Inferring community transmission of SARS-CoV-2 in the United Kingdom using the ONS COVID-19 Infection Survey

Key epidemiological parameters, including the effective reproduction number, R ( t ) , and the instantaneous growth rate, r ( t ) , generated from an ensemble of models, have been informing public health policy throughout the COVID-19 pandemic in the four nations of the United Kingdom of Great Britain and Northern Ireland (UK). However, estimation of these quantities became challenging with the scaling down of surveillance systems as part of the transition from the "emergency" to "endemic" phase of the pandemic. The Office for National Statistics (ONS) COVID-19 Infection Survey (CIS) provided an opportunity to continue estimating these parameters in the absence of other data streams. We used a penalised spline model fitted to the publicly-available ONS CIS test positivity estimates to produce a smoothed estimate of the prevalence of SARS-CoV-2 positivity over time. The resulting fitted curve was used to estimate the "ONS-based" R ( t ) and r ( t ) across the four nations of the UK. Estimates produced under this model are compared to government-published estimates with particular consideration given to the contribution that this single data stream can offer in the estimation of these parameters. Depending on the nation and parameter, we found that up to 77% of the variance in the government-published estimates can be explained by the ONS-based estimates, demonstrating the value of this singular data stream to track the epidemic in each of the four nations. We additionally find that the ONS-based estimates uncover epidemic trends earlier than the corresponding government-published estimates. Our work shows that the ONS CIS can be used to generate key COVID-19 epidemiological parameters across the four UK nations, further underlining the enormous value of such population-level studies of infection. This is not intended as an alternative to ensemble modelling, rather it is intended as a potential solution to the aforementioned challenge faced by public health officials in the UK in early 2022.

Marburg virus disease outbreaks, mathematical models, and disease parameters: a systematic review

The 2023 Marburg virus disease outbreaks in Equatorial Guinea and Tanzania highlighted the importance of better understanding this lethal pathogen. We did a systematic review (PROSPERO CRD42023393345) of peer-reviewed articles reporting historical outbreaks, modelling studies, and epidemiological parameters focused on Marburg virus disease. We searched PubMed and Web of Science from database inception to March 31, 2023. Two reviewers evaluated all titles and abstracts with consensus-based decision making. To ensure agreement, 13 (31%) of 42 studies were double-extracted and a custom-designed quality assessment questionnaire was used for risk of bias assessment. We present detailed information on 478 reported cases and 385 deaths from Marburg virus disease. Analysis of historical outbreaks and seroprevalence estimates suggests the possibility of undetected Marburg virus disease outbreaks, asymptomatic transmission, or cross-reactivity with other pathogens, or a combination of these. Only one study presented a mathematical model of Marburg virus transmission. We estimate an unadjusted, pooled total random effect case fatality ratio of 61·9% (95% CI 38·8-80·6; I2=93%). We identify epidemiological parameters relating to transmission and natural history, for which there are few estimates. This systematic review and the accompanying database provide a comprehensive overview of Marburg virus disease epidemiology and identify key knowledge gaps, contributing crucial information for mathematical models to support future Marburg virus disease epidemic responses.

Public awareness of and opinions on the use of mathematical transmission modelling to inform public health policy in the United Kingdom

Mathematical modelling is used to inform public health policy, particularly so during the COVID-19 pandemic. As the public are key stakeholders, understanding the public perceptions of these tools is vital. To complement our previous study on the science-policy interface, novel survey data were collected via an online panel ('representative' sample) and social media ('non-probability' sample). Many questions were asked twice, in reference to the period 'prior to' (retrospectively) and 'during' the COVID-19 pandemic. Respondents reported being increasingly aware of modelling in informing policy during the pandemic, with higher levels of awareness among social media respondents. Modelling informing policy was perceived as more reliable during the pandemic than in reference to the pre-pandemic period in both samples. Trust in government public health advice remained high within both samples but was lower during the pandemic in comparison with the (retrospective) pre-pandemic period. The decay in trust was greater among social media respondents. Many respondents explicitly made the distinction that their trust was reserved for 'scientists' and not 'politicians'. Almost all respondents believed governments have responsibility for communicating modelling to the public. These results provide a reminder of the skewed conclusions that could be drawn from non-representative samples.

