symptom clusters) after hospitalisation.

INTERPRETATION

After hospitalisation for COVID-19, people are at risk of multiorgan abnormalities in the medium term. Our findings emphasise the need for proactive multidisciplinary care pathways, with the potential for imaging to guide surveillance frequency and therapeutic stratification.

FUNDING

UK Research and Innovation and National Institute for Health Research.

Lawson Criterion for Ignition Exceeded in an Inertial Fusion Experiment

For more than half a century, researchers around the world have been engaged in attempts to achieve fusion ignition as a proof of principle of various fusion concepts. Following the Lawson criterion, an ignited plasma is one where the fusion heating power is high enough to overcome all the physical processes that cool the fusion plasma, creating a positive thermodynamic feedback loop with rapidly increasing temperature. In inertially confined fusion, ignition is a state where the fusion plasma can begin "burn propagation" into surrounding cold fuel, enabling the possibility of high energy gain. While "scientific breakeven" (i.e., unity target gain) has not yet been achieved (here target gain is 0.72, 1.37 MJ of fusion for 1.92 MJ of laser energy), this Letter reports the first controlled fusion experiment, using laser indirect drive, on the National Ignition Facility to produce capsule gain (here 5.8) and reach ignition by nine different formulations of the Lawson criterion.

Clinical characteristics with inflammation profiling of long COVID and association with 1-year recovery following hospitalisation in the UK: a prospective observational study

BACKGROUND

No effective pharmacological or non-pharmacological interventions exist for patients with long COVID. We aimed to describe recovery 1 year after hospital discharge for COVID-19, identify factors associated with patient-perceived recovery, and identify potential therapeutic targets by describing the underlying inflammatory profiles of the previously described recovery clusters at 5 months after hospital discharge.

METHODS

The Post-hospitalisation COVID-19 study (PHOSP-COVID) is a prospective, longitudinal cohort study recruiting adults (aged ≥18 years) discharged from hospital with COVID-19 across the UK. Recovery was assessed using patient-reported outcome measures, physical performance, and organ function at 5 months and 1 year after hospital discharge, and stratified by both patient-perceived recovery and recovery cluster. Hierarchical logistic regression modelling was performed for patient-perceived recovery at 1 year. Cluster analysis was done using the clustering large applications k-medoids approach using clinical outcomes at 5 months. Inflammatory protein profiling was analysed from plasma at the 5-month visit. This study is registered on the ISRCTN Registry, ISRCTN10980107, and recruitment is ongoing.

FINDINGS

2320 participants discharged from hospital between March 7, 2020, and April 18, 2021, were assessed at 5 months after discharge and 807 (32·7%) participants completed both the 5-month and 1-year visits. 279 (35·6%) of these 807 patients were women and 505 (64·4%) were men, with a mean age of 58·7 (SD 12·5) years, and 224 (27·8%) had received invasive mechanical ventilation (WHO class 7-9). The proportion of patients reporting full recovery was unchanged between 5 months (501 [25·5%] of 1965) and 1 year (232 [28·9%] of 804). Factors associated with being less likely to report full recovery at 1 year were female sex (odds ratio 0·68 [95% CI 0·46-0·99]), obesity (0·50 [0·34-0·74]) and invasive mechanical ventilation (0·42 [0·23-0·76]). Cluster analysis (n=1636) corroborated the previously reported four clusters: very severe, severe, moderate with cognitive impairment, and mild, relating to the severity of physical health, mental health, and cognitive impairment at 5 months. We found increased inflammatory mediators of tissue damage and repair in both the very severe and the moderate with cognitive impairment clusters compared with the mild cluster, including IL-6 concentration, which was increased in both comparisons (n=626 participants). We found a substantial deficit in median EQ-5D-5L utility index from before COVID-19 (retrospective assessment; 0·88 [IQR 0·74-1·00]), at 5 months (0·74 [0·64-0·88]) to 1 year (0·75 [0·62-0·88]), with minimal improvements across all outcome measures at 1 year after discharge in the whole cohort and within each of the four clusters.

INTERPRETATION

The sequelae of a hospital admission with COVID-19 were substantial 1 year after discharge across a range of health domains, with the minority in our cohort feeling fully recovered. Patient-perceived health-related quality of life was reduced at 1 year compared with before hospital admission. Systematic inflammation and obesity are potential treatable traits that warrant further investigation in clinical trials.

FUNDING

UK Research and Innovation and National Institute for Health Research.

Development of radiographic classification criteria for hand osteoarthritis: a methodological report (Phase 2)

OBJECTIVES

In Phase 1 of developing new hand osteoarthritis (OA) classification criteria, features associated with hand OA were identified in a population with hand complaints. Radiographic findings could better discriminate patients with hand OA and controls than clinical examination findings. The objective of Phase 2 was to achieve consensus on the features and their weights to be included in three radiographic criteria sets of overall hand OA, interphalangeal OA and thumb base OA.

METHODS

Multidisciplinary, international expert panels were convened. Patient vignettes were used to identify important features consistent with hand OA. A consensus-based decision analysis approach implemented using 1000minds software was applied to identify the most important features and their relative importance influencing the likelihood of symptoms being due to hand OA. Analyses were repeated for interphalangeal and thumb base OA. The reliability and validity of the proposed criteria sets were tested.

RESULTS

The experts agreed that the criteria sets should be applied in a population with pain, aching or stiffness in hand joint(s) not explained by another disease or acute injury. In this setting, five additional criteria were considered important: age, morning stiffness, radiographic osteophytes, radiographic joint space narrowing and concordance between symptoms and radiographic findings. The reliability and validity were very good.

CONCLUSION

Radiographic features were considered critical when determining whether a patient had symptoms due to hand OA. The consensus-based decision analysis approach in Phase 2 complemented the data-driven results from Phase 1, which will form the basis of the final classification criteria sets.

