Postpartum depression: Addressing misinformation and harmful attitudes

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Brain charts for the human lifespan

Over the past few decades, neuroimaging has become a ubiquitous tool in basic research and clinical studies of the human brain. However, no reference standards currently exist to quantify individual differences in neuroimaging metrics over time, in contrast to growth charts for anthropometric traits such as height and weight1. Here we assemble an interactive open resource to benchmark brain morphology derived from any current or future sample of MRI data ( http://www.brainchart.io/ ). With the goal of basing these reference charts on the largest and most inclusive dataset available, acknowledging limitations due to known biases of MRI studies relative to the diversity of the global population, we aggregated 123,984 MRI scans, across more than 100 primary studies, from 101,457 human participants between 115 days post-conception to 100 years of age. MRI metrics were quantified by centile scores, relative to non-linear trajectories2 of brain structural changes, and rates of change, over the lifespan. Brain charts identified previously unreported neurodevelopmental milestones3, showed high stability of individuals across longitudinal assessments, and demonstrated robustness to technical and methodological differences between primary studies. Centile scores showed increased heritability compared with non-centiled MRI phenotypes, and provided a standardized measure of atypical brain structure that revealed patterns of neuroanatomical variation across neurological and psychiatric disorders. In summary, brain charts are an essential step towards robust quantification of individual variation benchmarked to normative trajectories in multiple, commonly used neuroimaging phenotypes.

COVID-19 vaccine hesitancy and anti-vaxxers - supporting healthcare workers to navigate the unvaccinated: Reflections from clinical practice

An important step in preparation for the fourth COVID-19 wave is to provide healthcare workers (HCWs) with skills to facilitate behaviour change in vaccine-hesitant patients. Convincing members of the public who are vaccine hesitant rather than anti-vaxxers should be the focus of our efforts. Our experience is that vaccine-hesitant individuals and anti-vaxxers are generally distinct cohorts, with differing reasons for their vaccine reluctance. If we are to truly address hesitancy, we must take time to understand the reasons for an individual's hesitancy. Developing a conceptual framework and skills for HCWs during encounters with unvaccinated individuals will be important not only for shifting some to get vaccinated, but also to manage the complex emotions that HCWs will undoubtedly be forced to confront during the fourth wave.

Population-based cohort study of surgical myotomy and pneumatic dilatation as primary interventions for oesophageal achalasia

Background

The aim of this national population-based cohort study was to compare rates of reintervention after surgical myotomy versus sequential pneumatic dilatation for the primary management of oesophageal achalasia.

Methods

Patients with oesophageal achalasia diagnosed between 2002 and 2012, and without an intervention in the preceding 5 years were identified from the Hospital Episode Statistics database. Patients were divided into two groups based on the primary treatment, and propensity score matching was used to compensate for differences in baseline characteristics.

Results

Some 14 705 patients were diagnosed with oesophageal achalasia, of whom 7487 (50·9 per cent) received interventional treatment: 1742 (23·3 per cent) surgical myotomy, 4534 (60·6 per cent) pneumatic dilatation and 1211 (16·2 per cent) endoscopic botulinum toxin injection. As age increased, the proportion of patients receiving myotomy decreased and the proportion undergoing dilatation increased. Patients who underwent surgical myotomy were younger (mean age 44·8 years versus 58·5 years among those who had pneumatic dilatation; P < 0·001), a greater proportion had a Charlson co-morbidity index score of 0 (90·1 versus 87·7 per cent; P = 0·003) and they were more commonly men (55·6 versus 51·8 per cent; P = 0·020). Following propensity score matching, the safety of the two initial treatment approaches was equivalent, with no difference in incidence of oesophageal perforation (1·3 and 1·4 per cent after myotomy and dilatation respectively; P = 0·750). However, dilatation was associated with increased need for reintervention (59·6 versus 13·8 per cent; P < 0·001) and frequency of reinterventions (mean 0·34 versus 0·06 per year; P < 0·001).

Conclusion

Surgical myotomy was associated with a lower rate of reintervention and could be offered as primary treatment in patients with oesophageal achalasia who are fit for surgery. For those unfit for surgery, pneumatic dilatation may provide symptomatic relief with approximately 60 per cent of patients requiring reintervention.

Implementation of objective activity monitoring to supplement the interpretation of ambulatory esophageal PH investigations

Conventional catheter-based systems used for ambulatory esophageal pH monitoring have been reported to affect patient behavior. As physical activity has been associated with gastroesophageal reflux disease (GERD), there is a risk that abnormal behavior will degrade the value of this diagnostic investigation and consequent management strategies. The aim of this study was to quantify the effect of conventional pH monitoring on behavior and to investigate the temporal association between activity and reflux. A total of 20 patients listed for 24 hours pH monitoring underwent activity monitoring using a lightweight ear-worn accelerometer (e-AR sensor, Imperial College London) 2 days prior to, and during their investigation. PH was measured and recorded using a conventional nasogastric catheter and waist-worn receiver. Daily activity levels, including subject-specific activity intensity quartiles, were calculated and compared. Physical activity was added to the standard pH output to supplement interpretation. Average patient activity levels decreased by 26.5% during pH monitoring (range -4.5 to 51.0%, P = 0.036). High-intensity activity decreased by 24.4% (range -4.0 to 75.6%, P = 0.036), and restful activity increased on average by 34% although this failed to reach statistical significance (-24.0 to 289.2%, P = 0.161). Some patients exhibited consistent associations between bouts of activity and acidic episodes. The results of this study support the previously reported reduction in activity during ambulatory esophageal pH monitoring, with the added reliability of objective data. In the absence of more pervasive pH monitoring systems (e.g. wireless), quantifying activity changes in the setting of activity-induced reflux might guide the physicians' interpretation of patient DeMeester scores resulting in more appropriate management of GERD.

