The Blunt Liver and Spleen Trauma (BLAST) audit: national survey and prospective audit of children with blunt liver and spleen trauma in major trauma centres

PURPOSE

To compare the reported and observed management of UK children with blunt liver or spleen injury (BLSI) to the American Pediatric Surgical Association (APSA) 2019 BLSI guidance.

METHODS

UK Paediatric Major Trauma Centres (pMTCs) undertook 1 year of prospective data collection on children admitted to or discussed with those centres with BLSI and an online questionnaire was distributed to all consultants who care for children with BLSI in those centres.

RESULTS

All 21/21 (100%) pMTCs participated; 131 patients were included and 100/152 (65%) consultants responded to the survey. ICU care was reported and observed to be primarily determined using haemodynamic status or concomitant injuries rather than injury grade, in accordance with APSA guidance. Bed rest was reported to be determined by grade of injury by 63% of survey respondents and observed in a similar proportion of patients. Contrary to APSA guidance, follow-up radiological assessment of the injured spleen or liver was undertaken in 44% of patients before discharge and 32% after discharge, the majority of whom were asymptomatic.

CONCLUSIONS

UK management of BLSI differs from many aspects of APSA guidance. A shift towards using clinical features to determine ICU admission and readiness for discharge is demonstrated, in line with a strong evidence base. However, routine bed rest and re-imaging after BLSI is common, contrary to APSA guidance. This disparity may exist due to concern that evidence around the incidence, presentation and natural history of complications after conservatively managed BLSI, particularly bleeding from pseudoaneurysms, is weak.

Direct current cardioversion in pregnancy: a multicentre study

OBJECTIVE

Direct current cardioversion (DCCV) in pregnancy is rarely required and typically only documented in single case reports or case series. A recent UK confidential enquiry reported on several maternal deaths where appropriate DCCV appeared to have been withheld.

DESIGN

Retrospective cohort study.

SETTING

Seventeen UK and Ireland specialist maternity centres.

SAMPLE

Twenty-seven pregnant women requiring DCCV in pregnancy.

MAIN OUTCOME MEASURES

Maternal and fetal outcomes following DCCV.

RESULTS

Twenty-seven women had a total of 29 DCCVs in pregnancy. Of these, 19 (70%) initial presentations were to Emergency Departments and eight (30%) to maternity settings. There were no maternal deaths. Seventeen of the women (63%) had a prior history of heart disease. Median gestation at DCCV was 28 weeks, median gestation at delivery was 35 weeks, with a live birth in all cases. The abnormal heart rhythms documented at the first cardioversion were atrial fibrillation in 12/27 (44%) cases, atrial flutter in 8/27 (30%), supraventricular tachycardia in 5/27 (19%) and atrial tachycardia in 2/27 (7%). Fetal monitoring was undertaken following DCCV on 14/29 (48%) occasions (10 of 19 (53%) at ≥26 weeks) and on 2/29 (7%) occasions, urgent delivery was required post DCCV.

CONCLUSIONS

Direct current cardioversion in pregnancy is rarely required but should be undertaken when clinically indicated according to standard algorithms to optimise maternal wellbeing. Once the woman is stable post DCCV, gestation-relevant fetal monitoring should be undertaken. Maternity units should develop multidisciplinary processes to ensure pregnant women receive the same standard of care as their non-pregnant counterparts.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

The resilience of the developing reading system: multi-modal evidence of incident and recovery after a pediatric stroke

Decades of neuroscientific findings have elucidated the highly specialized brain areas involved in reading, especially along the ventral occipitotemporal stream where the critical step of recognizing words occurs. We report on a 14-year-old female with temporary dyslexia after a left ventral occipitotemporal ischemic stroke. Our longitudinal multimodal findings show that the resolution of the reading impairment was associated with heightened activity in the left posterior superior and inferior temporal gyri. Our findings highlight the role of the left inferior temporal gyrus in reading and the importance of perilesional and ipsilateral cortical areas for functional recovery after childhood stroke.

