Accelerating Medicines Partnership® Schizophrenia (AMP® SCZ): Rationale and Study Design of the Largest Global Prospective Cohort Study of Clinical High Risk for Psychosis

This article describes the rationale, aims, and methodology of the Accelerating Medicines Partnership® Schizophrenia (AMP® SCZ). This is the largest international collaboration to date that will develop algorithms to predict trajectories and outcomes of individuals at clinical high risk (CHR) for psychosis and to advance the development and use of novel pharmacological interventions for CHR individuals. We present a description of the participating research networks and the data processing analysis and coordination center, their processes for data harmonization across 43 sites from 13 participating countries (recruitment across North America, Australia, Europe, Asia, and South America), data flow and quality assessment processes, data analyses, and the transfer of data to the National Institute of Mental Health (NIMH) Data Archive (NDA) for use by the research community. In an expected sample of approximately 2000 CHR individuals and 640 matched healthy controls, AMP SCZ will collect clinical, environmental, and cognitive data along with multimodal biomarkers, including neuroimaging, electrophysiology, fluid biospecimens, speech and facial expression samples, novel measures derived from digital health technologies including smartphone-based daily surveys, and passive sensing as well as actigraphy. The study will investigate a range of clinical outcomes over a 2-year period, including transition to psychosis, remission or persistence of CHR status, attenuated positive symptoms, persistent negative symptoms, mood and anxiety symptoms, and psychosocial functioning. The global reach of AMP SCZ and its harmonized innovative methods promise to catalyze the development of new treatments to address critical unmet clinical and public health needs in CHR individuals.

A prospective clinical and biomechanical analysis of feet following first metatarsophalangeal joint arthrodesis for end stage hallux rigidus

BACKGROUND

Hallux Rigidus is the result of degeneration of the 1st metatarsophalangeal joint (1st MTPJ). In end-stage hallux rigidus, treatment is mainly surgical with arthrodesis being a favourable option. Although the biomechanical effects of arthrodesis have been examined, a detailed comparison of pre- and post-operative biomechanics has yet to be conducted.

RESEARCH QUESTION

Does 1st MTPJ arthrodesis positively affect foot kinematics and plantar pressure distribution?

METHODS

Twelve 1st MTPJ arthrodesis were performed in patients with a mean age of 53.5 ± 5.4 years and follow up time of 6.9 ± 1.0 months. Pre- and post-operative data were collected at a CMAS (Clinical Movement Analysis Society) accredited gait laboratory using a BTS motion capture system and pedobarographic pressure plates. Patient outcome measures were also assessed using the MOXFQ. Statistical analysis was conducted using a two-way repeated measures ANOVA.

RESULTS

Significant changes in stride length, cycle duration, cadence and velocity were identified following 1st MTPJ arthrodesis. A significant reduction in forefoot-hallux dorsiflexion at toe-off was identified for the operated foot from the pre-operative (20.23 ± 5.98°) to post-operative (7.56 ± 2.96°) assessment. Post-operative sagittal and transverse plane changes in the operated foot were also identified. Peak pressure and PTI results indicated significant lateralisation of load for the operated foot, but importantly this was not influenced following arthrodesis. Finally, there was a significant improvement in MOXFQ score.

SIGNIFICANCE

Following 1st MTPJ fusion there is an improvement in overall gait mechanics which accompanied by the improved MOXFQ score indicates a reduction in pain and improved confidence during gait. The lack of post-operative dorsiflexion at forefoot-hallux caused load to remain lateralised and compensatory mechanisms to occur at the more proximal joints within the foot. These results provide valuable information for clinicians and will enable more accurate counselling to be provided to patients with end-stage hallux rigidus.

The Sapienza University of Rome network of automated external defibrillators: a prototype webMap developed to speed access to community defibrillators and increase survival from out-of-hospital cardiac arrest

OBJECTIVE

In Italy, only around 10% of people who experience out-of-hospital cardiac arrest (OHCA) survive. A large portion of OHCA events in public settings are characterized by an initial shockable rhythm, which requires prompt defibrillation. We aimed to create a system to quickly locate nearby public access automated external defibrillators (AEDs) on the campus of Sapienza University of Rome, the largest public university in Europe.

MATERIALS AND METHODS

We developed the AED webMap through a 6-step process involving the: 1) collection of information and geographical coordinates for each AED from the university management system; 2) development of a new geolocation database; 3) integration of information contained in the new database with data provided by university departments; 4) geolocation of AEDs in the Google MyMaps environment; 5) graphic representation of all AEDs on digital map templates using specific symbols, with pop-ups containing additional information for each AED; and 6) publication of the webMap on the university website.