Population-based cohort study of the management and survival of patients with early-stage oesophageal adenocarcinoma in England

BACKGROUND

Until recently, oesophagectomy was the treatment of choice for early oesophageal cancer. Endoscopic treatment has been introduced relatively recently. This observational national database study aimed to describe how endoscopic therapy has been introduced in England and to examine the safety of this approach.

METHODS

A population-based cohort study was undertaken of patients diagnosed with oesophageal adenocarcinoma between October 2007 and June 2009 using three linked national databases. Patients with early-stage disease (T1 tumours with no evidence of spread) were identified, along with the primary treatment modality where treatment intent was curative. Short-term outcomes after treatment and 5-year survival were evaluated.

RESULTS

Of 5192 patients diagnosed with oesophageal adenocarcinoma, 306 (5·9 per cent) were considered to have early-stage disease before any treatment, of whom 239 (79·9 per cent of 299 patients with data on treatment intent) were managed with curative intent. Of 175 patients who had an oesophagectomy, 114 (65·1 (95 per cent c.i. 57·6 to 72·7) per cent) survived for 5 years. Among these, 47 (30·3 per cent of 155 patients with tissue results available) had their disease upstaged after pathological staging; this occurred more often in patients who did not have staging endoscopic ultrasonography before surgery. Of 41 patients who had an endoscopic resection, 27 (66 (95 per cent c.i. 49 to 80) per cent) survived for 5 years. Repeat endoscopic therapy was required by 23 (56 per cent) of these 41 patients.

CONCLUSION

Between 2007 and 2009, oesophagectomy remained the initial treatment of choice (73·2 per cent) among patients with early-stage oesophageal cancer treated with curative intent; one in five patients were managed endoscopically, and this treatment was more common in elderly patients. Although the groups had different patient characteristics, 5-year survival rates were similar.

Improvement over time in outcomes for patients undergoing endoscopic therapy for Barrett's oesophagus-related neoplasia: 6-year experience from the first 500 patients treated in the UK patient registry

BACKGROUND

Barrett's oesophagus (BE) is a pre-malignant condition leading to oesophageal adenocarcinoma (OAC). Treatment of neoplasia at an early stage is desirable. Combined endoscopic mucosal resection (EMR) followed by radiofrequency ablation (RFA) is an alternative to surgery for patients with BE-related neoplasia.

METHODS

We examined prospective data from the UK registry of patients undergoing RFA/EMR for BE-related neoplasia from 2008 to 2013. Before RFA, visible lesions were removed by EMR. Thereafter, patients had RFA 3-monthly until all BE was ablated or cancer developed (endpoints). End of treatment biopsies were recommended at around 12 months from first RFA treatment or when endpoints were reached. Outcomes for clearance of dysplasia (CR-D) and BE (CR-IM) at end of treatment were assessed over two time periods (2008-2010 and 2011-2013). Durability of successful treatment and progression to OAC were also evaluated.

RESULTS

508 patients have completed treatment. CR-D and CR-IM improved significantly between the former and later time periods, from 77% and 56% to 92% and 83%, respectively (p<0.0001). EMR for visible lesions prior to RFA increased from 48% to 60% (p=0.013). Rescue EMR after RFA decreased from 13% to 2% (p<0.0001). Progression to OAC at 12 months is not significantly different (3.6% vs 2.1%, p=0.51).

CONCLUSIONS

Clinical outcomes for BE neoplasia have improved significantly over the past 6 years with improved lesion recognition and aggressive resection of visible lesions before RFA. Despite advances in technique, the rate of cancer progression remains 2-4% at 1 year in these high-risk patients.

TRIAL REGISTRATION NUMBER

ISRCTN93069556.