Effect of electrode placement on speed of response to ECT

Objective

Electroconvulsive therapy (ECT) can be rapidly effective in treating severe depression. Right unilateral (RUL) or bitemporal (BT) electrode placement may affect the speed of ECT effectiveness although our current understanding of demographic and clinical factors for predicting predict speed of response and remission with ECT is limited. We investigated differences in improvement speed and also time to achieving response and remission criteria between brief-pulse moderate-dose (1.5 x seizure threshold) BT ECT and high-dose (6 x seizure threshold) RUL ECT. Additionally, we explored the influence of demographic and clinical characteristics.

Methods

Se analysed weekly 24-item Hamilton Depression Rating Scale scores obtained from severely depressed patients participating in the EFFECT-Dep trial (ISRCTN23577151). Improvement speeds in patients treated randomly with a course of either BT (n = 69) or RUL ECT (n = 69) were compared using independent sample t-tests. Weekly proportions of responders and remitters were compared using chi-square tests. Cox regression analyses were used to explore predictors of speed to achieve response and remission status.

Results

Se found no differences between RUL and BT ECT in speed of improvement or time to achieve response or remission. Exploratory analyses indicated that a wide variety of demographic and clinical features did not serve to predict speed of response and remission to ECT.

Conclusion

Electrode placement did not substantially influence speed of improvement, response and remission with twice-weekly brief-pulse ECT. Minimising the cognitive side-effects of ECT may be of more relevance when choosing between BT and RUL electrode placement for ECT.

Disclosure

Declan M. McLoughlin has received speaker’s honoraria from Mecta and Otsuka and an honorarium from Janssen for participating in an esketamine advisory board meeting. The other author reports no conflicts of interest. This work was supported by awards from

Letter to the Editor: Healthy for Life: An Innovative and Collaborative Approach to COVID 19 Lockdown in New Zealand

Recently Boreskie and colleagues published an editorial in the Journal of Frailty and Aging on Preventing Frailty Progression During the COVID-19 Pandemic (1). In it they proposed the SAVE programme (Socialization, Adequate nutrition, Vitamin D, Exercise) to prevent frailty. They concluded that creative thinking and concerted efforts would be needed to disseminate health recommendations to maintain the health of pre-frail and frail older adults in unprecedented times, such as those posed by the COVID-19 pandemic.

Cardiac function in pregnant women with a Fontan circulation following live birth

Background

Fontan circuits are used to palliate congenital heart disease where patients have a single functioning ventricle. The venous return to the heart is redirected to the pulmonary arteries through the use of a conduit, bypassing the heart. Many females with Fontan circuits are now reaching child-bearing age and some desire pregnancy. However, pregnancy in women with Fontan circuits is associated with high complication rates.

Purpose

We compared postnatal cardiac function in women with a Fontan circulation with pre-pregnancy cardiovascular investigations.

Methods

Data were collected from case notes of all women with a Fontan circulation giving birth after 24 weeks of gestation at Birmingham Women's Hospital between 1997 and 2019.

Results

18 women with a median age of 29±6 years were followed up for 8.0±9 years. There were 21 live births at a median gestation of 32±5 weeks, of which 81% were caesarean sections. Three infants (14%) were born before 30 weeks' gestation and only two (10%) at term. Significant dyspnoea complicated 19% of pregnancies and postpartum haemorrhage occurred in 24%.

Pre-pregnancy cardiac magnetic resonance (CMR) data were available for 11 women and post-pregnancy for 14. Post-pregnancy scans were performed a median of 1.5±4.8 years after birth. Ejection fraction was 63.6±5% at baseline and tended to reduce following pregnancy (median −5.0±8%, n=7). Pre-pregnancy peak oxygen consumption (VO2max) was 73±14% of predicted on cardiopulmonary exercise testing. Median change in VO2max was −8±22% post-pregnancy (n=4). There was no change New York Heart Association (NYHA) class or resting saturations after pregnancy.