POS1400 A SYSTEMATIC REVIEW OF INTERNATIONAL GUIDELINES REGARDING THE ROLE OF RADIOGRAPHY IN THE DIAGNOSIS OF OSTEOARTHRITIS

Background:

A substantial proportion of primary care osteoarthritis (OA) consultations are associated with an X-ray request (1,2). Uncertainty exists regarding the ability of radiography to improve a clinical OA diagnosis, and the over-use of radiography may lead to inappropriate referrals due to severe radiographic features that do not correlate with patients’ symptoms. Additionally, there are cost implications of unnecessarily imaging such a prevalent disease. As evidence questions the utility of routine radiography in OA, the extent to which radiography is supported by international guidelines is unknown.

Objectives:

To undertake a systematic review and narrative synthesis of UK and international guideline recommendations on the role of radiography in the diagnosis of OA.

Methods:

A systematic search of eleven electronic databases (including EMBASE, MEDLINE CINAHL, Epistemonikos and Guideline Central) and the websites of nine professional organisations (including NICE, Royal College of Radiologists (RCR), EULAR, and the American College of Radiology (ACR)) identified the most recent evidence-based guidelines produced by professional organisations on the role of imaging in OA. Guidelines not addressing the role of radiography in the diagnosis of OA were excluded, as were non-English and spinal OA guidelines. Each title was screened by one reviewer whilst each abstract and full text underwent dual screening. A single reviewer, using a standard proforma, undertook data extraction. Each guideline was independently appraised by two reviewers using the AGREE II tool. A narrative synthesis of the nature and consistency of OA radiographic recommendations was performed.

Results:

18 evidence-based OA guidelines published between 1998-2019 were included. These guidelines considered OA at any joint (n=8), or at the knee (n=3), hip (n=2), hand (n=2), wrist (n=1), foot (n=1), and ankle (n=1). Seven guidelines were produced by European organisations; four guidelines were produced by EULAR. Guidelines were targeted at general practitioners (n=11), radiologists (n=7), rheumatologist (n=4) and orthopaedic surgeons (n=3). Using the AGREE II tool, the identified guidelines scored highly on rigour of development (mean score 69%) but poorly on applicability (32%). All 18 guidelines recommended X-rays as the first-line modality, where imaging was indicated. A clinical diagnosis of OA without radiographic confirmation was recommended by all eleven guidelines produced by organisations represented general practitioners, with seven guidelines justifying this due to a poor correlation between radiographic features and clinical symptoms. Only three guidelines explicitly discouraged the routine use of radiography for the diagnosis of OA and only two guidelines reassured practitioners of a low probability of missing serious pathology when not routinely requesting radiographs. Guidelines produced by organisations representing radiologists were more supportive of radiography. The ACR recommended radiographic confirmation in patients suspected to have OA at the hand, wrist, hip, knee, ankle, and foot. Conversely, the RCR recommended radiographic confirmation in patients suspected to have OA at the hand, feet, and hip, but not the knee.

Conclusion:

Differences in guideline recommendations on the utility of radiography in OA appear related to country/region, professional organisation, and joint. The use and utility of radiography in OA may need to be reviewed in light of a shift towards remote consultations, a change that has been accelerated by COVID-19 in many countries.

References:

[1]Yu D, Jordan K, Bedson J, Englund M, Blyth F, Turkiewicz A et al. Population trends in the incidence and initial management of osteoarthritis: age-period-cohort analysis of the Clinical Practice Research Datalink, 1992–2013. Rheumatology. 2017;56(11):1902-1917.

[2]Brand C, Harrison C, Tropea J, Hinman R, Britt H, Bennell K. Management of Osteoarthritis in General Practice in Australia. Arthritis Care & Research. 2014;66(4):551-558

Acknowledgements:

JJE is funded by an Academic Clinical Lectureship from the National Institute for Health Research (NIHR) for this research project (CL-2016-10-003). The views expressed in this publication are those of the author(s) and not necessarily those of the NIHR, NHS or the UK Department of Health and Social Care.

Disclosure of Interests:

None declared

Dissolved organic nutrient uptake by riverine phytoplankton varies along a gradient of nutrient enrichment

The concentration of dissolved organic matter (DOM) in freshwaters is increasing in large areas of the world. In addition to carbon, DOM contains nitrogen and phosphorus and there is growing concern that these organic nutrients may be bioavailable and contribute to eutrophication. However, relatively few studies have assessed the potential for dissolved organic nitrogen (DON) or dissolved organic phosphorus (DOP) compounds to be bioavailable to natural river phytoplankton communities at different locations or times. Temporal and spatial variations in uptake, relative to environmental characteristics were examined at six riverine sites in two contrasting catchments in the UK. This study also examined how the uptake by riverine phytoplankton of four DON and four DOP compounds commonly found in rivers, varied with concentration. Total nitrogen (TN) and phosphorus (TP) concentrations, the proportion of inorganic nutrient species, and nutrient limitation varied temporally and spatially, as did the potential for DON and DOP uptake. All eight of the DOM compounds tested were bioavailable, but to different extents. Organic nutrient use depended on the concentration of the organic compound supplied, with simple compounds (urea and glucose-6-phosphate) supporting algal growth even at very low concentrations. DON use was negatively correlated with the TN and ammonia concentration and DOP use was negatively correlated with soluble reactive phosphorus (SRP) and dissolved organic carbon (DOC) concentration. The evidence indicates that DOM in rivers has been overlooked as a potential source of nutrients to phytoplankton and therefore as an agent of eutrophication.

EPA guidance on the early intervention in clinical high risk states of psychoses

This guidance paper from the European Psychiatric Association (EPA) aims to provide evidence-based recommendations on early intervention in clinical high risk (CHR) states of psychosis, assessed according to the EPA guidance on early detection. The recommendations were derived from a meta-analysis of current empirical evidence on the efficacy of psychological and pharmacological interventions in CHR samples. Eligible studies had to investigate conversion rate and/or functioning as a treatment outcome in CHR patients defined by the ultra-high risk and/or basic symptom criteria. Besides analyses on treatment effects on conversion rate and functional outcome, age and type of intervention were examined as potential moderators. Based on data from 15 studies (n = 1394), early intervention generally produced significantly reduced conversion rates at 6- to 48-month follow-up compared to control conditions. However, early intervention failed to achieve significantly greater functional improvements because both early intervention and control conditions produced similar positive effects. With regard to the type of intervention, both psychological and pharmacological interventions produced significant effects on conversion rates, but not on functional outcome relative to the control conditions. Early intervention in youth samples was generally less effective than in predominantly adult samples. Seven evidence-based recommendations for early intervention in CHR samples could have been formulated, although more studies are needed to investigate the specificity of treatment effects and potential age effects in order to tailor interventions to the individual treatment needs and risk status.