RESULTS

The AED webMap was published on the university website (https://www.uniroma1.it/it/pagina/defibrillatori-sapienza-in-rete) and facilitates prompt identification of nearby AEDs by providing: 1) detailed AED geolocalization with interactive pop-up information for each AED, including whether the AED is located internally or externally; 2) the option to use different base maps (e.g., digital street map); 3) calculation and display of the route to reach the chosen AED; and 4) the possibility to migrate towards multiple platforms.

CONCLUSIONS

The webMap can help bystanders quickly identify, locate, and reach nearby AEDs present on the campus of the largest public university in Europe, a measure that could help speed defibrillation and maximize the life-saving potential of AEDs in the event of OHCA.

A Sequential Adaptive Intervention Strategy Targeting Remission and Functional Recovery in Young People at Ultrahigh Risk of Psychosis: The Staged Treatment in Early Psychosis (STEP) Sequential Multiple Assignment Randomized Trial

Importance

Clinical trials have not established the optimal type, sequence, and duration of interventions for people at ultrahigh risk of psychosis.

Objective

To determine the effectiveness of a sequential and adaptive intervention strategy for individuals at ultrahigh risk of psychosis.

Design, Setting, and Participants

The Staged Treatment in Early Psychosis (STEP) sequential multiple assignment randomized trial took place within the clinical program at Orygen, Melbourne, Australia. Individuals aged 12 to 25 years who were seeking treatment and met criteria for ultrahigh risk of psychosis according to the Comprehensive Assessment of At-Risk Mental States were recruited between April 2016 and January 2019. Of 1343 individuals considered, 342 were recruited.

Interventions

Step 1: 6 weeks of support and problem solving (SPS); step 2: 20 weeks of cognitive-behavioral case management (CBCM) vs SPS; and step 3: 26 weeks of CBCM with fluoxetine vs CBCM with placebo with an embedded fast-fail option of ω-3 fatty acids or low-dose antipsychotic medication. Individuals who did not remit progressed through these steps; those who remitted received SPS or monitoring for up to 12 months.

Main Outcomes and Measures

Global Functioning: Social and Role scales (primary outcome), Brief Psychiatric Rating Scale, Scale for the Assessment of Negative Symptoms, Montgomery-Åsberg Depression Rating Scale, quality of life, transition to psychosis, and remission and relapse rates.

Results

The sample comprised 342 participants (198 female; mean [SD] age, 17.7 [3.1] years). Remission rates, reflecting sustained symptomatic and functional improvement, were 8.5%, 10.3%, and 11.4% at steps 1, 2, and 3, respectively. A total of 27.2% met remission criteria at any step. Relapse rates among those who remitted did not significantly differ between SPS and monitoring (step 1: 65.1% vs 58.3%; step 2: 37.7% vs 47.5%). There was no significant difference in functioning, symptoms, and transition rates between SPS and CBCM and between CBCM with fluoxetine and CBCM with placebo. Twelve-month transition rates to psychosis were 13.5% (entire sample), 3.3% (those who ever remitted), and 17.4% (those with no remission).

Conclusions and Relevance

In this sequential multiple assignment randomized trial, transition rates to psychosis were moderate, and remission rates were lower than expected, partly reflecting the ambitious criteria set and challenges with real-world treatment fidelity and adherence. While all groups showed mild to moderate functional and symptomatic improvement, this was typically short of remission. While further adaptive trials that address these challenges are needed, findings confirm substantial and sustained morbidity and reveal relatively poor responsiveness to existing treatments.

Trial Registration

ClinicalTrials.gov Identifier: NCT02751632.

Consumer perceptions on privacy and confidentiality in dermatology for 3D total-body imaging

As 3D total-body photography for the early detection of melanoma is not yet widely used in clinical practice, we do not have a full understanding of patient's concerns about use, privacy and confidentiality, and if their concerns differ depending on the use-case. We conducted a virtual consumer forum to assess patients concerns about privacy and confidentiality in dermatology imaging for research, artificial intelligence development and for their own clinical care.

Neutron star mass estimates from gamma-ray eclipses in spider millisecond pulsar binaries

Reliable neutron star mass measurements are key to determining the equation of state of cold nuclear matter, but such measurements are rare. Black widows and redbacks are compact binaries consisting of millisecond pulsars and semi-degenerate companion stars. Spectroscopy of the optically bright companions can determine their radial velocities, providing inclination-dependent pulsar mass estimates. Although inclinations can be inferred from subtle features in optical light curves, such estimates may be systematically biased due to incomplete heating models and poorly understood variability. Using data from the Fermi Large Area Telescope, we have searched for gamma-ray eclipses from 49 spider systems, discovering significant eclipses in 7 systems, including the prototypical black widow PSR B1957+20. Gamma-ray eclipses require direct occultation of the pulsar by the companion, and so the detection, or significant exclusion, of a gamma-ray eclipse strictly limits the binary inclination angle, providing new robust, model-independent pulsar mass constraints. For PSR B1957+20, the eclipse implies a much lighter pulsar (1.81 ± 0.07 solar masses) than inferred from optical light curve modelling.