Conclusions

Preterm delivery and maternal bleeding were prevalent in this cohort. Exercise capacity was moderately impaired and saturations were typically low. Pregnancy does not seem to have longer term impact on oxygen saturations or NYHA class. Larger series are needed to confirm whether pregnancy is detrimental to postpartum systolic function. CMR can give comprehensive assessment of cardiac function before and after pregnancy and provide data to inform the crucial pre-pregnancy counselling for Fontan patients of child-bearing age.

Funding Acknowledgement

Type of funding source: None

The peripheral immune response in hyperglycemic stroke

OBJECTIVES

Hyperglycemia is common in acute ischemic stroke patients and is associated with poor clinical outcome. However, aggressive reduction of post-stroke hyperglycemia did not improve clinical outcome, suggesting that other mechanisms are playing a detrimental role in hyperglycemic stroke. We hypothesize that the acute post-stroke immune response is altered in the hyperglycemic state leading to higher mortality and morbidity. The objective of this study was to characterize temporal changes in circulating immune cells after stroke and their association with clinical outcomes in hyperglycemic compared to euglycemic patients.

PATIENTS AND METHODS

This retrospective study included 97 (58 % euglycemic, 42 % hyperglycemic) patients presenting within 12 h of symptom onset of stroke. Blood neutrophil, monocyte and lymphocyte concentrations were measured sequentially for 96 h post stroke. Primary clinical outcome was the difference in the NIH stroke scale at admission compared to discharge. Secondary outcome measures included discharge disposition and the modified Rankin Scale (mRS) at 90 days.

RESULTS

Circulating neutrophils were significantly higher in hyperglycemic than in euglycemic patients within the first 48 h post stroke, while lymphocyte counts trended to be lower. Hyperglycemic patients had higher mortality rates, less favorable discharge disposition and worse neurological function at 90 days. In both groups, the neutrophil to lymphocytes ratio ((NLR) remained strongly associated with neurological function at discharge within the first 24 h (p < 0.001), and remained significant in hyperglycemic patients up to 48 h (p < 0.001). Multivariate regression analysis showed no confounding by other factors and a significant correlation with differences in NIHSS score (CI; - 9.287 to -1.46, p = 0.0077**) and NLR (CL; 0.6058-6.901, p = 0.0203*) in hyperglycemic patients.

CONCLUSIONS

Our data suggests that circulating immune cells play an important role in mediating poor clinical outcome in hyperglycemic patients following stroke. The NLR is a strong predictor of neurological outcomes in hyperglycemic patients. Thus, the modulation of immune cells may be a viable therapeutic approach to improve outcomes for this high risk group.

Contamination in complex healthcare trials: the falls in care homes (FinCH) study experience

Background

Trials are at risk of contamination bias which can occur when participants in the control group are inadvertently exposed to the intervention. This is a particular risk in rehabilitation studies where it is easy for trial interventions to be either intentionally or inadvertently adopted in control settings. The Falls in Care Homes (FinCH) trial is used in this paper as an example of a large randomised controlled trial of a complex intervention to explore the potential risks of contamination bias. We outline the FinCH trial design, present the potential risks from contamination bias, and the strategies used in the design of the trial to minimise or mitigate against this. The FinCH trial was a multi-centre randomised controlled trial, with embedded process evaluation, which evaluated whether systematic training in the use of the Guide to Action Tool for Care Homes reduced falls in care home residents.

Data were collected from a number of sources to explore contamination in the FinCH trial. Where specific procedures were adopted to reduce risk of, or mitigate against, contamination, this was recorded. Data were collected from study e-mails, meetings with clinicians, research assistant and clinician network communications, and an embedded process evaluation in six intervention care homes.