Midfoot osteoarthritis: potential phenotypes and their associations with demographic, symptomatic and clinical characteristics

OBJECTIVE

To investigate the demographic, symptomatic, clinical and structural foot characteristics associated with potential phenotypes of midfoot osteoarthritis (OA).

DESIGN

Cross-sectional study of 533 community-dwelling adults aged ≥50 years with foot pain in the past year. Health questionnaires and clinical assessments of symptoms, foot structure and function were undertaken. Potential midfoot OA phenotypes were defined by the pattern of radiographic joint involvement affecting either the medial midfoot (talonavicular, navicular-1^st cuneiform, or cuneiform-1^st metatarsal joint), central midfoot (2^nd cuneiform-metatarsal joint), or both medial and central midfoot joints. Multivariable regression models with generalised estimating equations were used to investigate the associations between patterns of midfoot joint involvement and symptomatic, clinical and structural characteristics compared to those with no or minimal midfoot OA.

RESULTS

Of 879 eligible feet, 168 had medial midfoot OA, 103 central midfoot OA, 76 both medial and central midfoot OA and 532 no/minimal OA. Having both medial and central midfoot OA was associated with higher pain scores, dorsally-located midfoot pain (OR 2.54, 95%CI 1.45, 4.45), hallux valgus (OR 1.76, 95%CI 1.02, 3.05), flatter foot posture (β 0.44, 95%CI 0.12, 0.77), lower medial arch height (β 0.02, 95%CI 0.01, 0.03) and less subtalar inversion and 1^st MTPJ dorsiflexion. Isolated medial midfoot OA and central midfoot OA had few distinguishing clinical characteristics.

CONCLUSIONS

Distinct phenotypes of midfoot OA appear challenging to identify, with substantial overlap in symptoms and clinical characteristics. Phenotypic differences in symptoms, foot posture and function were apparent in this study only when both the medial and central midfoot were involved.

A longitudinal assessment of periodontal health status in 53 Labrador retrievers

OBJECTIVES

To determine the incidence and rates of progression of gingivitis and periodontitis in Labrador retrievers.

MATERIALS AND METHODS

Fifty-three dogs, aged 1·1 to 5·9 years, had their periodontal health assessed every 6 months for up to 2 years. The extent of gingivitis and periodontitis was measured around the whole gingival margin of every tooth under general anaesthesia.

RESULTS

All dogs had gingivitis at the initial assessment. The majority (64·2%) of tooth aspects had very mild gingivitis. The palatal/lingual aspect of all tooth types was most likely to show bleeding when probed: 63·0% of these aspects had mild or moderate gingivitis. Over 2 years, 56·6% of dogs developed periodontitis and dogs as young as 1·9 years were affected. There was a significant positive correlation between the proportion of teeth with periodontitis and age. In total, 124 teeth (5·7%) developed periodontitis; 88 (71·0%) of these were incisors. The palatal/lingual aspect of the incisors developed the disease first (2·8% of incisor aspects).

CLINICAL SIGNIFICANCE

Periodontitis developed in regions that are difficult to see in conscious dogs implying that detection and treatment of disease requires periodic sedation or anaesthesia.

Metabolic risk factors and the incidence and progression of radiographic hand osteoarthritis: a population-based cohort study

OBJECTIVE

To determine whether selected metabolic factors are associated with greater amounts of radiographic hand osteoarthritis (OA) incidence and progression.

METHODS

The study identified 706 adults, aged 50-69 years, with hand pain and hand radiographs at baseline, from two population-based cohorts. Metabolic factors (body mass index, hypertension, dyslipidaemia, and diabetes) were ascertained at baseline by direct measurement and medical records. Analyses were undertaken following multiple imputation of missing data, and in complete cases (sensitivity analyses). Multivariable regression models estimated associations between metabolic factors and two measures of radiographic change at 7 years for all participants, individuals free of baseline radiographic OA, and in baseline hand OA subsets. Estimates were adjusted for baseline values and other covariates.

RESULTS

The most consistent and strong associations observed were between the presence of diabetes and the amount of radiographic progression in individuals with nodal OA [adjusted mean differences in Kellgren-Lawrence summed score of 4.50 (-0.26, 9.25)], generalized OA [3.27 (-2.89, 9.42)], and erosive OA [3.05 (-13.56, 19.67)]. The remaining associations were generally weak or inconsistent, although numbers were limited for analyses of incident radiographic OA and erosive OA in particular.

CONCLUSION

Overall metabolic risk factors were not independently or collectively associated with greater amounts of radiographic hand OA incidence or progression over 7 years, but diabetes was associated with radiographic progression in nodal, and possibly generalized and erosive OA. Diabetes has previously been associated with prevalent but not incident hand OA. Further investigation in hand OA subsets using objective measures accounting for disease duration and control is warranted.

Whole-exome sequencing for mutation detection in pediatric disorders of insulin secretion: Maturity onset diabetes of the young and congenital hyperinsulinism

BACKGROUND

To assess the utility of whole-exome sequencing (WES) for mutation detection in maturity-onset diabetes of the young (MODY) and congenital hyperinsulinism (CHI). MODY and CHI are the two commonest monogenic disorders of glucose-regulated insulin secretion in childhood, with 13 causative genes known for MODY and 10 causative genes identified for CHI. The large number of potential genes makes comprehensive screening using traditional methods expensive and time-consuming.

METHODS

Ten subjects with MODY and five with CHI with known mutations underwent WES using two different exome capture kits (Nimblegen SeqCap EZ Human v3.0 Exome Enrichment Kit, Nextera Rapid Capture Exome Kit). Analysis was blinded to previously identified mutations, and included assessment for large deletions. The target capture of five exome capture technologies was also analyzed using sequencing data from >2800 unrelated samples.