An investigation to determine the normal 1st to 5th metatarsal peak pressure and PTI ratio of the forefoot

BACKGROUND

The foot support has been described as that of a tripod. Biomechanical studies often report on peak pressures and pressure time integrals under specific areas of the foot. Reference needs to be made to the normal tripod distribution especially in the forefoot. In the forefoot the ratio between the 1st metatarsal and the 5th metatarsal on the medial and lateral columns of the foot respectively provide an excellent reference especially if the normal ratio is known. This study provides conclusive evidence of the 1st to 5th metatarsal ratio for peak pressures and pressure time integrals in the normal foot to be used as a reference.

METHODS

A group of normal healthy volunteers (n = 12) and a group of patients with unilateral end stage hallux rigidus (n = 17) were recruited. Repeated measures of 1st and 5th metatarsal peak pressures and Pressure time integrals were measured to determine reliability of measurement and to provide a reference normal ratio.

RESULTS

In the healthy volunteer group, the 1st/5th metatarsal ratio for PTI was very close to 1 while it was just over 1.5 for peak pressure. In patients with unilateral end stage hallux rigidus, in the normal foot the 1st/5th metatarsal ratio for PP and PTI was very close to 1. These ratios were reproduced in the operated foot following 1st MTPJ replacement.

CONCLUSION

This study using normal healthy volunteers and patients undergoing 1st MTPJ replacement has demonstrated that the normal 1st/5th metatarsal peak pressure and pressure time integrals should be close to 1.

My child's future mental health: Carer's engagement with risk identification in an intervention study for youth with at-risk mental states

AIM

Prevention and early intervention efforts of serious mental illnesses has yielded promising results. However, alongside benefits, several ethical concerns have been raised, including the effects of being identified as being at-risk. In these debates, the voice of parents or carers is conspicuously absent. This is especially concerning as several at-risk interventions are trialled in under-age youth where parents consent on behalf of young people. Therefore, this study aimed to understand carer's experiences of their teenager being identified as at risk for psychosis.

METHODS

Semi-structured interviews were conducted with seven carers who had provided consent for their teenager to participate in a stepped intervention study for youth at-risk for psychosis. Questions explored their experiences regarding having their teenager being identified as at-risk. Transcripts were analysed using thematic analysis.

RESULTS

We identified five main themes from seven female carers' experiences of risk identification including: (a) recall of risk information was limited, or variable, (b) goal of risk disclosure was perceived to be positive, (c) negative emotions were associated with knowledge of risk, (d) relief from uncertainty and helplessness and (e) effects of risk disclosure were mediated by individual circumstance.

CONCLUSION

Overall, the results demonstrate that carers' experience of risk disclosure varied with factors surrounding their individual circumstances, and the process of disclosure. Whilst participants acknowledged potential adverse effects associated with risk disclosure, many still adopted a positive outlook. Tailoring safe and effective disclosure of risk to suit the needs of youth and carers could outweigh the potential risks.

Cannabidiol for at risk for psychosis youth: A randomized controlled trial

BACKGROUND

No biological treatment has been firmly established for the at-risk stage of psychotic disorder. In this study we aim to test if subthreshold psychotic symptoms can be effectively treated with cannabidiol (CBD), a non-psychoactive compound of the plant Cannabis sativa. The question has taken on increased importance in the wake of evidence questioning both the need and efficacy of specific pharmacological interventions in the ultra-high risk (UHR) for psychosis group.

METHODS

Three-arm randomized controlled trial of 405 patients (135 per arm) aged 12-25 years who meet UHR for psychosis criteria. The study includes a 6-week lead-in phase during which 10% of UHR individuals are expected to experience symptom remission. Participants will receive CBD (per oral) at doses 600 or 1000 mg per day (fixed schedule) for 12 weeks. Participants in the third arm of the trial will receive matching placebo capsules. Primary outcome is severity of positive psychotic symptoms as measured by the Comprehensive Assessment of At-Risk Mental States at 12 weeks. We hypothesize that CBD will be significantly more effective than placebo in improving positive psychotic symptoms in UHR patients. All participants will also be followed up 6 months post baseline to evaluate if treatment effects are sustained.

CONCLUSION

This paper reports on the rationale and protocol of the Cannabidiol for At Risk for psychosis Youth (CanARY) study. This study will test CBD for the first time in the UHR phase of psychotic disorder.