During the FinCH trial, there were six new falls prevention initiatives implemented outside the study which could have contaminated our intervention and findings. Methods used to minimise contamination were: cluster randomisation at the level of care home; engagement with the clinical community to highlight the risks of early adoption; establishing local collaborators in each site familiar with the local context; signing agreements with NHS falls specialists that they would maintain confidentiality regarding details of the intervention; opening additional research sites; and by raising awareness about the importance of contamination in research among participants.

Conclusion

Complex rehabilitation trials are at risk of contamination bias. The potential for contamination bias in studies can be minimized by strengthening collaboration and dialogue with the clinical community. Researchers should recognise that clinicians may contaminate a study through lack of research expertise.

Modified Immunodiffusion Method for Detection of Salmonella in Raw Flesh and Highly Contaminated Foods: Collaborative Study

A total of 19 government and private industry laboratories in Canada and the United States participated in the collaborative study. Naturally contaminated ground poultry and animal meals, as well as inoculated raw shrimp, were examined for presence of Salmonella by both the modified immunodiffusion method and the Bacteriological Analytical Manual culture method, resulting in an agreement rate of 93.1%. The 2 methods are statistically equivalent for all food types at each inoculation level and for all lots of naturally contaminated foods evaluated in this study. The modification of the AOAC Official Method 989.13, immunodiffusion (1–2 TEST) method for detection of motile Salmonella in all foods, has been adopted revised first action by AOAC INTERNATIONAL.

Health Outcomes of Youth in Clinical Pediatric Weight Management Programs in POWER

OBJECTIVE

To describe treatment outcomes of children and adolescents enrolled in the Pediatric Obesity Weight Evaluation Registry, a consortium of multicomponent pediatric weight management programs in the US.

STUDY DESIGN

This multicenter prospective observational cohort study, established in 2013, includes youth (2-18 years of age) with obesity enrolled from 31 Pediatric Obesity Weight Evaluation Registry (POWER) sites over a 2-year period and followed up to 12 months. Weight status was evaluated by the percentage of the 95th percentile for body mass index (%BMIp95). Associations of weight status outcomes with patient characteristics and program exposure were analyzed with multivariable mixed effects modeling.

RESULTS

We included 6454 children and adolescents (median age, 11 years; IQR, 9-14 years; 53% white, 32% Hispanic; 73% with severe obesity) who were enrolled in POWER. Median changes in %BMIp95 for this cohort were -1.88 (IQR, -5.8 to 1.4), -2.50 (IQR, -7.4 to 1.8), -2.86 (IQR, -8.7 to 1.9), at 4-6, 7-9, and 10-12 of months follow-up, respectively (all P < .05). Older age (≥12 years), greater severity of obesity, and Hispanic race/ethnicity were associated with better improvement in %BMIp95. A 5-percentage point decrease in %BMIp95 was associated with improvement in cardiometabolic risk factors.

CONCLUSIONS

Overall, treatment in pediatric weight management programs is associated with a modest median decrease in BMI as measured by change in %BMIp95. Further studies are needed to confirm these findings, as well as to identify additional strategies to enhance the effectiveness of these multicomponent interventions for youth with severe obesity.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02121132.

Factors predicting incidence of post-operative delirium in older people following hip fracture surgery: a systematic review and meta-analysis

OBJECTIVE

Delirium is one of the most common complications following hip fracture surgery in older people. This study identified pre- and peri-operative factors associated with the development of post-operative delirium following hip fracture surgery.

METHODS

Published and unpublished literature were searched to identify all evidence reporting variables on patient characteristics, on-admission, intra-operative and post-operative management assessing incident delirium in older people following hip fracture surgery. Pooled odds ratio (OR) and mean difference of those who experienced delirium compared to those who did not were calculated for each variable. Evidence was assessed using the Downs and Black appraisal tool and interpreted using the GRADE approach.