RESULTS

Four of five MODY mutations were identified using Nimblegen (including a large deletion in HNF1B). Although targeted, one mutation (in INS) had insufficient coverage for detection. Eleven of eleven mutations (six MODY, five CHI) were identified using Nextera Rapid (including the previously missed mutation). On reconciliation, all mutations concorded with previous data and no additional variants in MODY genes were detected. There were marked differences in the performance of the capture technologies.

CONCLUSIONS

WES can be useful for screening for MODY/CHI mutations, detecting both point mutations and large deletions. However, capture technologies require careful selection.

Leitlinien zur peripheren Gefäßdiagnostik mit der direktionalen continuous-wave (CW) Doppler-Sonographie

Leitlinien sind systematisch erarbeitete Empfehlungen, um Kliniker und Praktiker bei Entscheidungen zur Versorgung ihrer Patienten im Rahmen spezifischer Umstände zu unterstützen. Leitlinien gelten für »Standardsituationen« und berücksichtigen die aktuellen, zu den entsprechenden Fragestellungen zur Verfügung stehenden wissenschaftlichen Erkenntnisse. Leitlinien bedürfen der ständigen Überprüfung und eventuell der Ände-rung auf dem Boden des wissenschaftlichen Erkenntnisstandes und der Praktikabilität in der täglichen Anwendung. Leitlinien entbinden den Arzt nicht von seiner Sorgfaltspflicht und der Beachtung der individuell angepassten diagnostischen und therapeutischen Maßnahmen. Leitlinien erheben keinen Anspruch auf Vollständigkeit.

Die oberflächliche Thrombophlebitis, ein Nicht-der-Rede-wert-Krankheitsbild?

Es werden Klinik, Diagnostik und Therapie der Thrombophlebitis superficialis in ihren verschiedenen Erscheinungsformen dargestellt. Die grundlegende Therapie der oberflächlichen Venenentzündung (Thrombophlebitis und Varikophlebitis) hat sich nicht geändert. Geändert haben sich die Prognosebeurteilung und die Anforderungen an eine angemessene Diagnostik: Bei einer Magna- oder Parvaphlebitis kann der Entzündungsprozess mit Thrombosierung deutlich weiter nach proximal reichen als der klinische Befund dies vermuten lässt mit der Gefahr des Übergreifens der oberflächlichen Phlebitis über die Mündung der Stammvenen auf das tiefe Venensystem (sapheno-femorale Thrombose). Die Koinzidenz zwischen oberflächlicher Venenentzündung und tiefer Venenthrombose liegt bei rund 10 bis 40%. Daher sind duplexsonographische Kontrollen zum Ausschluss einer zusätzlichen tiefen Venenthrombose und/oder einer Aszension der Entzündung in den Mündungsbereich der Stammvenen erforderlich.

Die grundlegende Therapie der Thrombophlebitis superficialis ist die Kompressionsbehandlung mit Mobilisierung. Niedermolekulares Heparin wird inzwischen häufig eingesetzt, obwohl der Stellenwert noch nicht ausreichend definiert ist (Anwendung ohne Beweis). Als Behandlungsdauer wird gegebenenfalls in den vorliegenden Studien ein Monat vorgegeben. Die Indikation zur „Notfall-Krossektomie” bei mündungsnaher Magna-Phlebitis bedarf weiterer Abklärung. Nach dem heutigen Kenntnisstand ist die oberflächliche Thrombophlebitis ein ernst zu nehmendes Krankheitsbild mit dringlicher Betreuungsindikation.

Duplex sonography phlebologically accentuated

Without any doubt colour duplex sonography was an enormous progress in angiological and/or phlebological diagnostics. Starting with the directional Doppler sonography, the large spectrum of phlebological diagnostics by colour duplex sonography is presented. Colour duplex sonography is used for a) the fundamental, morphologically and haemodynamically based diagnostics of deep vein thrombosis, of the insufficiency of subfascial and epifascial veins and for differential diagnostic delimitations (of arterial disorders, lip- and lymphedema, Baker-cysts, haematomas and so on), b) intrainterventional controls (steering of endovenous catheters and of foam sclerotherapy), c) the postinterventional assessment of results and disease course (definitively successful elimination of refluxes, relapses, complications as deep vein thrombosis and so on). Finally, the optimal position of the patient for duplex examination – supine or standing – is discussed, and methodical developments of the angiologic-phlebological diagnostics with ultrasound devices are described. Conclusion: In many cases duplexsonography avoids invasive examinations. It is part of the obligatory medical education in the field of phlebology.

Insight and treatment attitude in schizophrenia: comparison of patients on depot and atypical antipsychotics

Aims and Method

To establish if participants with schizophrenia receiving depot antipsychotics had less insight than similar participants receiving oral atypical antipsychotics. We assessed the difference between these two groups.

Results

Participants on oral antipsychotics had greater insight than those on depot antipsychotics (ITAQ, P=0.01). In the multiple regression analysis, only receiving depot antipsychotics contributed significantly to explaining variance in insight (adjusted R2=0.135, F=8.99, P=0.004).

Clinical Implications

Depot antipsychotics seem to be prescribed to a subgroup of people with schizophrenia who are likely to be less adherent because of lower levels of insight. These individuals are on significantly higher doses of antipsychotic medication. Clinicians should review their patients on depot antipsychotics at regular intervals.

Untreated schizophrenia in hostels for the homeless: a cause for concern?

We report two cases from a study of Oxford hostels for the homeless of patients who were suffering from schizophrenia and are not receiving medication. After compulsory admission to hospital and treatment both showed a dramatic improvement in behaviour which was confirmed by a standardised rating scale. We discuss how hostels for the homeless have become both asylums and traps for those who suffer from schizophrenia and conclude that doctors should not under-estimate the potential benefit of anti-psychotic drug therapy even in homeless people with chronic psychosis.