Alternative epidemic indicators for COVID-19 in three settings with incomplete death registration systems

Not all COVID-19 deaths are officially reported, and particularly in low-income and humanitarian settings, the magnitude of reporting gaps remains sparsely characterized. Alternative data sources, including burial site worker reports, satellite imagery of cemeteries, and social media-conducted surveys of infection may offer solutions. By merging these data with independently conducted, representative serological studies within a mathematical modeling framework, we aim to better understand the range of underreporting using examples from three major cities: Addis Ababa (Ethiopia), Aden (Yemen), and Khartoum (Sudan) during 2020. We estimate that 69 to 100%, 0.8 to 8.0%, and 3.0 to 6.0% of COVID-19 deaths were reported in each setting, respectively. In future epidemics, and in settings where vital registration systems are limited, using multiple alternative data sources could provide critically needed, improved estimates of epidemic impact. However, ultimately, these systems are needed to ensure that, in contrast to COVID-19, the impact of future pandemics or other drivers of mortality is reported and understood worldwide.

Adapting field-mosquito collection techniques in a perspective of near-infrared spectroscopy implementation

BACKGROUND

Near-infrared spectroscopy (NIRS) has the potential to be a useful tool for assessing key entomological parameters of malaria-transmitting mosquitoes, including age, infectious status and species identity. However, before NIRS can be reliably used in the field at scale, methods for killing mosquitoes and conserving samples prior to NIRS scanning need to be further optimized. Historically, mosquitoes used in studies have been killed with chloroform, although this approach is not without health hazards and should not be used in human dwellings. For the application of NIRS scanning it is also unclear which mosquito preservation method to use. The aim of the study reported here was to investigate the use of pyrethrum spray, a commercially available insecticide spray in Burkina Faso, for killing mosquitoes METHODS: Laboratory-reared Anopheles gambiae and Anopheles coluzzii were killed using either a pyrethrum insecticide spray routinely used in studies involving indoor mosquito collections (Kaltox Paalga®; Saphyto, Bobo-Dioulasso, Burkina Faso) or chloroform ("gold standard"). Preservative methods were also investigated to determine their impact on NIRS accuracy in predicting the species of laboratory-reared Anopheles and wild-caught mosquito species. After analysis of fresh samples, mosquitoes were stored in 80% ethanol or in silica gel for 2 weeks and re-analyzed by NIRS. In addition, experimentally infected An. coluzzii and wild-caught An. gambiae sensu lato (s.l.) were scanned as fresh samples to determine whether they contained sporozoites, then stored in the preservatives mentioned above for 2 weeks before being re-analyzed.

RESULTS

The difference in the accuracy of NIRS to differentiate between laboratory-reared An. gambiae mosquitoes and An. coluzzii mosquitoes killed with either insecticide (90%) or chloroform (92%) was not substantial. NIRS had an accuracy of 90% in determining mosquito species for mosquitoes killed with chloroform and preserved in ethanol or silica gel. The accuracy was the same when the pyrethrum spray was used to kill mosquitoes followed by preservation in silica gel, but was lower when ethanol was used as a preservative (80%). Regarding infection status, NIRS was able to differentiate between infected and uninfected mosquitoes, with a slightly lower accuracy for both laboratory and wild-caught mosquitoes preserved in silica gel or ethanol.

CONCLUSIONS

The results show that NIRS can be used to classify An. gambiae s.l. species killed by pyrethrum spray with no loss of accuracy. This insecticide may have practical advantages over chloroform for the killing of mosquitoes in NIRS analysis.