Biological Psychiatry Congress 2015

<p><strong>List of Abstract Titles and authors:<br /></strong></p><p><strong>1. Psychosis: A matter of mental effort?</strong></p><p>M Borg, Y Y van der Zee, J H Hsieh, H Temmingh, D J Stein, F M Howells</p><p><strong>2.In search of an affordable, effective post-discharge intervention: A randomised control trial assessing the influence of a telephone-based intervention on readmissions for patients with severe mental illness in a developing country</strong></p><p><strong></strong>U A Botha, L Koen, M Mazinu, E Jordaan, D J H Niehaus</p><p><strong>3. The effect of early abstinence from long-term methamphetamine use on brain metabolism using 1H-magnetic resonance spectro-scopy (1H-MRS)</strong></p><p>A Burger, S Brooks, D J Stein, F M Howells</p><p><strong>4. The effect of <em>in utero exposure </em>to methamphetamine on brain metabolism in childhood using 1H-magnetic resonance spectroscopy (1H-MRS)</strong></p><p>A Burger, A Roos, M Kwiatkowski, D J Stein, K A Donald, F M Howells</p><p><strong>5. A prospective study of clinical, biological and functional aspects of outcome in first-episode psychosis: The EONKCS Study</strong></p><p><strong></strong>B Chiliza, L Asmal, R Emsley</p><p><strong>6. Stimulants as cognitive enhancers - perceptions v. evidence in a very real world</strong></p><p><strong></strong>H M Clark</p><p><strong>7. Pharmacogenomics in antipsychotic drugs</strong></p><p><strong></strong>Ilse du Plessis</p><p><strong>8. Serotonin in anxiety disorders and beyond</strong></p><p><strong></strong>Ilse du Plessis</p><p><strong>9. HIV infection results in ventral-striatal reward system hypo-activation during cue processing</strong></p><p><strong></strong>S du Plessis, M Vink, J A Joska, E Koutsilieri, A Bagadia, D J Stein, R Emsley</p><p><strong>10. Disease progression in schizophrenia: Is the illness or the treatment to blame?</strong></p><p>R Emsley, M J Sian</p><p><strong>11. Serotonin transporter variants play a role in anxiety sensitivity in South African adolescents</strong></p><p> S M J Hemmings, L I Martin, L van der Merwe, R Benecke, K Domschke, S Seedat</p><p><strong>12. Iron deficiency in two children diagnosed with multiple sclerosis: Report on whole exom sequencing</strong></p><p><strong></strong>S Janse van Rensburg, R van Toorn, J F Schoeman, A Peeters, L R Fisher, K Moremi, M J Kotze</p><p><strong>13. Benzodiazepines: Practical pharmacokinetics</strong></p><p><strong></strong>P Joubert</p><p><strong>14. What to consider when prescribing psychotropic medications</strong></p><p><strong></strong>G Lippi</p><p><strong>15. Current prescribing practices for obsessive-compulsive disorder in South Africa: Controversies and consensus</strong></p><p><strong></strong>C Lochner, L Taljaard, D J Stein</p><p><strong>16. Correlates of emotional and behavioural problems in children with preinatally acquired HIV in Cape Town, South Africa</strong></p><p><strong></strong>K-A Louw, N Phillips, JIpser, J Hoare</p><p><strong>17. The role of non-coding RNAs in fear extinction</strong></p><p><strong></strong>S Malan-Muller, L Fairbairn, W M U Daniels, M J S Dashti, E J Oakleley, M Altorfer, J Harvey, S Seedat, J Gamieldien, S M J Hemmings</p><p><strong>18. An analysis of the management og HIV-mental illness comorbidity at the psychiatric unit of the Dr George Mukhari Academic Hospital</strong></p><p><strong></strong>M L Maodi, S T Rataemane, T Kyaw</p><p><strong>19. The identification of novel genes in anxiety disorders: A gene X environment correlation and interaction study</strong></p><p><strong></strong>N W McGregor, J Dimatelis, S M J Hemmings, C J Kinnear, D J Stein, V Russel, C Lochner</p><p><strong>20. Collaborations between conventional medicine and traditional healers: Obstacles and possibilities</strong></p><p><strong></strong>G Nortje, S Seedat, O Gureje</p><p><strong>21. Thought disorder and form perception: Relationships with symptoms and cognitive function in first-episode schizophrenia</strong></p><p>M R Olivier, R Emsley</p><p><strong>22. Investigating the functional significance of genome-wide variants associated with antipsychotic treatment response</strong></p><p><strong></strong>E Ovenden, B Drogemoller, L van der Merwe, R Emsley, L Warnich</p><p><strong>23. The moral and bioethical determinants of "futility" in psychiatry</strong></p><p><strong></strong>W P Pienaar</p><p><strong>24. Single voxel proton magnetic resonance spectroscopy (1H-MRS) and volumetry of the amylgdala in social anxiety disorder in the context of early developmental trauma</strong></p><p>D Rosenstein, A T Hess, J Zwart, F Ahmed-Leitao, E Meintjies, S Seedat</p><p><strong>25. Schizoaffective disorder in an acute psychiatric unit: Profile of users and agreement with Operational Criteria (OPCRIT)</strong></p><p><strong></strong>R R Singh, U Subramaney</p><p><strong>26. The right to privacy and confidentiality: The ethics of expert diagnosis in the public media and the Oscar Pistorius trial</strong></p><p><strong></strong>C Smith</p><p><strong>27. A birth cohort study in South Africa: A psychiatric perspective</strong></p><p>D J Stein</p><p><strong>28. 'Womb Raiders': Women referred for observation in terms of the Criminal Procedures Act (CPA) charged with fetal abduction and murder</strong></p><p><strong></strong>U Subramaney</p><p><strong>29. Psycho-pharmacology of sleep wake disorders: An update</strong></p><p>R Sykes</p><p><strong>30. Refugee post-settlement in South Africa: Role of adjustment challenges and family in mental health outcomes</strong></p><p><strong></strong>L Thela, A Tomita, V Maharaj, M Mhlongo, K Jonathan</p><p><strong>31. Dstinguishing ADHD symptoms in psychotic disorders: A new insight in the adult ADHD questionnaire</strong></p><p>Y van der Zee, M Borg, J H Hsieh, H Temmingh, D J Stein, F M Howells</p><p><strong>32. Oscar Pistorius ethical dilemmas in a trial by media: Does this include psychiatric evaluation by media?