Prävalenz des Lipödems bei berufstätigen Frauen in Deutschland

Hintergrund: Nach eigener Recherche fehlen standardisiert erhobene Daten zur Prävalenz des Lipödems (in Mitteleuropa). Deshalb untersuchten wir zu dieser Fragestellung 62 Frauen anamnestisch, klinisch und (duplex-)sonografisch. Dabei bemühten wir uns, einen „Inanspruchnahme-Bias“ strikt zu vermeiden und eine ausgewogene soziale Zusammensetzung des Kollektivs zu erreichen.

Ergebnisse: In einer Vorstudie an 2 x 100 Frau-en hatten wir eine Prävalenz erkennbarer Lip -ödme von 7–8 % gefunden. Werden alle Ausprägungen eines Beinlipödems berücksichtigt, hatten 39 % der Frauen ein Lipödem be-ziehungsweise eine Lipohyperplasie. Wird nur der mäßig bis deutlich ausgeprägte Befund im Sinne der deutlich verstrichenen Fesseltaille mit entsprechendem sonografischen Befund bewertet, sind 9,7 % von einem Lipödem betroffen; ausschließlich der Reithosentyp fand sich bei 4,8 % unserer Probandinnen. Bezüglich Alter, Körperlänge und Menarchealter bestan-den keine relevanten Unterschiede zwischen den Gruppen. Die Frauen mit Lipödem waren schwerer als die ohne und zeigten eine entsprechend höhere Körpermassenzahl (Body-Mass-Index, BMI). Die Dicke von Subkutis + Ku-tis supramalleolär-medial betrug bei den Frau-en ohne Lipödem rund 11 ± 2,8 mm; bei den Frauen mit Lipödem lag der durchschnittliche Wert mit rund 16 mm z.T. jenseits der doppelten Standardabweichung des Wertes der Frauen ohne Lipödem. Die Kutisdicke lag in beiden Gruppen im Mittel deutlich unter 2 mm. Die so-nografische Beurteilung und Vermessung von Subkutis und Kutis eignet sich offensichtlich gut zur Diagnosesicherung und Schweregradbeurteilung eine Lipödems – auch im Rahmen epidemiologischer Studien.

Neue Ergebnisse der duplexsonographischen Diagnostik des Lip- und Lymphödems

An insgesamt 100 Patienten einer phlebologischen Praxis sollten die Kriterien bei der sonographischen Diagnostik des Lymph- und Lipödems, auch in der Abgrenzung zum Phlebödem, weiterentwickelt werden. Dabei konnte gezeigt werden, dass zusätzlich zur spezifischen »Sonomorphologie« des Lip- und Lymphödems die Kompressionssonographie ein unterschiedliches Verhalten bei schmerzhaftem und nicht schmerzhaftem Lipödem aufweist. Voraussetzung ist eine exaktere Abgrenzung von Kutis und Subkutis mit einem neuen 13-MHz-Schallkopf. Das schmerzhafte Lipödem erlaubt eine Kompression des verdickten und homogen vermehrt echogenen Subkutanbereichs um nur maximal 10 bis 20%, wogegen beim nicht schmerzhaften Lipödem eine Kompression um bis zu ca. 50% möglich ist. Die für das Lymphödem typischen echolosen Spalten im Subkutanbereich zeigten keine Farbkodierung und erwiesen sich als ebenfalls nicht komprimierbar. Besonders wegen des geringen Zeitaufwands, der Nichtinvasivität des Verfahrens und der fehlenden Strahlenbelastung ist die sonographische Darstellung, Vermessung und Kompression des Subkutanbereichs an einer definierten Stelle des Unterschenkels zur Diagnose, objektiven Kontrolle des Verlaufs, Überprüfung der Wirkung von Therapiemaßnahmen und Zuordnung zur klinischen Symptomatik – letzteres speziell beim Lipödem – geeignet und der rein klinischen Untersuchung überlegen.

Hydroxyethylrutoside zur Behandlung der chronischen Veneninsuffizienz Grad I und II

Nach wie vor zählt der Einsatz von Ödemprotektiva zu den wichtigen Therapieoptionen bei der chronischen Veneninsuffizienz (CVI). Voraussetzung für die Verkehrsfähigkeit sind Nachweis von Qualität, Wirksamkeit und Unbedenklichkeit. In zahlreichen experimentellen Untersuchungen von unabhängigen Arbeitsgruppen sind überzeugend pharmakologische Wirkungen belegt, die auf eine humanpharmakologische Wirkung bei der CVI hinweisen. Die aktuelle Studienlage belegt die experimentellen Ergebnisse. Danach sind Hydroxyethylrutoside (HR) wirksam bei der Behandlung der CVI im Stadium I-II (CEAP 3-4). Diese Aussage betrifft neuere, gut konzipierte, vorwiegend doppelblinde, plazebokontrollierte Studien, wobei jeweils nicht nur die Ödemreduktion sondern auch die Besserung der klinischen Symptomatik geprüft wurde. Wird die Ödemreduktion korrekter Weise in Relation zum tatsächlichen Ödemverteilungsraum und nicht zum gesamten Unterschenkelvolumen gesehen, ergeben sich durchaus relevante“ relative und absolute Änderungen unter der wirksamen Therapie. Da zum Zeitpunkt der Durchführung der verfügbaren neueren Studien die strenge Berücksichtigung einer Beeinfussung der Lebensqualität (LQ) (quality of life) nicht üblich war, darf dies kein Argument sein, entsprechende hochwertige Studien zu verwerfen.