Tracking the incidence and risk factors for SARS-CoV-2 infection using historical maternal booking serum samples

The early transmission dynamics of SARS-CoV-2 in the UK are unknown but their investigation is critical to aid future pandemic planning. We tested over 11,000 anonymised, stored historic antenatal serum samples, given at two north-west London NHS trusts in 2019 and 2020, for total antibody to SARS-CoV-2 receptor binding domain (anti-RBD). Estimated prevalence of seroreactivity increased from 1% prior to mid-February 2020 to 17% in September 2020. Our results show higher prevalence of seroreactivity to SARS-CoV-2 in younger, non-white ethnicity, and more deprived groups. We found no significant interaction between the effects of ethnicity and deprivation. Derived from prevalence, the estimated incidence of seroreactivity reflects the trends observed in daily hospitalisations and deaths in London that followed 10 and 13 days later, respectively. We quantified community transmission of SARS-CoV-2 in London, which peaked in late March / early April 2020 with no evidence of community transmission until after January 2020. Our study was not able to determine the date of introduction of the SARS-CoV-2 virus but demonstrates the value of stored antenatal serum samples as a resource for serosurveillance during future outbreaks.

Back to the Future: Quantifying Wing Wear as a Method to Measure Mosquito Age

Vector biologists have long sought the ability to accurately quantify the age of wild mosquito populations, a metric used to measure vector control efficiency. This has proven difficult due to the difficulties of working in the field and the biological complexities of wild mosquitoes. Ideal age grading techniques must overcome both challenges while also providing epidemiologically relevant age measurements. Given these requirements, the Detinova parity technique, which estimates age from the mosquito ovary and tracheole skein morphology, has been most often used for mosquito age grading despite significant limitations, including being based solely on the physiology of ovarian development. Here, we have developed a modernized version of the original mosquito aging method that evaluated wing wear, expanding it to estimate mosquito chronological age from wing scale loss. We conducted laboratory experiments using adult Anopheles gambiae held in insectary cages or mesocosms, the latter of which also featured ivermectin bloodmeal treatments to change the population age structure. Mosquitoes were age graded by parity assessments and both human- and computational-based wing evaluations. Although the Detinova technique was not able to detect differences in age population structure between treated and control mesocosms, significant differences were apparent using the wing scale technique. Analysis of wing images using averaged left- and right-wing pixel intensity scores predicted mosquito age at high accuracy (overall test accuracy: 83.4%, average training accuracy: 89.7%). This suggests that this technique could be an accurate and practical tool for mosquito age grading though further evaluation in wild mosquito populations is required.

Milestone house: The story of a hospice for people with HIV/AIDS

The HIV/AIDS epidemic of the early 1980s has been extensively documented, with all its epidemiological, scientific and medical impacts. Cultural implications for many sectors of society have been profound and long-lasting. Some areas merit reflection for their ingenuity in the face of a crisis and the effect they have had on clinical practice. This report gives an account of a venture into the unknown territory of palliative care. Described here is a group of young people and their families propelled into a nightmarish condition. Those involved were outlawed and stigmatised, suffering from a disease leading to their inevitable death. By association with this group, carers and medical staff were left to interpret unhelpful guidelines and to venture into unknown therapeutic territory, sometimes beyond the margins of conventional practice.

Disease transmission and control modelling at the science-policy interface

The coronavirus disease 2019 (COVID-19) pandemic has disrupted the lives of billions across the world. Mathematical modelling has been a key tool deployed throughout the pandemic to explore the potential public health impact of an unmitigated epidemic. The results of such studies have informed governments' decisions to implement non-pharmaceutical interventions to control the spread of the virus. In this article, we explore the complex relationships between models, decision-making, the media and the public during the COVID-19 pandemic in the United Kingdom of Great Britain and Northern Ireland (UK). Doing so not only provides an important historical context of COVID-19 modelling and how it has shaped the UK response, but as the pandemic continues and looking towards future pandemic preparedness, understanding these relationships and how they might be improved is critical. As such, we have synthesized information gathered via three methods: a survey to publicly list attendees of the Scientific Advisory Group for Emergencies, the Scientific Pandemic Influenza Group on Modelling and other comparable advisory bodies, interviews with science communication experts and former scientific advisors, and reviewing some of the key COVID-19 modelling literature from 2020. Our research highlights the desire for increased bidirectional communication between modellers, decision-makers and the public, as well as the need to convey uncertainty inherent in transmission models in a clear manner. These aspects should be considered carefully ahead of the next emergency response.