</strong></p><p>M Vorster</p><p><strong>33. Genetic investigation of apetite aggression in South African former young offenders: The involvement of serotonin transporter gene</strong></p><p>K Xulu, J Somer, M Hinsberger, R Weierstall, T Elbert, S Seedat, S Hemmings</p><p><strong>34. Effects of HIV and childhood trauma on brain morphemtry and neurocognitive function</strong></p><p>G Spies, F Ahmed-Leitao, C Fennema-Notestine, M Cherner, S Seedat</p><p><strong>35. Measuring intentional behaviour normative data of a newly developed motor task battery</strong></p><p><strong></strong>S Bakelaar, J Blampain, S Seedat, J van Hoof, Y Delevoye-Turrel</p><p><strong>36. Resilience in social anxiety disorder and post-traumatic stress disorder in the context of childhood trauma</strong></p><p>M Bship, S Bakelaar, D Rosenstein, S Seedat</p><p><strong>37. The ethical dilemma of seclusion practices in psychiatry</strong></p><p>G Chiba, U Subramaney</p><p><strong>38. Physical activity and neurological soft signs in patients with schizophrenia</strong></p><p>O Esan, C Osunbote, I Oladele, S Fakunle, C Ehindero</p><p><strong>39. A retrospective study of completed suicides in the Nelson Mandela Bay Metropolitan Area from 2008 to 2013 - preliminary results</strong></p><p><strong></strong>C Grobler, J Strumpher, R Jacobs</p><p><strong>40. Serotonin transporter variants play a role in anxiety sensitivity in South African adolescents</strong></p><p><strong></strong>S M J Hemmings, L I Martin, L van der Merwe, R Benecke, K Domschke, S Seedat</p><p><strong>41. Investigation of variants within antipsychotic candidate pharmacogenes associated with treatment outcome</strong></p><p>F Higgins, B Drogmoller, G Wright, L van der Merwe, N McGregor, B Chiliza, L Asmal, L Koen, D Niehaus, R Emsley, L Warnich</p><p><strong>42. Effects of diet, smoking and alcohol consumption on disability (EDSS) in people diagnosed with multiple sclerosis</strong></p><p>S Janse van Rensburg, W Davis, D Geiger, F J Cronje, L Whati, M Kidd, M J Kotze</p><p><strong>43. The clinical utility of neuroimaging in an acute adolescnet psychiatric inpatient population</strong></p><p><strong></strong>Z Khan, A Lachman, J Harvey</p><p><strong>44. Relationships between childhood trauma (CT) and premorbid adjustment (PA) in a highly traumatised sample of patients with first-episode schizophrenia (FES</strong>)</p><p>S Kilian, J Burns, S Seedat, L Asmal, B Chiliza, S du Plessis, R Olivier, R Emsley</p><p><strong>45. Functional and cognitive outcomes using an mTOR inhibitor in an adolescent with TSC</strong></p><p>A Lachman, C van der Merwe, P Boyes, P de Vries</p><p><strong>46. Perceptions about adolescent body image and eating behaviour</strong></p><p><strong></strong>K Laxton, A B R Janse van Rensburg</p><p><strong>47. Clinical relevance of FTO rs9939609 as a determinant of cardio-metabolic risk in South African patients with major depressive disorder</strong></p><p>H K Luckhoff, M J Kotze</p><p><strong>48. Childhood abuse and neglect as predictors of deficits in verbal auditory memory in non-clinical adolescents with low anxiety proneness</strong></p><p>L Martin, K Martin, S Seedat</p><p><strong>49. The changes of pro-inflammatory cytokines in a prenatally stressed febrile seizure animal model and whether <em>Rhus chirindensis</em> may attenuate these changes</strong></p><p><strong></strong>A Mohamed, M V Mabandla, L Qulu</p><p><strong>50. Influence of TMPRSS6 A736v and HFE C282y on serum iron parameters and age of onset in patients with multiple sclerosis</strong></p><p><strong></strong>K E Moremi, M J Kotze, H K Luckhoff, L R Fisher, M Kidd, R van Toorn, S Janse van Rensburg</p><p><strong>51. Polypharmacy in pregnant women with serious mental illness</strong></p><p>E Thomas, E du Toit, L Koen, D Niehaus</p><p><strong>52. Infant attachment and maternal depression as predictors of neurodevelopmental and behavioural outcomes at follow-up</strong></p><p>J Nothling, B Laughton, S Seedat</p><p><strong>53. Differences in abuse, neglect and exposure to community violence in adolescents with and without PTSD</strong></p><p><strong></strong>J Nothling, S Suliman, L Martin, C Simmons, S Seedat</p><p><strong>54. Assessment of oxidative stress markers in children with autistic spectrum disorders in Lagos, Nigeria</strong></p><p><strong></strong>Y Oshodi, O Ojewunmi, T A Oshodi, T Ijarogbe, O F Aina, J Okpuzor, O C F E A Lesi</p><p><strong>55. Change in diagnosis and management of 'gender identity disorder' in pre-adolescent children</strong></p><p>S Pickstone-Taylor</p><p><strong>56. Brain network connectivity in women exposed to intimate partner violence</strong></p><p>A Roos, J-P Fouche, B Vythilingum, D J Stein</p><p><strong>57. Prolonged exposure treatment for PTSD in a Third-World, task-shifting, community-based environment</strong></p><p>J Rossouw, E Yadin, I Mbanga, T Jacobs, W Rossouw, D Alexander, S Seedat</p><p><strong>58. Contrasting effects of early0life stress on mitochondrial energy-related proteins in striatum and hippocampus of a rat model of attention-deficit/ hyperactivity disorder</strong></p><p><strong></strong>V Russell, J Dimatelis, J Womersley, T-L Sterley</p><p><strong>59. Attention-deficit hyperactivity disorder in adults: A South African perspective</strong></p><p>R Schoeman, M de Klerk, M Kidd</p><p><strong>60. Cognitive function in women with HIV infection and early-life stress</strong></p><p>G Spies, C Fennema-Notestine, M Cherner, S Seedat</p><p><strong>61. Changes in functional connectivity networks in bipolar disorder patients after mindfulness-based cognitic therapy</strong></p><p>J A Starke, C F Beckmann, N Horn</p><p><strong>62. Post-traumatic stress disorder, overweight and obesity: A systematic review and meta-analysis</strong></p><p><strong></strong>S Suliman, L Anthonissen, J Carr, S du Plessis, R Emsley, S M J Hemmings, C Lochner, N McGregor L van den Heuvel, S Seedat</p><p><strong>63. The brain and behaviour in a third-trimester equivalent animal model of fetal alcohol spectrum disorders</strong></p><p>P C Swart, C B Currin, J J Dimatelis, V A Russell</p><p><strong>64. Irritability Assessment Model (IAM) to monitor irritability in child and adolescent psychiatric disorders.</strong></p><p>D van der Westhuizen</p><p><strong>65. Outcome of parent-adolescent training in chilhood victimisation: Adaptive functioning, psychosocial and physiological variables</strong></p><p>D van der Westhuizen</p><p><strong>66. The effect of ketamine in the Wistar-Kyoto and Sprague Dawley rat models of depression</strong></p><p>P J van Zyl, J J Dimatelis, V A Russell</p><p><strong>67. Investigating COMT variants in anxiety sensitivity in South African adolescents</strong></p><p>L J Zass, L Martin, S Seedat, S M J Hemmings</p><p> </p><p> </p><p> </p><p> </p><p> </p><p> </p><p> </p><p> </p><p> </p><p> </p><p> </p><p> </p><p><strong><br /></strong></p><p> </p><p> </p><p> </p><p> </p><p> </p><p> </p><p> </p><p> </p><p> </p><p> </p><p> </p>