Understanding the Barriers and Facilitators to Employment for People with Bipolar Disorder

People with Bipolar Disorder (BD) consistently report a desire for employment; however, this is not reflected in employment figures. Individuals' perceptions of barriers to employment, along with endorsement of facilitators to employment remain under-investigated. We aimed to address this limitation by: (i) first examining differences in employed versus unemployed individuals (demographic, clinical, functioning); then (ii) identifying barriers and/or facilitators to employment, perception of same, and subsequent impact on employment. We assessed demographics, functioning, and illness-related characteristics in 35 participants with BD (19 employed, 16 unemployed). Participants were asked to indicate perception of common barriers and facilitators to employment. Groups did not differ regarding demographic or clinical variables. High levels of absenteeism, termination of last role and commonly perceived barriers were attributed to mental ill-health. 93.3% of unemployed participants reportedly desired employment, and more perceived barriers were observed in the unemployed group. Identified facilitators included increased support and flexible work strategies. A comprehensive understanding of perceptions of limiting and helpful factors related to employment for people with BD was obtained. These findings have implications for service provision, encouraging targeted discussion, and tailored treatment approaches to individual's unique perceptions of factors related to employment.

A prospective clinical and biomechanical analysis of feet following first metatarsophalangeal joint replacement

BACKGROUND

There is a lack of research providing a biomechanical outcome following 1^st MTPJ replacement for hallux rigidus. Despite this, 1^st MTPJ replacement continues to be an alternative surgical option to fusion for this painful debilitating condition. Several studies do consider the patient reported outcomes which are subjective.

RESEARCH QUESTION

The objective of this study is to provide an in depth biomechanical analysis to examine the effects of 1^st MTPJ replacement for hallux rigidus on gait mechanics.

METHODS

Kinematic data was collected at our CMAS (Clinical Movement Analysis Society) UK accredited gait laboratory during the gait cycle together with pressure plate pressure readings and a validated patient outcome measure before surgery and at 6 and 12 months after surgery. A complete literature review is performed.

RESULTS

Kinematic data revealed a significant increase in stride length, cadence and velocity following 1^st MTPJ replacement for hallux rigidus. Foot kinematic data revealed significantly reduced tibia-hindfoot abduction and pronation and reduced hindfoot-forefoot supination and adduction. There was no effect on 1^st MTPJ weight bearing range of motion. Pressure plate data revealed an increase in peak pressure and pressure time integral towards the 1^st metatarsal following surgery. There was a significant improvement in the patient reported outcome measure.

SIGNIFICANCE

This study has demonstrated objectively that following 1^st MTPJ replacement, biomechanically, a restoration of the foot posture to allow medialisation of foot pressures towards the medial column and normalisation of gait including an increase in the stride length, cadence and velocity and that clinically, there was an improvement in the MOXFQ.

Diabetic mitochondria are resistant to palmitoyl CoA inhibition of respiration, which is detrimental during ischemia

The bioactive lipid intermediate palmitoyl CoA (PCoA) can inhibit mitochondrial ADP/ATP transport, though the physiological relevance of this regulation remains unclear. We questioned whether myocardial ischemia provides a pathological setting in which PCoA regulation of ADP/ATP transport would be beneficial, and secondly, whether the chronically elevated lipid content within the diabetic heart could make mitochondria less sensitive to the effects of PCoA. PCoA acutely decreased ADP‐stimulated state 3 respiration and increased the apparent K_m for ADP twofold. The half maximal inhibitory concentration (IC₅₀) of PCoA in control mitochondria was 22 µM. This inhibitory effect of PCoA on respiration was blunted in diabetic mitochondria, with no significant difference in the K_m for ADP in the presence of PCoA, and an increase in the IC₅₀ to 32 µM PCoA. The competitive inhibition by PCoA was localised to the phosphorylation apparatus, particularly the ADP/ATP carrier (AAC). During ischemia, the AAC imports ATP into the mitochondria, where it is hydrolysed by reversal of the ATP synthase, regenerating the membrane potential. Addition of PCoA dose‐dependently prevented this wasteful ATP hydrolysis for membrane repolarisation during ischemia, however, this beneficial effect was blunted in diabetic mitochondria. Finally, using ³¹P‐magnetic resonance spectroscopy we demonstrated that diabetic hearts lose ATP more rapidly during ischemia, with a threefold higher ATP decay rate compared with control hearts. In conclusion, PCoA plays a role in protecting mitochondrial energetics during ischemia, by preventing wasteful ATP hydrolysis. However, this beneficial effect is blunted in diabetes, contributing to the impaired energy metabolism seen during myocardial ischemia in the diabetic heart.

Optimal care for the management of older people non-weight bearing after lower limb fracture: a consensus study

Background

Older people who are non-weight-bearing after a lower limb fracture are at risk of poor outcomes but there are no clinical guidelines for this group of patients. Given the paucity of the research evidence base, we conducted a consensus exercise to ascertain expert opinion about the management of this group.

Methods

A three-round e-Delphi technique was planned to use the online JISC survey tool with a multidisciplinary panel of health professionals. Panellists were invited by email via professional organisations and UK NHS Trusts. The initial statements for this study were prepared by the authors based upon the findings of their scoping review. Consensus required >/= 70% agreement with statements.