Communicating uncertainty in epidemic models

While mathematical models of disease transmission are widely used to inform public health decision-makers globally, the uncertainty inherent in results are often poorly communicated. We outline some potential sources of uncertainty in epidemic models, present traditional methods used to illustrate uncertainty and discuss alternative presentation formats used by modelling groups throughout the COVID-19 pandemic. Then, by drawing on the experience of our own recent modelling, we seek to contribute to the ongoing discussion of how to improve upon traditional methods used to visualise uncertainty by providing a suggestion of how this can be presented in a clear and simple manner.

752 Routine In-Hospital Radiographs Following Anterior Cervical Discectomy and Fusion Surgery: Neither Necessary nor Cost-Effective?

Aim

To evaluate whether a post-operative radiograph of the cervical spine before discharge is either clinically justified or cost-effective in patients who have undergone an ACDF, despite having satisfactory intra-operative imaging.

Method

A retrospective review of 101 ACDF patients from a single neurosurgical centre. 78 had an in-hospital post-operative radiograph, 23 did not. In 95 of these, it was documented that there was ‘satisfactory intra-operative imaging’. All patients had intra-operative imaging of completed instrumentation. Any post-operative complications were noted, and the length of hospital stay (LOS) recorded. Study parameters also included: levels operated on, whether or not a plate was used with a cage, additional costings to the hospital.

Results

There was one post-operative complication relating to the metalwork in the 101 patients. However, the decision to perform this x-ray was based purely on the deteriorating post-operative clinical picture. In the cohort that had POXR’s, the average length of stay was 66.7 hours. Without POXR, it was 21 hours. The additional cost to the trust of performing the in-hospital radiographs was calculated to be £71,523 per year.

Conclusions

In patients who undergo ACDF surgery with an uneventful post-operative course and satisfactory intra-operative imaging, in-hospital post-operative radiographs serve no clinical purpose and delay discharge. This gives additional cost to the trust, unnecessary radiation exposure and occupies potential bedspace.

Modelling intensive care unit capacity under different epidemiological scenarios of the COVID-19 pandemic in three Western European countries

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic has placed enormous strain on intensive care units (ICUs) in Europe. Ensuring access to care, irrespective of COVID-19 status, in winter 2020-2021 is essential.

METHODS

An integrated model of hospital capacity planning and epidemiological projections of COVID-19 patients is used to estimate the demand for and resultant spare capacity of ICU beds, staff and ventilators under different epidemic scenarios in France, Germany and Italy across the 2020-2021 winter period. The effect of implementing lockdowns triggered by different numbers of COVID-19 patients in ICUs under varying levels of effectiveness is examined, using a 'dual-demand' (COVID-19 and non-COVID-19) patient model.

RESULTS

Without sufficient mitigation, we estimate that COVID-19 ICU patient numbers will exceed those seen in the first peak, resulting in substantial capacity deficits, with beds being consistently found to be the most constrained resource. Reactive lockdowns could lead to large improvements in ICU capacity during the winter season, with pressure being most effectively alleviated when lockdown is triggered early and sustained under a higher level of suppression. The success of such interventions also depends on baseline bed numbers and average non-COVID-19 patient occupancy.

CONCLUSION

Reductions in capacity deficits under different scenarios must be weighed against the feasibility and drawbacks of further lockdowns. Careful, continuous decision-making by national policymakers will be required across the winter period 2020-2021.