The neurobiology of HIV dementia: implications for practice in South Africa

In this review, the neuropathogenesis of HIV dementia (HIV-D) is discussed in the context of the local epidemic. HIV-D continues to be prevalent in the era of highly active anti-retroviral therapy. HIV neuro-invasion into the central nervous system may result in the development of separate HIV genotypes in an individual through compartmentalisation. The blood brain barrier continues to limit penetration of anti-retroviral drugs into the cerebrospinal fluid. Individuals with active neuro-inflammation appear to respond well to HAART. In some cases low grade neuro-degeneration persists with consequent clinical deterioration. In South Africa, the emergence of a sub-epidemic of HIV-D is being driven by various factors, including the incomplete coverage of HAART to all who need it, the late stage presentation of people living with HIV/AIDS (PLWHA) and a co-occurring methamphetamine epidemic. Differences in viral subtype do not appear to confer protection against HIV-D. Implications for PLWHA who are at risk for HIV-D in South Africa are explored, with a view to providing suggestions for improving practice and research into this area.

Images of the terminal ileum are more convincing than cecal images for verifying the extent of colonoscopy

BACKGROUND AND STUDY AIMS

Independent verification of colonoscopy completion is important for quality assurance. Cecal photographs aimed at showing key landmarks, including the ileocecal valve (ICV) and appendiceal orifice are the currently recommended standard, but are often perceived as unreliable. Images of the terminal ileum demonstrating villi may provide more robust evidence of completion. We sought to prospectively evaluate the ease of routine intubation of the terminal ileum and to compare the effectiveness of terminal ileum and cecal photographs in convincing independent reviewers that total colonoscopy had been accomplished.

PATIENTS AND METHODS

A prospective, observational study evaluated 216 consecutively completed colonoscopies performed in routine clinical practice. Cecal and terminal ileum photographs were evaluated and scored by independent reviewers. Frequency of terminal ileum intubation, time required, and safety parameters were recorded.

RESULTS

The terminal ileum was intubated and photographed in 188/216 (87%) of cases. Median time taken to intubate, or attempt to intubate the terminal ileum was 1 min 24 s, and was achieved without complications or requirement for additional sedation. Terminal ileum images were significantly more likely to be considered convincing than cecal images ( P<0.0001 for all reviewers). There was excellent interobserver agreement amongst the opinion of reviewers regarding terminal ileum photographs (kappa=0.91).

CONCLUSION

Terminal ileum intubation is achievable rapidly and safely in the majority of patients undergoing colonoscopy. Terminal ileum images provide more convincing evidence of complete examination of the colon than cecal images, even when attempts to capture images specifically of the ICV and appendiceal orifice are made.

What is the most reliable imaging modality for small colonic polyp characterization? Study of white-light, autofluorescence, and narrow-band imaging

BACKGROUND AND STUDY AIMS

In vivo optical diagnosis of small colorectal polyps has potential clinical and cost advantages, but requires accuracy and high interobserver agreement for clinically acceptability. We aimed to assess interobserver variability and diagnostic performance of endoscopic imaging modalities in characterizing small colonic polyps.

METHODS

High quality still images of 80 polyps < 1 cm were recorded using white-light endoscopy (WLE), autofluorescence imaging (AFI) and narrow-band imaging with and without magnification (NBI and NBImag). All images were assessed for quality, prediction of polyp histology, and vascular pattern intensity (with NBI) by nine experienced colonoscopists (four experts in advanced imaging) from five UK centers. Interobserver agreement (kappa statistic), sensitivity, specificity, and accuracy were calculated compared with histopathological findings.

RESULTS

Interobserver agreement for predicting polyp histology using NBImag was significantly better for experts (κ = 0.63, substantial) compared with nonexperts (κ = 0.30, fair; P < 0.001), and was moderate for all colonoscopists with WLE, AFI and NBI. Interobserver agreement for vascular pattern intensity using NBI was 0.69 (substantial) for experts and 0.57 (good) for nonexperts. NBImag had higher sensitivity than WLE (experts, 0.93 vs. 0.68, P < 0.001; nonexperts, 0.90 vs. 0.52, P < 0.001) and higher overall accuracy (experts, 0.76 vs. 0.64, P = 0.003; nonexperts 0.61 vs. 0.40, P < 0.001). AFI had worse accuracy than WLE for both expert colonoscopists (0.53 vs. 0.64, P = 0.02) and nonexperts (0.32 vs. 0.40, P = 0.04).

CONCLUSIONS

Of the imaging modalities tested, NBImag appeared to have the best overall accuracy and interobserver agreement, although not adequate for in vivo diagnosis. NBI and AFI did not have better sensitivity, specificity, or accuracy compared with WLE.