Results

Only 2 survey rounds were required. Ninety panellists, representing seven clinical disciplines, reached consensus for 24 statements about general issues (osteoporosis detection and management, falls risk reduction and nutrition) and specific non-weight bearing issues (such as the need for activity to be promoted during this period).

Conclusions

These findings can be used in the generation of a clinical guideline for this group of patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02265-z.

Exploring rehabilitation potential in older people living with frailty: a qualitative focus group study

BACKGROUND

Rehabilitation interventions are frequently cited as key in supporting frail older people's recovery following periods of decompensation and acute ill-health. Clinicians are required to make decisions about a patient's potential to respond to rehabilitation. 'Rehabilitation potential' decisions can determine access to services. In acute settings clinicians have limited time to assess and work with patients, families and carers. The complexities of ageing, recovery, rehabilitation and frailty may not be fully appreciated. This study aimed to explore multiple perspectives of the concept of rehabilitation potential and how it is assessed in older people living with frailty in the acute healthcare setting.

METHODS

Five focus groups with a purposive sample of 28 participants which included clinicians and members of the public were conducted. Analysis comprised a thematic approach using the Framework method.

RESULTS

Rehabilitation potential was found to encapsulate a complex decision-making process where clinicians judged an individual's ability to benefit from and participate in targeted rehabilitation. They asked, "Will it work?", "Is it wanted?" and "Is it available?" In order to predict who would benefit from rehabilitation interventions, clinicians assessed a range of holistic clinical and non-clinical factors. An iterative approach to assessment delivered by a multi-disciplinary team, centred around patient and carer needs and wants was needed to accommodate complexity. Participants believed that everyone had some form of potential but this was dependent on availability of rehabilitation resources and conceptualisations of frailty and rehabilitation. Tensions between iterative approaches to rehabilitation potential assessment and the realities of rapid decision making in the acute hospital setting were found.

CONCLUSION

Rehabilitation potential decisions involve a complex process of multidisciplinary decision-making and prognostication on the likely outcome and benefit from rehabilitation programmes. These findings lay the foundation for developing structured approaches to rehabilitation potential decision making tools and guidance.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

Youth Depression Alleviation with Anti-inflammatory Agents (YoDA-A): a randomised clinical trial of rosuvastatin and aspirin

BACKGROUND

Inflammation contributes to the pathophysiology of major depressive disorder (MDD), and anti-inflammatory strategies might therefore have therapeutic potential. This trial aimed to determine whether adjunctive aspirin or rosuvastatin, compared with placebo, reduced depressive symptoms in young people (15-25 years).

METHODS

YoDA-A, Youth Depression Alleviation with Anti-inflammatory Agents, was a 12-week triple-blind, randomised, controlled trial. Participants were young people (aged 15-25 years) with moderate to severe MDD (MADRS mean at baseline 32.5 ± 6.0; N = 130; age 20.2 ± 2.6; 60% female), recruited between June 2013 and June 2017 across six sites in Victoria, Australia. In addition to treatment as usual, participants were randomised to receive aspirin (n = 40), rosuvastatin (n = 48), or placebo (n = 42), with assessments at baseline and weeks 4, 8, 12, and 26. The primary outcome was change in the Montgomery-Åsberg Depression Rating Scale (MADRS) from baseline to week 12.

RESULTS

At the a priori primary endpoint of MADRS differential change from baseline at week 12, there was no significant difference between aspirin and placebo (1.9, 95% CI (- 2.8, 6.6), p = 0.433), or rosuvastatin and placebo (- 4.2, 95% CI (- 9.1, 0.6), p = 0.089). For rosuvastatin, secondary outcomes on self-rated depression and global impression, quality of life, functioning, and mania were not significantly different from placebo. Aspirin was inferior to placebo on the Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q-SF) at week 12. Statins were superior to aspirin on the MADRS, the Clinical Global Impressions Severity Scale (CGI-S), and the Negative Problem Orientation Questionnaire scale (NPOQ) at week 12.

CONCLUSIONS

The addition of either aspirin or rosuvastatin did not to confer any beneficial effect over and above routine treatment for depression in young people. Exploratory comparisons of secondary outcomes provide limited support for a potential therapeutic role for adjunctive rosuvastatin, but not for aspirin, in youth depression.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry, ACTRN12613000112763. Registered on 30/01/2013.

Taurine Analysis in Milk and Infant Formulae by Liquid Chromatography: Collaborative Study

A collaborative study was conducted on a liquid chromatographic (LC) method for determination of taurine in infant formula and milk powders. Twenty laboratories participated in the analysis of 8 blind duplicates over the range of approximately 3–60 mg/100 g sample. The method involved protein removal, conversion to the dansyl-derivative, and isocratic LC separation with UV and/or fluorescence detection. Following outlier treatment, overall mean RSDR has been estimated at 7.00% for sup. plemented products with a HORRAT value of 1.1. The poorer precision at endogenous levels establishes a lower limit of determination of about 5 mg/100 g. An overall mean RSDr:RSDR value of 0.7 for all products demonstrated acceptable performance.