The J-IDEA Pandemic Planner: A Framework for Implementing Hospital Provision Interventions During the COVID-19 Pandemic

BACKGROUND

Planning for extreme surges in demand for hospital care of patients requiring urgent life-saving treatment for coronavirus disease 2019 (COVID-19), while retaining capacity for other emergency conditions, is one of the most challenging tasks faced by health care providers and policymakers during the pandemic. Health systems must be well-prepared to cope with large and sudden changes in demand by implementing interventions to ensure adequate access to care. We developed the first planning tool for the COVID-19 pandemic to account for how hospital provision interventions (such as cancelling elective surgery, setting up field hospitals, or hiring retired staff) will affect the capacity of hospitals to provide life-saving care.

METHODS

We conducted a review of interventions implemented or considered in 12 European countries in March to April 2020, an evaluation of their impact on capacity, and a review of key parameters in the care of COVID-19 patients. This information was used to develop a planner capable of estimating the impact of specific interventions on doctors, nurses, beds, and respiratory support equipment. We applied this to a scenario-based case study of 1 intervention, the set-up of field hospitals in England, under varying levels of COVID-19 patients.

RESULTS

The Abdul Latif Jameel Institute for Disease and Emergency Analytics pandemic planner is a hospital planning tool that allows hospital administrators, policymakers, and other decision-makers to calculate the amount of capacity in terms of beds, staff, and crucial medical equipment obtained by implementing the interventions. Flexible assumptions on baseline capacity, the number of hospitalizations, staff-to-beds ratios, and staff absences due to COVID-19 make the planner adaptable to multiple settings. The results of the case study show that while field hospitals alleviate the burden on the number of beds available, this intervention is futile unless the deficit of critical care nurses is addressed first.

DISCUSSION

The tool supports decision-makers in delivering a fast and effective response to the pandemic. The unique contribution of the planner is that it allows users to compare the impact of interventions that change some or all inputs.

Feasibility of salivary cortisol collection in patients and companions attending dementia diagnostic meetings in memory clinics

Objectives

Receiving a diagnosis of dementia is life-changing for the individual and their companion. The aim of the study was to explore the feasibility of collecting salivary cortisol from patients who are informed if they have dementia and their companions. Patients and companions collected nine saliva samples in three batches: 1–2 weeks before, immediately before, and immediately after the diagnostic meeting. Each batch consisted of three samples taken in the evening, after awaking and 30 mins post-waking.

Results

22.7% (N = 10) of 44 invited patients and nine companions agreed, with 18.2% patients (N = 8) and 15.9% companions (N = 7) providing samples. Participants found that saliva collection was demanding and disrupted routines. On a purely descriptive level, some indications of an increased cortisol stress response in patients diagnosed with dementia were found in this very small sample. Researchers should expect low recruitment rates in this elderly population. Simpler collection procedures, e.g. pre-labelled packages with date/time, possible omission of morning samples and objective rather than self-report assessment of waking and saliva collection times—using actigraphy wrist-watches bleeps to prompt people at the timepoints and electronic track caps—might improve adherence and improve the accuracy of timepoints when swabs were actually collected.

Database of epidemic trends and control measures during the first wave of COVID-19 in mainland China

OBJECTIVES

In this data collation study, we aimed to provide a comprehensive database describing the epidemic trends and responses during the first wave of coronavirus disease 2019 (COVID-19) throughout the main provinces in China.

METHODS

From mid-January to March 2020, we extracted publicly available data regarding the spread and control of COVID-19 from 31 provincial health authorities and major media outlets in mainland China. Based on these data, we conducted descriptive analyses of the epidemic in the six most-affected provinces.

RESULTS

School closures, travel restrictions, community-level lockdown, and contact tracing were introduced concurrently around late January but subsequent epidemic trends differed among provinces. Compared with Hubei, the other five most-affected provinces reported a lower crude case fatality ratio and proportion of critical and severe hospitalised cases. From March 2020, as the local transmission of COVID-19 declined, switching the focus of measures to the testing and quarantine of inbound travellers may have helped to sustain the control of the epidemic.