Homeopathic prescribing for chronic conditions in equine veterinary practice in the UK

Twelve Faculty of Homeopathy veterinarians recorded data systematically at 777 consecutive homeopathic appointments for horses over a period of 12 months. A spreadsheet enabled the recording of information, which included the date of appointment; horse and owner identity (anonymised); sex of horse; main medical problem treated; whether the condition was chronic or acute; whether the appointment was new or a follow-up; owner-assessed clinical outcome on a seven-point scale, ranging from -3 to +3, compared with the first appointment; homeopathic medicine(s) prescribed; and whether any conventional or other complementary/alternative medicine (CAM) was being used concurrently to treat the condition. Data from 289 horses comprised a total of 305 individual conditions identified as chronic in nature, of which 234 had a follow-up assessment. At the final appointment for chronic cases during the study period, 4.3 per cent were receiving conventional medication and 17.1 per cent were being given another CAM treatment in addition to homeopathy. The eight chronic conditions most frequently treated with homeopathy were: arthritis, headshaking, laminitis, chronic obstructive pulmonary disease, sweet itch, dermatitis, sarcoidosis and Cushing's syndrome.

Outcomes from homeopathic prescribing in veterinary practice: a prospective, research-targeted, pilot study

BACKGROUND AND AIMS

Targeted research development in veterinary homeopathy is properly informed by the systematic collection and analysis of relevant clinical data obtained by its practitioners. We organised a pilot data collection study, in which 8 Faculty of Homeopathy veterinarians collected practice-based clinical and outcomes data over a 6-month period.

METHODS

A specifically designed Excel spreadsheet enabled recording of consecutive clinical appointments under the following headings: date; identity of patient and owner (anonymised); age, sex and species of patient; medical condition/complaint treated; whether confirmed diagnosis, chronic or acute, new or follow-up case; owner-assessed outcome (7-point Likert scale: -3 to +3) compared with first appointment; homeopathic medicine/s prescribed; other medication/s for the condition/complaint. Spreadsheets were submitted monthly by e-mail to the project organisers for data checking, synthesis and analysis.

RESULTS

Practitioners submitted data regularly and punctually, and most data cells were completed. 767 individual patients were treated (547 dogs, 155 cats, 50 horses, 5 rabbits, 4 guinea-pigs, 2 birds, 2 goats, 1 cow, and 1 tortoise). Outcome from two or more homeopathic appointments per patient condition was obtained in 539 cases (79.8% showing improvement, 6.1% deterioration, 11.7% no change; outcome not recorded in 2.4% of follow-ups). Strongly positive outcomes (scores of +2 or +3) were achieved in: arthritis and epilepsy in dogs and, in smaller numbers, in atopic dermatitis, gingivitis and hyperthyroidism in cats.

CONCLUSIONS

Systematic recording of data by veterinarians in clinical practice is feasible and capable of informing future research in veterinary homeopathy. A refined version of the spreadsheet can be used in larger-scale research-targeted veterinary data collection.

Decline in admission rates for acute appendicitis in England

BACKGROUND

The incidence of acute appendicitis declined in western countries between the 1930s and the early 1990s. The aim of this study was to determine time trends in hospital admissions for acute appendicitis in England between 1989-1990 and 1999-2000, and in population mortality rates for appendicitis from 1979 to 1999.

METHODS

: Hospital Episode Statistics for admissions were obtained from the Department of Health and mortality data from the Office for National Statistics.

RESULTS

Between 1989-1990 and 1999-2000, age-standardized hospital admission rates for acute appendicitis decreased by 12.5 per cent in male patients and by 18.8 per cent in female patients. The proportions of admissions that resulted in operation remained stable. Admission rates for non-specific mesenteric lymphadenitis fell. Admission rates for abdominal pain increased between 1989-1990 and 1995-1996, at which time the International Classification of Diseases codes changed. Between 1995-1996 and 1999-2000, admission rates for abdominal pain declined. Analysis of age-specific admission rates for acute appendicitis and abdominal pain from 1989-1990 to 1995-1996 showed that the decline in acute appendicitis could not be accounted for by a change in diagnostic practice. Mortality rates for acute appendicitis remained stable over the study period.

CONCLUSION

Admission rates for acute appendicitis declined over the study period. This decline cannot be explained by reclassification.

Diverticular disease of the colon--on the rise: a study of hospital admissions in England between 1989/1990 and 1999/2000

BACKGROUND

Diverticular disease emerged as a common problem in Western countries over the course of the 20th century.

AIMS

To determine the time trends in diverticular disease for hospital admissions in England between 1989/1990 and 1999/2000 and population mortality rates from 1979 to 1999.

METHODS

Hospital Episode Statistics were obtained from the Department of Health and mortality data from the Office for National Statistics.

RESULTS

Between 1989/1990 and 1999/2000, annual age-standardized hospital admission rates for diverticular disease increased by 16% for males (from 20.1 to 23.2 per 100,000) and 12% for females (from 28.6 to 31.9 per 100,000). Female rates were significantly higher than male rates throughout the study period. The proportions of admissions with an operation increased by 16% for males (from 22.9% to 24.1%) and 14% for females (from 19.7% to 22.3%). Older patients were less likely to undergo operation than younger patients. In-patient case fatality rates and population mortality rates remained unchanged.

CONCLUSIONS

Admission rates for diverticular disease increased over the study period. The proportion of patients who underwent operation increased, but in-patient and population mortality rates remained unchanged. With an ageing population, diverticular disease will become an increasingly important clinical problem in England.

Gallstones--an increasing problem: a study of hospital admissions in England between 1989/1990 and 1999/2000

BACKGROUND

The number of operations for cholelithiasis increased from the 1950s to the 1990s.

AIMS

To determine the time trends in cholelithiasis for hospital admissions, operations and in-hospital case fatalities in England between 1989/1990 and 1999/2000, and population mortality rates between 1979 and 1999.

METHODS

Hospital Episode Statistics for admissions were obtained from the Department of Health and mortality data were obtained from the Office for National Statistics.

RESULTS

Between 1989/1990 and 1999/2000, age-standardized hospital admission rates for cholelithiasis increased by 30% for males and 64% for females. The proportions of admissions undergoing an operation declined progressively over the study period. In 1999/2000, the frequency of operation was approximately 50-60% for most age groups, but decreased progressively with advancing age at > or = 65 years. The proportions of admissions undergoing therapeutic endoscopy increased several-fold, especially amongst older individuals. Case fatality rates declined. Mortality rates declined from 1979 to 1988, but showed no further change from 1989 to 1999.