The cost of diabetic foot ulcers and amputations to the National Health Service in England

AIM

To estimate the healthcare costs of diabetic foot disease in England.

METHODS

Patient-level data sets at a national and local level, and evidence from clinical studies, were used to estimate the annual cost of health care for foot ulceration and amputation in people with diabetes in England in 2014-2015.

RESULTS

The cost of health care for ulceration and amputation in diabetes in 2014-2015 is estimated at between £837 million and £962 million; 0.8% to 0.9% of the National Health Service (NHS) budget for England. More than 90% of expenditure was related to ulceration, and 60% was for care in community, outpatient and primary settings. For inpatients, multiple regression analysis suggested that ulceration was associated with a length of stay 8.04 days longer (95% confidence interval 7.65 to 8.42) than that for diabetes admissions without ulceration.

CONCLUSIONS

Diabetic foot care accounts for a substantial proportion of healthcare expenditure in England, more than the combined cost of breast, prostate and lung cancers. Much of this expenditure arises through prolonged and severe ulceration. If the NHS were to reduce the prevalence of diabetic foot ulcers in England by one-third, the gross annual saving would be more than £250 million. Diabetic foot ulceration is a large and growing problem globally, and it is likely that there is potential to improve outcomes and reduce expenditure in many countries.

A single fast radio burst localized to a massive galaxy at cosmological distance

Fast radio bursts (FRBs) are brief radio emissions from distant astronomical sources. Some are known to repeat, but most are single bursts. Nonrepeating FRB observations have had insufficient positional accuracy to localize them to an individual host galaxy. We report the interferometric localization of the single-pulse FRB 180924 to a position 4 kiloparsecs from the center of a luminous galaxy at redshift 0.3214. The burst has not been observed to repeat. The properties of the burst and its host are markedly different from those of the only other accurately localized FRB source. The integrated electron column density along the line of sight closely matches models of the intergalactic medium, indicating that some FRBs are clean probes of the baryonic component of the cosmic web.

A consecutive, prospective analysis of the Rotoglide 1st metatarsophalangeal joint replacement

Following 1st metatarsophalangeal joint replacement, there is a normalisation of foot pressure distribution as demonstrated by peak pressures of the 1st and 5th metatarsal heads and their ratio as measured by pedobarographs. This compares favourably with the unaffected foot. Functional dorsiflexion range of motion is maintained and there is a significant improvement in the reported patient outcome measure.

Youth Depression Alleviation-Augmentation with an anti-inflammatory agent (YoDA-A): protocol and rationale for a placebo-controlled randomized trial of rosuvastatin and aspirin

AIM

There is growing support for the role of inflammation and oxidative stress in the pathophysiology of major depressive disorder (MDD). This has led to the development of novel strategies targeting inflammation in the treatment of depression. Rosuvastatin and aspirin have well-documented, anti-inflammatory and antioxidant properties. The aim of the Youth Depression Alleviation: Augmentation with an anti-inflammatory agent (YoDA-A) study is to determine whether individuals receiving adjunctive anti-inflammatory agents, aspirin and rosuvastatin experience a reduction in the severity of MDD compared with individuals receiving placebo.

METHODS

YoDA-A is a 12-week triple-blind, randomized controlled trial funded by the National Health and Medical Research Council, Australia. Participants aged 15-25, with moderate-to-severe MDD, are allocated to receive either 10 mg/day rosuvastatin, 100 mg/day aspirin, or placebo, in addition to treatment as usual. Participants are assessed at baseline and at weeks 4, 8, 12 and 26. The primary outcome is change in the Montgomery-Åsberg Depression Rating Scale (MADRS) from baseline to week 12.

RESULTS

The study is planned to be completed in 2017. At date of publication, 85 participants have been recruited.

CONCLUSION

Timely and targeted intervention for youth MDD is crucial. Given the paucity of new agents to treat youth MDD, adjunctive trials are not only pragmatic and 'real-world', but additionally aim to target shortfalls in conventional medications. This study has the potential to first provide two new adjunctive treatment options for youth MDD; aspirin and rosuvastatin. Second, this study will serve as proof of principle of the role of inflammation in MDD.

First Search for Nontensorial Gravitational Waves from Known Pulsars

We present results from the first directed search for nontensorial gravitational waves. While general relativity allows for tensorial (plus and cross) modes only, a generic metric theory may, in principle, predict waves with up to six different polarizations. This analysis is sensitive to continuous signals of scalar, vector, or tensor polarizations, and does not rely on any specific theory of gravity. After searching data from the first observation run of the advanced LIGO detectors for signals at twice the rotational frequency of 200 known pulsars, we find no evidence of gravitational waves of any polarization. We report the first upper limits for scalar and vector strains, finding values comparable in magnitude to previously published limits for tensor strain. Our results may be translated into constraints on specific alternative theories of gravity.