CONCLUSIONS

Aggregated indicators of case notifications and severity distributions are essential for monitoring an epidemic. A publicly available database containing these indicators and information regarding control measures is a useful resource for further research and policy planning in response to the COVID-19 epidemic.

Adapting hospital capacity to meet changing demands during the COVID-19 pandemic

BACKGROUND

To calculate hospital surge capacity, achieved via hospital provision interventions implemented for the emergency treatment of coronavirus disease 2019 (COVID-19) and other patients through March to May 2020; to evaluate the conditions for admitting patients for elective surgery under varying admission levels of COVID-19 patients.

METHODS

We analysed National Health Service (NHS) datasets and literature reviews to estimate hospital care capacity before the pandemic (pre-pandemic baseline) and to quantify the impact of interventions (cancellation of elective surgery, field hospitals, use of private hospitals, deployment of former medical staff and deployment of newly qualified medical staff) for treatment of adult COVID-19 patients, focusing on general and acute (G&A) and critical care (CC) beds, staff and ventilators.

RESULTS

NHS England would not have had sufficient capacity to treat all COVID-19 and other patients in March and April 2020 without the hospital provision interventions, which alleviated significant shortfalls in CC nurses, CC and G&A beds and CC junior doctors. All elective surgery can be conducted at normal pre-pandemic levels provided the other interventions are sustained, but only if the daily number of COVID-19 patients occupying CC beds is not greater than 1550 in the whole of England. If the other interventions are not maintained, then elective surgery can only be conducted if the number of COVID-19 patients occupying CC beds is not greater than 320. However, there is greater national capacity to treat G&A patients: without interventions, it takes almost 10,000 G&A COVID-19 patients before any G&A elective patients would be unable to be accommodated.

CONCLUSIONS

Unless COVID-19 hospitalisations drop to low levels, there is a continued need to enhance critical care capacity in England with field hospitals, use of private hospitals or deployment of former and newly qualified medical staff to allow some or all elective surgery to take place.

Clinical relevance of findings in trials of CBT for depression

Cognitive behavioural therapy (CBT) is beneficial in depression. Symptom scores can be translated into Clinical Global Impression (CGI) scale scores to indicate clinical relevance. We aimed to assess the clinical relevance of findings of randomised controlled trials (RCTs) of CBT in depression. We identified RCTs of CBT that used the Hamilton Rating Scale for Depression (HAMD). HAMD scores were translated into Clinical Global Impression – Change scale (CGI-I) scores to measure clinical relevance. One hundred and seventy datasets from 82 studies were included. The mean percentage HAMD change for treatment arms was 53.66%, and 29.81% for control arms, a statistically significant difference. Combined active therapies showed the biggest improvement on CGI-I score, followed by CBT alone. All active treatments had better than expected HAMD percentage reduction and CGI-I scores. CBT has a clinically relevant effect in depression, with a notional CGI-I score of 2.2, indicating a significant clinical response. The non-specific or placebo effect of being in a psychotherapy trial was a 29% reduction of HAMD.

Maternal and Fetal Platelet Responses and Adrenoceptor Binding Characteristics

Paired blood samples were obtained from mothers (venous) and babies (cord venous blood) at the time of delivery by caesarean section under epidural anaesthetic. Fetal platelets failed to aggregate in response to adrenaline in vitro although adrenaline could potentiate the threshold response to adenosine diphosphate (1 μM). Fetal platelet responses to collagen and 8 Arg vasopressin did not differ significantly from maternal responses. Maternal and fetal platelets also showed similar inhibition of aggregation after activation of adenylate cyclase (PGE1 and parathormone), in contrast to the inhibition of adenylate cyclase by adrenaline.

Alpha2 adrenoceptors were investigated using [3H] yohimbine binding receptor number and were reduced modestly but significantly on fetal compared to maternal platelets. The failure of fetal platelet aggregation in response to adrenaline appears to be related to a failure of receptor coupling and may represent a delayed maturation of fetal platelet alpha receptors or a response- to increased circulating catecholamines during birth.