CONCLUSIONS

There has been a steady increase in admission rates for cholelithiasis over the study period. Whilst the frequency of operation has declined, the proportion of patients undergoing therapeutic endoscopy has increased.

Subcellular localisation of the X protein in HBV infected hepatocytes

Hepatitis B virus X protein (HBx) is a multifunctional protein that exerts its effects primarily by acting as a transcriptional transactivator of viral and multiple host cell genes. HBx is thought to be essential for maintaining viral replication and has been implicated in the development of hepatocellular carcinoma in patients chronically infected with hepatitis B virus. Very little is known about its functional mechanisms and although interactions with several nuclear and cytoplasmic proteins have been demonstrated in vitro, there is no clear consensus as to where HBx localises in infected hepatocytes. In this study, the expression and intracellular distribution of HBx were examined in human liver biopsies using an anti-HBx rabbit polyclonal antiserum. HBx was detected in a high proportion (69%) of samples from patients with chronic HBV infection. Detection of HBx correlated with the absence of cirrhosis and the presence of serum e-antigen. HBx was detected predominantly in the cytoplasm; however, it was also found in the nuclei of up to 20% of positively stained hepatocytes, either exclusively nuclear or localised both in the nucleus and cytoplasm within the same cell. Furthermore, the intracellular distribution of HBx was analysed in transfected Huh-7 cells by confocal microscopy, using the monoclonal antibody 16F1. In these experiments, a substantial nuclear detection was confirmed in a significant proportion of HBx expressing cells. The data indicate a high functional significance of nuclear HBx, consistent with the concept that transactivation may involve interactions with nuclear proteins.

Long-lasting conditioning of the human soleus H reflex following quadriceps tendon tap

Percussion of the quadriceps tendon was used to test the hypothesis that knee extensor muscle spindle discharge initiates down-regulation of the gain of the soleus H reflex. Seven subjects participated. Soleus H reflex magnitude was observed for up to 15 s, following conditioning tendon taps of 60 N or 80 N force and 10 ms duration, with the knee at 60 degrees or 90 degrees of flexion. The tap elicited quadriceps stretch reflexes in four subjects, with a mean latency of 42 ms. The major component of the conditioning of the soleus H reflex was significant attenuation of magnitude by 30-90% of controls, starting as early as 36 ms post-percussion and lasting as long as 3-8 s. The attenuation of reflex magnitude was evident, whichever combination of duration and force of tap was used. Preceding and/or following this inhibition, there was mild facilitation. Static stretch of quadriceps also significantly reduced soleus H reflex magnitude. These results support the spindle receptor origin for the gain attenuation seen during movement. The time course of the gain attenuation suggests a spinal route, by which the spindle discharge of the heteronymous extensor muscles initiates presynaptic inhibition of transmission through the reflex pathway.

Neonatal onset of medium-chain acyl-coenzyme A dehydrogenase deficiency with confusing biochemical features

A female neonate was seen because of shock, ketosis, and undetectable blood glucose. Initial urinary findings indicated the possibility of a defect of fatty acid beta-oxidation; subsequent studies showed that she had medium-chain acyl-coenzyme. A dehydrogenase deficiency. This case highlights the fact that the initial symptoms may occur in the first few days of life, and that the presence of ketosis does not exclude the possibility of a fatty acid oxidation defect; the profiles of urinary organic acids and acylglycines may not be characteristic at that time.

The quiet revolution

The IHSM's day conference threw a wide spotlight on 'alternative settings for acute care'. The occasion provided a powerful and unifying commentary on a number of trends discernible in most of the specialties examined in the Medicine for Managers series.

Rheumatology

Arthritis disables more people than all other diseases and injuries put together. Given the high cost of some of the techniques used for rheumatoid arthritis, the long-term nature of the disease and the growth in demand, it is increasingly important to pose and answer questions of cost effectiveness and priority-important to clinician and manager alike.

Managing for health gain

The concept of health gain is growing in the NHS; The Health of the Nation is the first national strategy to set targets for health gain. The initiative holds implications for change for NHS managers in the way in which they perceive their task and the way in which they manage.

Plastic surgery

Plastic surgery is all too often thought of as an indulgence of the rich and famous with little attention paid to the repair of bodies and limbs disfigured or deformed by accident or illness. Surgeons look to management to address those issues that create an insecure base for planning the service and for its organisation nationwide.

Palliative care

Palliative care may not seem the highest of priorities; it is sometimes thought of as a 'luxury' to be paid for privately while the NHS picks up the 'public' cost of acute medicine. But anyone who has witnessed or experienced the work of palliative care teams would be dissuaded from these views.

Geriatric medicine

Old age never harmed anyone - but the problems that may arise in the elderly of multiple illnesses, social isolation and poverty conspire to present clinicians and managers with a challenge: an increasing challenge, as the number of people over the age of 85 by the year 2000 will be in the order of a million.

Psychiatry of old age

Some 25% of those over 80 suffer from dementia -- just one of the mental health problems that affect elderly people. Their care is compounded by physical difficulties and ill health and, often, by the lack of relatives to assist in their care.

General practice

Medicine is developing at an extraordinary rate in all clinical specialties, the pace largely driven by science and technology. General practice is developing professionally at a similar pace, but in addition is experiencing a huge change in the management of primary care, generated by the engine of policy and organisational change in the NHS.

Anaesthesia

Anaesthesia is, perhaps, the single greatest advance in medical history. Yet even today there are uncertainties about the patient's depth of sleep and the efficacy of some techniques. Cost and quality are issues that managers and anaesthetists must tackle together.