RESULTS

A total of 6704 people (2090 people with post-operative delirium) from 32 studies were analysed. There was moderate evidence of nearly a two-times greater probability of post-operative delirium for those aged 80 years and over (OR: 1.77; 95% CI: 1.09, 2.87), whether patients lived in a care institution pre-admission (OR: 2.65; 95% CI: 1.79, 3.92), and a six-times greater probability of developing post-operative delirium with a pre-admission diagnosis of dementia (OR: 6.07, 95% CI: 4.84, 7.62). There was no association with intra-operative variables and probability of delirium.

CONCLUSION

Clinicians treating people with a hip fracture should be vigilant towards post-operative delirium if their patients are older, have pre-existing cognitive impairment and poorer overall general health. This is also the case for those who experience post-operative complications such as pneumonia or a urinary tract infection. Copyright © 2017 John Wiley & Sons, Ltd.

Higher infliximab trough levels are associated with perianal fistula healing in patients with Crohn's disease

BACKGROUND

Infliximab has been found to be efficacious in the treatment of fistulas in the setting of Crohn's disease, even though some patients do not benefit from therapy.

AIM

To assess the correlation between perianal fistula healing and trough levels of infliximab.

METHODS

In this cross-sectional study, we identified patients with Crohn's disease who had perianal fistulas and were treated with infliximab for at least 24 weeks. We excluded patients who underwent a faecal diversion procedure or proctectomy. Predictive variables included demographics, disease phenotype, disease activity, infliximab levels, anti-infliximab antibodies. The primary outcome was fistula healing defined as the absence of drainage. The secondary outcome was complete fistula closure and mucosal healing.

RESULTS

117 patients were included. Patients with fistula healing had significantly higher median serum infliximab levels when compared to those with active fistulas [15.8 vs. 4.4 μg/mL, respectively (P < 0.0001)]. There was an incremental gain in fistula healing with higher infliximab levels. The AUC for the association between fistula healing and infliximab levels was 0.82 (P < 0.0001), while the AUC for the association of infliximab levels and fistula closure was 0.69 (P = 0.014). Patients with anti-infliximab antibodies had a lower chance of achieving fistula healing (OR: 0.04 [95%CI: 0.005-0.3], P < 0.001).

CONCLUSIONS

There is a significant association between serum infliximab levels and rates of fistula healing. Achieving infliximab levels ≥10.1 mcg/mL in patients with Crohn's disease and perianal fistulas may improve outcomes as part of a treat-to-target strategy.

Focusing the Neuroscience and Societal Implications of Cognitive Enhancers

Cognitive enhancement can benefit the individual and society, but also has associated risks and ethical concerns. Cognitive-enhancing drugs are used in the treatment of neuropsychiatric disorders. Nonpharmacological strategies are also emerging, which have the potential to improve motivational deficits associated with neuropsychiatric symptoms and should be prioritized for development. The increasing lifestyle use of "smart" and other drugs indicates the desire for healthy people to improve themselves. Safety and ethical implications are discussed.

Does anticholinergics drug burden relate to global neuro-disability outcome measures and length of hospital stay?

PRIMARY OBJECTIVE

To assess the relationship between disability, length of stay (LOS) and anticholinergic burden (ACB) with people following acquired brain or spinal cord injury.

RESEARCH DESIGN

A retrospective case note review assessed total rehabilitation unit admission.

METHODS AND PROCEDURES

Assessment of 52 consecutive patients with acquired brain/spinal injury and neuropathy in an in-patient neuro-rehabilitation unit of a UK university hospital. Data analysed included: Northwick Park Dependency Score (NPDS), Rehabilitation complexity Scale (RCS), Functional Independence Measure and Functional Assessment Measure FIM-FAM (UK version 2.2), LOS and ACB. Outcome was different in RCS, NPDS and FIM-FAM between admission and discharge.