Sklerotherapie mit Polidocanol in einer angiologisch-phlebologischen Spezialpraxis

Die Autoren berichten über Methodik, Ergebnisse und Komplikationen bei der Verödungsbehandlung in den vergangenen 12 Jahren bei über 8000 Behandlungen an über 2700 Patienten. Methoden: Neben der klinischen Untersuchung war die Dopplersonographie kombiniert mit der (Farb-)Duplexsonographie fester Bestandteil der Diagnostik. Von wenigen Ausnahmen abgesehen, wurde die Stammvarikose der Vena saphena magna und parva immer einer möglichst begrenzten varizenchirurgischen Intervention zugeführt. Eine postoperativ verbleibende Varikose wurde mit der Sklerotherapie behandelt. Dabei wurden groß- und kleinkalibrige Seitenäste mit mehreren besonders kurzen Kanülen am stehenden Patienten punktiert, der Patient anschließend auf der Kippliege in eine liegende Position gebracht und Aethoxysklerol® (2, 3 und 4% je nach Kaliber der Varize) injiziert (Technik der »offenen Nadel«). Retikuläre Varizen wurden mit 1%igem, Besenreiser mit 0,5%igem Aethoxysklerol® gemischt mit 10%iger NaCl (1: 2) am liegenden Patienten mit vielfacher direkter Injektion behandelt (Technik der »geschlossenen Nadel«). Bei allen Patienten wurde ein Kompressionsverband bis zum Oberschenkel angelegt und eine sofortige Mobilisierung durchgeführt. Als Nachbehandlung trugen die Patienten für 6 Wochen einen Schenkelkompressionsstrumpf der Klasse 2. Ergebnisse: Mit dieser Methode hatten wir nach 6 Wochen gute Ergebnisse in 82%, mäßige in 14% und schlechte (Varize nicht verödet) in 3%. Fast alle nicht obliterierten Varizen konnten erfolgreich nachverödet werden. Die Verödung von Astvarizen war erfolgreicher als die von Besenreisern und retikulären Varizen. Als schwerste Komplikation ereignete sich eine tödliche Lungenembolie. Weitere schwere Komplikationen waren zwei ausgedehnte tiefe Beinvenenthrombosen, zwei (größere) Hautnekrosen und zwei aszendierende Magnaphlebitiden (je 0,02% der Behandlungen). Schlussfolgerung: Verglichen mit den Literaturdaten ist die vorgestellte Methode als besonders risikoarm einzustufen.

Wirksamkeit und Verträglichkeit einer oralen Enzymtherapie bei der schmerzhaften akuten Thrombophlebitis superficialis

Ziel: In einer doppelblinden, randomisierten, plazebokontrollierten, multizentrischen klinischen Studie wurden Wirksamkeit und Verträglichkeit einer systemischen Enzymtherapie bei Patienten mit akuter Thrombophlebitis superficialis im Beinbereich untersucht. Methode: 159 Patienten wurden aufgenommen; in der Verumgruppe wurden 79, in der Plazebogruppe 77 Patienten einer maximal 14 ± 2-tägigen Behandlung unterzogen. Die eingesetzte Dosis des Enzympräparats (Wobenzym® N, Mucos Pharma) betrug 3 × 4 magensaftresistente Dragees täglich. Alle Patienten erhielten zusätzlich einen Kompressionsstrumpf. Das Hauptzielkriterium war die Abnahme des Spontanschmerzes bis Tag 7, der bei Studienbeginn wenigstens 4 Scorepunkte auf einer Visual Rating Analogue Scale (VRAS) betragen musste. Ergebnisse: Unter der Behandlung kam es am Tag 7 zu einer signifikant stärkeren Schmerzreduktion unter Verum verglichen mit Plazebo (p = 0,0071). Das sekundäre Zielkriterium, die Responderraten (Abnahme des Schmerzscores auf 0 oder 1), betrug bei Abschluss der Behandlung unter Verum 77,0% und unter Plazebo 58,1% (p = 0,011). 8 Nebenzielparameter wurden untersucht. Diese Parameter und auch die Abschlussurteile zur Wirksamkeit ergaben signifikante Gruppenunterschiede zugunsten der Enzymtherapie. Schlussfolgerung: Diese Studie konnte die klinische Wirksamkeit und die gute Verträglichkeit der systemischen Enzymtherapie bei der Behandlung der akuten Thrombophlebitis superficialis beweisen, was für die antiphlogistische, antiödematöse und analgetische Wirkung dieser Therapie spricht.

Konsensuskonferenz zur Schaumsklerotherapie anlässlich des 2. Internationalen Europäischen Symposiums über Sklerotherapie (4.-6. April 2003, Tegernsee)

Ziel: Die Sklerotherapie mit aufgeschäumten Detergenz- Sklerosierungsmitteln, die in der klassischen Flüssigsklerosierung (CLS) schon lange als sehr effektiv und sicher anerkannt sind, bewirkte eine Renaissance der Sklerotherapie. Europäische Experten der Schaumsklerotherapie (FS) tauschten ihre Erfahrungen aus, um daraus Stellungnahmen und Empfehlungen zu erarbeiten. Methoden: Den Teilnehmern, die Ergebnisse publiziert, an Studien teilgenommen oder in anderer Weise zur Weiterentwicklung des selbst hergestellten Sklerosierungsschaums beigetragen hatten, wurde ein Fragebogen zur FS geschickt. Anhand der Fragebogenergebnisse wurden Konsensusstellungnahmen und -empfehlungen ausgearbeitet, die im Konsensus-Meeting von den Teilnehmer geändert und/oder genehmigt wurden. Ergebnisse: Die Behandlung von Beinvarizen mit Sklerosierungsschaum ist ein geeignetes Verfahren. Der durch einen Experten auf dem Gebiet der Sklerotherapie applizierte Sklerosierungsschaum ist als Therapeutikum generell wirksamer als flüssiges Sklerosierungsmittel. Die meisten Empfehlungen für die klassische CLS gelten auch für die FS. Dennoch gibt es Unterschiede. Schlussfolgerung: Die Schaumsklerotherapie ist eine interessante Variante einer bereits sehr etablierten Behandlung, die das Behandlungsmanagement der Krampfadererkrankung offensichtlich verbessert. Europäische Experten stimmten ihre Ansichten darüber ab. Dieses Abschlussdokument spiegelt ihre Meinungen hinsichtlich definierter Prinzipien für eine sichere, effektive und praktische Anwendung von Sklerosierungsschaum wider.