What can patients do to facilitate shared decision making? A qualitative study of patients with depression or schizophrenia and psychiatrists

PURPOSE

Patient involvement in decision making is endorsed by patients and professionals. While research has recently been conducted on how professionals can promote shared decision making (SDM), little is known about how patients can also facilitate SDM.

METHODS

Seven focus groups were conducted: 3 with psychiatrists and 4 with patients with schizophrenia or depression. The focus groups were transcribed and independently coded line by line by 2 researchers. Data were analyzed using content analysis.

RESULTS

Seven themes related to patient attitudes and behaviors were identified: honesty and openness with one's psychiatrist and oneself, trust in one's psychiatrist and patience with the treatment, respect and politeness, informing the psychiatrist and giving feedback, engagement/active participation during the consultation, gathering information/preparing for the consultation and implementing decisions. Barriers (e.g., avolition, lack of decisional capacity, powerlessness during involuntary treatment) and facilitators of active patient behavior were also identified.

CONCLUSIONS

There are various ways in which patients can facilitate SDM/play a more active role in decision making, with patients emphasizing being open and honest and psychiatrists emphasizing being active in the consultation. Interventions to increase active patient behavior may enhance SDM in mental health care.

Non-verbal communication in meetings of psychiatrists and patients with schizophrenia

OBJECTIVE

Recent evidence found that patients with schizophrenia display non-verbal behaviour designed to avoid social engagement during the opening moments of their meetings with psychiatrists. This study aimed to replicate, and build on, this finding, assessing the non-verbal behaviour of patients and psychiatrists during meetings, exploring changes over time and its association with patients' symptoms and the quality of the therapeutic relationship.

METHOD

40-videotaped routine out-patient consultations, involving patients with schizophrenia, were analysed. Non-verbal behaviour of patients and psychiatrists was assessed during three fixed, 2-min intervals using a modified Ethological Coding System for Interviews. Symptoms, satisfaction with communication and the quality of the therapeutic relationship were also measured.

RESULTS

Over time, patients' non-verbal behaviour remained stable, whilst psychiatrists' flight behaviour decreased. Patients formed two groups based on their non-verbal profiles, one group (n = 25) displaying pro-social behaviour, inviting interaction and a second (n = 15) displaying flight behaviour, avoiding interaction. Psychiatrists interacting with pro-social patients displayed more pro-social behaviours (P < 0.001). Patients' pro-social profile was associated reduced symptom severity (P < 0.05), greater satisfaction with communication (P < 0.001) and positive therapeutic relationships (P < 0.05).

CONCLUSION

Patients' non-verbal behaviour during routine psychiatric consultations remains unchanged, and is linked to both their psychiatrist's non-verbal behaviour and the quality of the therapeutic relationship.

Insight, duration of untreated psychosis and attachment in first-episode psychosis: prospective study of psychiatric recovery over 12-month follow-up

BACKGROUND

Increasing evidence shows attachment security influences symptom expression and adaptation in people diagnosed with schizophrenia and other psychoses.

AIMS

To describe the distribution of secure and insecure attachment in a cohort of individuals with first-episode psychosis, and to explore the relationship between attachment security and recovery from positive and negative symptoms in the first 12 months.

METHOD

The study was a prospective 12-month cohort study. The role of attachment, duration of untreated psychosis (DUP), baseline symptoms and insight in predicting and mediating recovery from symptoms was investigated using multiple regression analysis and path analysis.

RESULTS

Of the 79 participants, 54 completed the Adult Attachment Interview (AAI): 37 (68.5%) were classified as insecure, of which 26 (48.1%) were insecure/dismissing and 11 (20.4%) insecure preoccupied. Both DUP and insight predicted recovery from positive symptoms at 12 months. Attachment security, DUP and insight predicted recovery from negative symptoms at 12 months.