MAIN OUTCOMES AND RESULTS

A positive change was reported in ACB results in a positive change in NPDS, with no significant effect on FIM-FAM, either Motor or Cognitive, or on the RCS. Change in ACB correlated to the length of hospital stay (regression correlation = -6.64; SE = 3.89). There was a significant harmful impact of increase in ACB score during hospital stay, from low to high ACB on NPDS (OR = 9.65; 95% CI = 1.36-68.64) and FIM-FAM Total scores (OR = 0.03; 95% CI = 0.002-0.35).

CONCLUSIONS

There was a statistically significant correlation of ACB and neuro-disability measures and LOS amongst this patient cohort.

NFκB1 is a suppressor of neutrophil-driven hepatocellular carcinoma

Hepatocellular carcinoma (HCC) develops on the background of chronic hepatitis. Leukocytes found within the HCC microenvironment are implicated as regulators of tumour growth. We show that diethylnitrosamine (DEN)-induced murine HCC is attenuated by antibody-mediated depletion of hepatic neutrophils, the latter stimulating hepatocellular ROS and telomere DNA damage. We additionally report a previously unappreciated tumour suppressor function for hepatocellular nfkb1 operating via p50:p50 dimers and the co-repressor HDAC1. These anti-inflammatory proteins combine to transcriptionally repress hepatic expression of a S100A8/9, CXCL1 and CXCL2 neutrophil chemokine network. Loss of nfkb1 promotes ageing-associated chronic liver disease (CLD), characterized by steatosis, neutrophillia, fibrosis, hepatocyte telomere damage and HCC. Nfkb1^S340A/S340Amice carrying a mutation designed to selectively disrupt p50:p50:HDAC1 complexes are more susceptible to HCC; by contrast, mice lacking S100A9 express reduced neutrophil chemokines and are protected from HCC. Inhibiting neutrophil accumulation in CLD or targeting their tumour-promoting activities may offer therapeutic opportunities in HCC.

The role of neutrophils in cancer development is not widely appreciated. Here, the authors show that NF-κB-deficient hepatocytes overproduce chemokines, leading to hepatocellular carcinoma due to excessive neutrophil recruitment, and that neutrophil depletion prevents liver cancer in these mice.

Feasibility of conducting a randomised controlled trial of a cookstove intervention in rural Malawi

BACKGROUND:

Exposure to household air pollution (HAP) causes 4 million deaths annually, and strategies to reduce HAP exposure are urgently required.

OBJECTIVE:

To evaluate the acceptability and feasibility of conducting a trial of a cookstove intervention in rural Malawi.

DESIGN:

Non-smoking women were randomised to continuing to use an open fire (control) or to using a wood-burning clay cookstove (intervention). Symptom burden, oxygen saturation and exhaled carbon monoxide (eCO) were assessed at baseline and 7-day follow-up. A subset of women underwent HAP exposure monitoring.

Of 51 women recruited, 50 (98%) completed the main study. The methodology was acceptable to participants. Headache, back pain and cough were the most commonly reported symptoms at baseline and follow-up. Median eCO was within normal limits, but with a difference of 0.5 parts per million (ppm) in median change of eCO from baseline to follow-up seen between the two groups (P ∙ 0.035). The peak ambient CO concentration detected was 150 ppm.

This study suggests that a large cookstove intervention trial in Malawi would be feasible with careful community sensitisation. Monitoring exposure to HAP is challenging, and further studies evaluating potential biomarkers of exposure, including eCO, should be undertaken.

Screening for dementia--is it a no brainer?

As people are living longer, dementia is becoming a significant issue for society. Dementia is now recognised as a major concern in society, and the numbers of people estimated to have dementia in the UK population appear to have stabilised at around 700,000 . Globally, 35.6 million people are estimated to meet criteria for dementia, a number predicted to double every 20 years . Given the absence of treatments that significantly alter the natural history of the clinical syndrome of dementia, there has been increased emphasis on early diagnosis, with research exploring assessment tools and biomarkers that might predict with certainty a particular clinical outcome. At the same time, there has been pressure to focus on biomedical profiles, which assume a very close link between the pathobiology and the manifest clinical syndrome.