Innendurchmesser der Vena femoralis communis als diagnostischer und prognostischer Parameter für die CVI

Ziel: Überprüfung der Hypothese über den Zusammenhang zwischen dem Innendurchmesser der V. femoralis communis (VFC) sowie der Magna-Krosse (M-K) und der Anwesenheit und Ausprägung der chronischen Veneninsuffizienz (CVI). Methode: erstmalige phlebologische Untersuchung von 199 ambulanten Patientinnen im Alter von 20-75 Jahren mit Berücksichtigung der Duplex-sonographischen Diametervermessung der proximalen Beinvenen bei Valsalva-Preß-versuch. Ergebnis: Im Material von insgesamt 181 rechten Beinen erschienen 54 Extremitäten klinisch unauffällig (CVI 0), 93 mit CVI 1., 34 mit CVI 2. oder 3. Grades. Die statistische Analyse bestätigte, daß größere Durchmesser der VFC signifikant öfter mit einer klinisch manifesten CVI einhergehen. Dagegen wurde die Hypothese über einen Zusammenhang zwischen diesem Parameter und der CVI-Progression nicht bestätigt. In der logistischen Multivarianz-Regressions-analyse, unter Berücksichtigung des Alters, Gewichts, der Körperlänge, der Varikosis, der Wiederauffüllzeit und mehrerer Refluxe, wurde die Bedeutung des Diameters der VFC für die CVI-Manifestation bestätigt, nicht aber die vom M-KDurchmesser (grenzwertige Signifikanz). Das Risiko einer klinisch manifesten CVI bei Frauen ohne ausgedehnte Stamm-Astvarikosis mit einem Durchmesser der VFC >14,0 mm wurde 15fach höher eingeschätzt (95% CI 3,5-65,2) als bei Frauen mit einem Durchmesser ≤14,0 mm. Schlußfolgerung: Der sonographische Innendurchmesser der VFC erscheint als ein wichtiger, von anderen Faktoren unabhängiger Prädiktor der CVI.

A pilot interventional study to evaluate the impact of cholecalciferol treatment on HbA1c in type 1 diabetes (T1D)

BACKGROUND

Higher 25(OH)D3 levels are associated with lower HbA1c, but there are limited UK interventional trials assessing the effect of cholecalciferol on HbA1c.

AIMS

(1) To assess the baseline 25(OH)D3 status in a Manchester cohort of children with type 1 diabetes (T1D). (2) To determine the effect of cholecalciferol administration on HbA1c.

METHODS

Children with T1D attending routine clinic appointments over three months in late winter/early spring had blood samples taken with consent. Participants with a 25(OH)D3 level <50 nmol/L were treated with a one-off cholecalciferol dose of 100,000 (2-10 years) or 160,000 (>10 years) units. HbA1c levels before and after treatment were recorded.

RESULTS

Vitamin D levels were obtained from 51 children. 35 were Caucasian, 11 South Asian and 5 from other ethnic groups. 42 were vitamin D deficient, but 2 were excluded from the analysis. All South Asian children were vitamin D deficient, with mean 25(OH)D3 of 28 nmol/L. In Caucasians, there was a negative relationship between baseline 25(OH)D3 level and HbA1c (r = -0.484, P < 0.01). In treated participants, there was no significant difference in mean HbA1c at 3 months (t = 1.010, P = 0.328) or at 1 year (t = -1.173, P = 0.248) before and after treatment. One-way ANCOVA, controlling for age, gender, ethnicity, BMI and diabetes duration showed no difference in Δ HbA1c level.

CONCLUSION

We report important findings at baseline, but in children treated with a stat dose of cholecalciferol, there was no effect on HbA1c. Further studies with larger sample sizes and using maintenance therapy are required.

Short-term outcome of substance-induced psychotic disorder in a large UK first episode psychosis cohort

OBJECTIVE

The incidence and outcome of first-episode substance-induced psychotic disorder (SIPD) are unclear. The study aimed to compare the 1-year outcomes of those given a SIPD diagnosis by clinicians compared to other psychosis diagnoses in a first-episode cohort.

METHOD

Data were from a large (n = 1027) cohort of first-episode psychosis (FEP) patients admitted to early intervention services in the UK (National EDEN). Diagnosis, including that of SIPD, was made by treating psychiatrists at baseline using ICD10 criteria. Details on symptoms, functioning, quality of life, relapse and recovery were available at baseline and 12 months.

RESULTS

There were 67 cases of SIPD (6.5% of the cohort). At baseline, SIPD patients were no different to other psychoses on symptoms, functioning and quality of life. At 12 months, there was no difference in SIPD and other psychoses on functioning, quality of life or relapse and recovery rates. Levels of psychotic and general symptomatology were similar but depressive symptoms were higher in the SIPD group.

CONCLUSIONS

First-episode psychosis patients with a diagnosis of SIPD do not appear to have better outcomes than those with other primary psychotic diagnoses. The higher levels of depressive symptoms may be a specific marker in these patients.

Blood Rheology in Post-Thrombotic Syndrome — A Pilot Study

Patients suffering from post-thromobotic syndrome are compared to controls in terms of ex-vivo measurements to quantify the rheological behavior of blood: blood and plasma viscosity, haematocrit, red cell aggregation, red cell filterability, erythrocyte sedimentation rate (ESR), plasma fibrinogen. The results show that plasma viscosity, red cell filterability, ESR and fibrinogen are significantly changed indicating a lack of blood fluidity in post-thrombotic disease. It is suggested that the rheological deficit and the venous pathology both contribute to a disturbed microcirculation in the affected limb.

Limited Blood Fluidity as a Contributory Factor of Venous Stasis in Chronic Venous Insufficiency

Patients with chronic venous insufficiency were compared to matched controls in terms of blood and plasma viscosity, haematocrit, blood cell filterability, red cell aggregation, fibrinogen and ESR. The results show that in chronic venous insufficiency plasma viscosity and red cell aggregation are elevated, while blood cell filterability is reduced. Furthermore, the venous blood flow velocity (as determined by Doppler technique) correlates inversely with both plasma viscosity and red cell aggregation. We conclude that the systematic rheological abnormality increases the resistance to venous blood flow and may represent a contributory factor of venous stasis in this disorder.

Clinical diagnosis of symptomatic midfoot osteoarthritis: cross-sectional findings from the Clinical Assessment Study of the Foot

OBJECTIVE

To derive a multivariable diagnostic model for symptomatic midfoot osteoarthritis (OA).