Grouping of Stimuli and Apparent Exceptions to the Psychological Refractory Period

When a subject is called upon to respond independently to two stimuli, the second of the two responses is often delayed if the stimuli follow closely on one another, and this has led to the suggestion that in making decisions the human operator accepts and organizes the available input information intermittently in the manner of a discontinuous servo. According to this view two nearly simultaneous stimuli can only be dealt with equally fast if they are grouped into a single decision to respond to both stimuli; otherwise one will have to wait for the attention of the central mechanism until the other has been dealt with. In the present experiment it is shown that delays in the second response are not necessary or invariable, and that the pattern and timing of the second responses when they are performed without delay differ in important respects from those to be expected of grouped responses. It is concluded that the central mechanisms concerned in the response do not possess the limitations that the single channel theory would suggest.

The magnetic field and turbulence of the cosmic web measured using a brilliant fast radio burst

Fast radio bursts (FRBs) are millisecond-duration events thought to originate beyond the Milky Way galaxy. Uncertainty surrounding the burst sources, and their propagation through intervening plasma, has limited their use as cosmological probes. We report on a mildly dispersed (dispersion measure 266.5 ± 0.1 parsecs per cubic centimeter), exceptionally intense (120 ± 30 janskys), linearly polarized, scintillating burst (FRB 150807) that we directly localize to 9 square arc minutes. On the basis of a low Faraday rotation (12.0 ± 0.7 radians per square meter), we infer negligible magnetization in the circum-burst plasma and constrain the net magnetization of the cosmic web along this sightline to <21 nanogauss, parallel to the line-of-sight. The burst scintillation suggests weak turbulence in the ionized intergalactic medium.

Prevalence and associated features of depression in women with Rett syndrome

BACKGROUND

Little is known about depression among women with Rett syndrome (RTT) despite recent advances in knowledge about RTT. In this study, we aimed to establish the prevalence of depression among women with RTT as identified by a screening telephone interview and to explore the clinical factors associated with this.

METHODS

The study employed the cross-sectional analysis of data from telephone interviews with carers of 56 women with RTT, using validated questionnaires for assessing mental health problems, challenging behaviour and RTT severity.

RESULTS

Scores on the mental health assessment reached the affective/neurotic threshold in eight cases (14.3%). No significant differences were found between those reaching the threshold and those who did not in terms of severity of RTT phenotype, health problems or social circumstances. There was a significant association between screening identified depression and higher lethargy and social withdrawal.

CONCLUSIONS

Screening identified depression was found among a sizeable minority of women with RTT. Further investigation is needed to establish a clinically validated prevalence of depression among this group and to identify behavioural features that would lead to prompt psychiatric assessment.

Ageing in Rett syndrome

BACKGROUND

The aim was to gain a UK national sample of people with Rett syndrome across the age range and (1) conduct a cross-sectional comparison of age groups and (2) undertake a longitudinal follow-up.

METHODS

From 308 potential participants approached to take part, a sample of 91 girls and women was achieved (29.5%). Their ages ranged from 4 to 47 years, and 71 were known to have a mutation in the methyl-CpG binding protein-2 (MECP2) gene. Seventy-two of the initial sample were followed up 16 months later, and 50 returned completed assessments (69.4%). Their ages ranged from 7 to 48 years, and 42 were MECP2 positive. Parental questionnaire measures of Rett syndrome specific characteristics, impulsivity, overactivity, mood, interest and pleasure, repetitive behaviour and self-injury were administered.

RESULTS

Adaptive behaviour and behavioural characteristics of Rett syndrome were similar across age groups and, where assessed, stable over time, as were repetitive behaviours generally and self-injury. There was some suggestion of deterioration in health arising with ageing, principally contributed to by deteriorations in dental and gastro-intestinal problems both with moderate effect sizes. Indicators of mood, interest and pleasure differed significantly across age groups. The total scale score significantly deteriorated over time, with a moderate effect size.

CONCLUSIONS

This study provides further evidence for the post-regression stability that characterises Rett syndrome. Emergent low mood in Rett syndrome requires further research.

Cost of diabetic foot disease to the National Health Service in England

AIM

To estimate the annual cost of diabetic foot care in a universal healthcare system.

METHODS

National datasets and economic modelling were used to estimate the cost of diabetic foot disease to the National Health Service in England in 2010-2011. The cost of hospital admissions specific to foot disease or amputation was estimated from Hospital Episode Statistics and national tariffs. Multivariate regression analysis was used to estimate the impact of foot disease on length of stay in admissions that were not specific to foot disease or amputation. Costs in other areas were estimated from published studies and data from individual hospitals.