Cardiovascular disease

A figure between 550 pounds and 960 pounds is the estimated cost of buying one quality adjusted life year by screening for and preventing development of coronary heart disease risk factors. So what is it that is stopping the prevention of 180,000 deaths each year?

Child health

Current provision for children's health involves many different professions in many different locations. Managers must find local solutions to improve the organisation of services which will lead to better and more coordinated health care.

Minimally invasive therapy

Minimally invasive therapy is a new and important development in medicine. With minimal disruption to the patient's body or way of life, outcomes are at least as effective and procedures are safer than conventional surgery. But there are clear implications for management on costs, and organisational and strategic issues.

Day surgery

Costing half as much as inpatient treatment, with good results and advantages to patients, day surgery might be expected to be more widespread than it is. Purchasers may be those who push for more by specifying targets for day surgery for certain procedures. How can managers respond?

A strain-gauge study of the effect of external fixation on the canine tibia

Electrical resistance rosette strain gauges bonded directly to the surface of the midshaft of the normal canine tibia were utilized to study the effect of the AO external skeletal fixator on the magnitude and orientation of the peak strain values recorded during locomotion. The application of the fixator in a single lateral bar configuration resulted in a significant decrease in surface bone strain magnitude but in only minor changes in the orientation of those strains. However, in only one of three dogs tested did the addition of a second external connecting bar result in significant further decreases in bone strain.

A technique for electrically induced perturbation of rhythmic leg movement

The paper describes electrical circuitry which replaces a mechanical brake, for perturbation of the contractile load of the legs during pedalling. The turning flywheel of an ergometer is connected to an alternator, with the electrical load provided by a power resistor connected across the output terminals. A 12-V battery provides the field current. Through variable resistors the field current is altered under microprocessor control, providing different steady-state loads when pedalling and also sudden transient changes of load. The point of change in load in the movement cycle can be accurately selected. The ergometer is instrumented for accurate measurement of pedal crank position, crank angular velocity and reaction force at the foot, to provide a physical description of the evoked steady states and transients, using microprocessor controlled sampling. The results show that the technique has application to the study of the range of reflex responses within a movement cycle and also to the more complex restoration of a movement pattern over a number of cycles. It is applicable to investigation of normal and diseased states.

Practical preparation and deblocking conditions for N-alpha-(2-(p-biphenylyl)-2-propyloxycarbonyl)-amino acid (N-a-Bpoc-Xxx-OH) derivatives

Reproducible preparations are given for salts of the following L-amino acid derivatives: Bpoc-Ala-OH, Bpoc-Arg(Mtr)-OH, Bpoc-Asn-OH, Bpoc-Asp(OtBu)-OH, Bpoc-Cys(Acm)-OH, Bpoc-Cys(S-tBu)-OH, Bpoc-Gln-OH, Bpoc-Glu(OtBu)-OH, Bpoc-Gly-OH, Bpoc-Ile-OH, Bpoc-Leu-OH, N-alpha-Bpoc-Lys(epsilon-Boc)-OH, Bpoc-Met-OH, Bpoc-Phe-OH, Bpoc-Pro-OH, Bpoc-Ser(OtBu)-OH, Bpoc-Thr(OtBu)-OH, Bpoc-Tyr-OH, Bpoc-Val-OH. A study of the deblocking of N-alpha-Bpoc peptides in dichloromethane containing 0.5% trifluoroacetic acid revealed that a rapid equilbrium is established between the first-formed monomeric alkene 2-p-biphenylylpropene and the hindered dimer 2,4-bis(p-biphenylyl)-4-methyl-1-pentene. Thioethers were found to be inefficient carbocation scavengers for the deblocking reaction. The most efficient scavengers were found to be thiophenol and benzyl mercaptan, and the following approximate reactivity order was established: benzyl mercaptan approximately thiophenol greater than indole much greater than 1,3-dimethoxybenzene approximately resorcinol greater than 1,3,5-trimethoxybenzene approximately dimethyl sulfide approximately thioanisole.

Heat exposure-induced changes in motor outflow component of reaction time

Conduction velocity, absolute refractory period, and subnormal conduction period measures of the right ulnar motor nerve were obtained during a simple reaction time task. 6 young, healthy, right-arm dominant male subjects were tested following 30 min. exposure in ambient (20 degrees C) and hot (36 degrees C) room air conditions. Motor and premotor components of fractionated reaction time were tested on the same arm. Oral, right forearm skin and a four-site mean skin temperature were monitored. During heat exposure, forearm skin temperature increased 4.7 degrees C and mean skin temperature 2.9 degrees C. Oral temperature did not alter. Conduction velocity increased 11.4%, absolute refractory period decreased 22.7%, and subnormal conduction period decreased 14.1% in the hot condition. Concomitantly, a 5.2% increase in premotor reaction time and 12.2% decrease in motor reaction time were observed. Total RT did not alter significantly. It was concluded that different component parts of reaction time were differentially influenced by exposure to heat.

Patient management problems. Issues of validity

Patient management problems (PMP) are being used in medical examinations with increasing frequency despite evidence which throws doubt on their validity as measures of clinical competence. This study investigated the construct validity of a PMP constructed in both written and interview formats. Each test was administered to groups of students of different seniorities and to two groups of doctors, interns and post-interns. The pattern of scores for the different groups was not that expected of a valid test of competence. The most competent groups (the post-interns) generally scored less well on the calculated indices than the senior students and interns. These findings were similar for both formats of the test so cueing was not thought to be the major factor. It appears that the scoring system is at fault. A comparison of performance on the written and interview (uncued) formats showed that many more options were chosen by all groups tested on the written PMP. It was concluded that written PMPs cannot yet be regarded as a valid simulation of clinical performance. Although content validity is high this does not appear to be so for construct validity or concurrent validity.