METHODS

Information on potential risk factors and clinical manifestations of symptomatic midfoot OA was collected using a health survey and standardised clinical examination of a population-based sample of 274 adults aged ≥50 years with midfoot pain. Following univariable analysis, random intercept multi-level logistic regression modelling that accounted for clustered data was used to identify the presence of midfoot OA independently scored on plain radiographs (dorso-plantar and lateral views), and defined as a score of ≥2 for osteophytes or joint space narrowing in at least one of four joints (first and second cuneometatarsal, navicular-first cuneiform and talonavicular joints). Model performance was summarised using the calibration slope and area under the curve (AUC). Internal validation and sensitivity analyses explored model over-fitting and certain assumptions.

RESULTS

Compared to persons with midfoot pain only, symptomatic midfoot OA was associated with measures of static foot posture and range-of-motion at subtalar and ankle joints. Arch Index was the only retained clinical variable in a model containing age, gender and body mass index. The final model was poorly calibrated (calibration slope, 0.64, 95% CI: 0.39, 0.89) and discrimination was fair-to-poor (AUC, 0.64, 95% CI: 0.58, 0.70). Final model sensitivity and specificity were 29.9% (95% CI: 22.7, 38.0) and 87.5% (95% CI: 82.9, 91.3), respectively. Bootstrapping revealed the model to be over-optimistic and performance was not improved using continuous predictors.

CONCLUSIONS

Brief clinical assessments provided only marginal information for identifying the presence of radiographic midfoot OA among community-dwelling persons with midfoot pain.

EPA guidance on the early detection of clinical high risk states of psychoses

The aim of this guidance paper of the European Psychiatric Association is to provide evidence-based recommendations on the early detection of a clinical high risk (CHR) for psychosis in patients with mental problems. To this aim, we conducted a meta-analysis of studies reporting on conversion rates to psychosis in non-overlapping samples meeting any at least any one of the main CHR criteria: ultra-high risk (UHR) and/or basic symptoms criteria. Further, effects of potential moderators (different UHR criteria definitions, single UHR criteria and age) on conversion rates were examined. Conversion rates in the identified 42 samples with altogether more than 4000 CHR patients who had mainly been identified by UHR criteria and/or the basic symptom criterion 'cognitive disturbances' (COGDIS) showed considerable heterogeneity. While UHR criteria and COGDIS were related to similar conversion rates until 2-year follow-up, conversion rates of COGDIS were significantly higher thereafter. Differences in onset and frequency requirements of symptomatic UHR criteria or in their different consideration of functional decline, substance use and co-morbidity did not seem to impact on conversion rates. The 'genetic risk and functional decline' UHR criterion was rarely met and only showed an insignificant pooled sample effect. However, age significantly affected UHR conversion rates with lower rates in children and adolescents. Although more research into potential sources of heterogeneity in conversion rates is needed to facilitate improvement of CHR criteria, six evidence-based recommendations for an early detection of psychosis were developed as a basis for the EPA guidance on early intervention in CHR states.

Demographic and clinical factors associated with radiographic severity of first metatarsophalangeal joint osteoarthritis: cross-sectional findings from the Clinical Assessment Study of the Foot

OBJECTIVE

To explore demographic and clinical factors associated with radiographic severity of first metatarsophalangeal joint osteoarthritis (OA) (First MTPJ OA).

DESIGN

Adults aged ≥50 years registered with four general practices were mailed a Health Survey. Responders reporting foot pain within the last 12 months were invited to undergo a clinical assessment and weight-bearing dorso-plantar and lateral radiographs of both feet. Radiographic first MTPJ OA in the most severely affected foot was graded into four categories using a validated atlas. Differences in selected demographic and clinical factors were explored across the four radiographic severity subgroups using analysis of variance (ANOVA) and ordinal regression.

RESULTS

Clinical and radiographic data were available from 517 participants, categorised as having no (n = 105), mild (n = 228), moderate (n = 122) or severe (n = 62) first MTPJ OA. Increased radiographic severity was associated with older age and lower educational attainment. After adjusting for age, increased radiographic first MTPJ OA severity was significantly associated with an increased prevalence of dorsal hallux and first MTPJ pain, hallux valgus, first interphalangeal joint (IPJ) hyperextension, keratotic lesions on the dorsal aspect of the hallux and first MTPJ, decreased first MTPJ dorsiflexion, ankle/subtalar joint eversion and ankle joint dorsiflexion range of motion, and a trend towards a more pronated foot posture.

CONCLUSIONS

This cross-sectional study has identified several dose-response associations between radiographic severity of first MTPJ OA and a range of demographic and clinical factors. These findings highlight the progressive nature of first MTPJ OA and provide insights into the spectrum of presentation of the condition in clinical practice.

A phase-specific psychological therapy for people with problematic cannabis use following a first episode of psychosis: a randomized controlled trial

BACKGROUND

Cannabis use is high amongst young people who have recently had their first episode of psychosis, and is associated with worse outcomes. To date, interventions to reduce cannabis consumption have been largely ineffective, and it has been suggested that longer treatment periods are required.

METHOD

In a pragmatic single-blind randomized controlled trial 110 participants were randomly allocated to one of three conditions: a brief motivational interviewing and cognitive behavioural therapy (MI-CBT) intervention (up to 12 sessions over 4.5 months) with standard care from an early intervention service; a long MI-CBT intervention (up to 24 sessions over 9 months) with standard care; or standard care alone. The primary outcome was change in cannabis use as measured by Timeline Followback.

RESULTS

Neither the extended nor the brief interventions conferred benefit over standard care in terms of reductions in frequency or amount of cannabis use. Also the interventions did not result in improvements in the assessed clinical outcomes, including symptoms, functioning, hospital admissions or relapse.

CONCLUSIONS

Integrated MI and CBT for people with cannabis use and recent-onset psychosis does not reduce cannabis use or improve clinical outcomes. These findings are consistent with those in the published literature, and additionally demonstrate that offering a more extended intervention does not confer any advantage. Many participants were not at an action stage for change and for those not ready to reduce or quit cannabis, targeting associated problems rather than the cannabis use per se may be the best current strategy for mental health services to adopt.