RESULTS

The cost of diabetic foot care in 2010-2011 is estimated at £580 m, almost 0.6% of National Health Service expenditure in England. We estimate that more than half this sum (£307 m) was spent on care for ulceration in primary and community settings. Of hospital admissions with recorded diabetes, 8.8% included ulcer care or amputation. Regression analysis suggests that foot disease was associated with a 2.51-fold (95% CI 2.43-2.59) increase in length of stay.The cost of inpatient ulcer care is estimated at £219 m, and that of amputation care at £55 m.

CONCLUSIONS

The cost of diabetic foot disease is substantial. Ignorance of the cost of current care may hinder commissioning of effective services for prevention and management in both community and secondary care.

High sensitivity troponin T in acute medicine; more questions than answers?

BACKGROUND

Troponin testing in acute medicine is routine. The introduction of a high sensitivity assay (hs Tn T) has created uncertainty regarding the clinical significance of 'abnormal' troponin T levels. The previous assay could not detect troponin levels <30 ng/l.

AIMS AND METHODS

To characterize those with a hs Tn T ≥14 ng/l. Prospective cohort study of consecutive admissions to an acute medical unit.

RESULTS

Troponin was measured in 564 consecutive patients (∼50% of all admissions) over 1 month; was ≥14 ng/l in 224 (40%) of which 220 patients had demographic data for this analysis. Median (inter-quartile range) peak troponin was 47.5 ng/l (24-130) and 36% had a Tn T between 14 and 30 ng/l. Mean [standard deviation (SD)] age was 72 (12) years and 57% were male. Only 44 patients (20%) had an acute myocardial infarction, reflecting the increased sensitivity but reduced specificity of the assay. Prognosis was poor with 31% mortality at 1 year. Over a mean (SD) follow-up of 648 (61) days, there were 87 deaths (40%). Those with a primary non-cardiac diagnosis (n = 126) had poorer survival than those with a primary cardiac diagnosis (n = 94). Troponin elevation related to sepsis conferred a very poor prognosis with 24 deaths (70%) over the follow-up period.

CONCLUSION

Elevated hs Tn T is very common in acute medicine, but myocardial infarction as an explanation is uncommon. Overall, the prognosis is poor with a tendency to worse outcomes in those with a primary 'non-cardiac' diagnosis.

Pre-rigor carcass stretching counteracts the negative effects of high rigor temperature on tenderness and water-holding capacity – using lamb muscles as a model

High pre-rigor muscle temperature has negative consequences on quality and has been predominantly studied in the excised longissimus muscle of beef and lamb carcasses. There is little data on other muscles, the application in whole carcasses or potential amelioration techniques such as stretching. This study evaluated the effects of electrical stimulation, high pre-rigor temperature and stretching of lamb sides on quality traits and protein denaturation in four leg muscles [gluteus medius (GM), rectus femoris (RF), semimembranosus (SM) and semitendinosus (ST)]. Twenty lamb carcasses were used with two electrical stimulation treatments (stimulated or non-stimulated, +/−) and two pre-rigor temperature treatments (chilled at 2°C directly after slaughter, or held in 37°C water for 4.5 h before transfer to a 2°C chiller) applied. One side of each carcass was suspended from the Achilles tendon, whereas the other side was stretched by allowing the leg to drop and tying it to the ribs. Electrical stimulation did not influence the different traits except for pH fall post slaughter and myosin denaturation. Stretching resulted in greater muscle and sarcomere lengths for the GM, SM and ST, but a decrease in sarcomere length for the RF. For the non-stretched GM and SM, the 37°C treatment resulted in tougher meat at 1 and 8 days post mortem compared with the 2°C treatment. In contrast, the stretched 37°C treatment resulted in more tender meat for the GM, SM and ST at 1 day post mortem compared with the 2°C treatment. For all muscles, the 37°C treatment resulted in a decrease in the water-holding capacity (increased purge, surface exudate and cooking losses). The magnitude of this effect was generally diminished by stretching for the GM, SM and ST, but for the RF, (which was not stretched by the treatment) this effect was reversed. The 37°C treatment resulted in paler meat (increased L*-values) for the GM, SM and ST relative to the 2°C treatment. The observed effects of the 37°C treatment on water-holding capacity and colour could be explained by the effects of this treatment on indicators of protein denaturation (sarcoplasmic protein solubility and myofibrillar ATPase activity), which were decreased for the GM, SM and ST. The response to both temperature and stretching varied between the muscles, due to different anatomical location and also due to postulated differences in the fibre types. In conclusion, pre-rigor stretching of lamb sides can counteract the negative effects of high early post-mortem temperature on tenderness and water-holding capacity for those muscles that are stretched as a result of this hanging method.