CONCLUSIONS

Attachment is an important construct contributing to understanding and development of interventions promoting recovery following first-episode psychosis.

How effective is high-support community-based step-down housing for women in secure mental health care? A quasi-experimental pilot study

In the past decade UK government policy has been to develop alternative care for women detained in secure psychiatric hospital. This study evaluated the relative benefits of community-based step-down housing. Comparisons were made between female patients in community step-down housing and a control group in secure hospital who were on the waiting list for the houses. For each woman in the sample, a range of assessments was conducted on three separate occasions over a 12-month period. We noted a gradual improvement over time in women in both settings. However, by the final assessment psychological well-being and security needs were significantly better in the community group (P < 0.05). Although risks for violence and social functioning were also somewhat better in this group throughout the study, no statistically significant differences between the groups were found in these areas at any assessment time. This study has generated evidence in support of the further development of high-support step-down community housing for women in secure psychiatric care. This initiative may provide greater personal freedom and enhanced relational security for the women concerned while also facilitating improvements in their psychological well-being, with no increased risk to the women themselves or to the wider community.

Communication about psychotic symptoms in long-term psychiatric illness

BACKGROUND

Communicating about psychotic symptoms can be challenging. This study aimed to identify (1) how psychiatrists and patients communicate about psychotic symptoms from a research and clinical perspective and (2) whether communication patterns depend on patients' symptom levels.

SAMPLING AND METHODS

Consultations between 27 psychiatrists and 100 patients with long-term schizophrenia/schizoaffective disorder in outpatient clinics were video-recorded, transcribed and coded. Symptoms were assessed on the Positive and Negative Syndrome Scale. Avoidance or engagement with psychotic symptoms was coded separately by researchers and three clinical psychiatrists.

RESULTS

Psychotic symptoms were not mentioned in 27% of consultations. Patients reported their absence in 34% of consultations and avoided talking about symptoms in 6%. Researchers rated psychiatrists as engaged in talking about psychotic symptoms in 15% of consultations and avoiding talking about them in 18% of consultations. Psychiatrists identified somewhat less avoidance (10%) and more engagement (23%). Psychiatrist avoidance was seen when the patient raised the topic and the psychiatrist gave brief responses and/or changed the topic. When psychiatrists engaged, they asked specific questions about symptoms, responded to patient concerns and provided explanations about symptoms. Psychotic symptoms were more often discussed with patients with more negative and general symptoms.

CONCLUSIONS

There is considerable variation in whether psychotic symptoms are discussed or not in outpatient consultations. Whether psychiatrists discuss psychotic symptoms is influenced by patients' symptoms; however, not by their psychotic symptoms but rather by the presence of negative and general symptoms. Psychiatrists' ratings of communication identify broadly similar patterns as detailed research analyses.

Poster - Thur Eve - 21: ROC analysis in patient specific quality assurance

INTRODUCTION

Many institutions rely on a patient specific measurement for IMRT/VMAT patient QA. In diagnostic imaging, radiologists use Receiver Operator Curves (ROC) to help quantify the value of a diagnostic imaging test. The purpose of this work is to investigate the value or ROC methodology for patient specific IMRT QA.

METHODS AND MATERIALS

Beam fluences for 34 prostate IMRT patients were analyzed using gamma analysis. For half of these, measurements were done using the planned beam fluences. For the rest, perturbations to the MLC leaf positions were introduced. Gamma analysis was then used to measure fluence differences. Assuming that the unperturbed fluencies were positive measurements, distributions of true positive and false negatives were calculated.

RESULTS

For poorly performing beam delivery systems the choice of γ-DTA criterion has little effect on test sensitivity and specificity. The AUC is increased by about 10% for high performance beam delivery systems. For a 3%/3mm γ-DTA condition, ideal cut off values are reasonably independent of MLC performance. At a tighter γ-DTA condition of 2%/2mm, then the optimal sensitivity and specificity of the test is more dependent on MLC performance.

DISCUSSION

For a pass-fail test such as the γ-DTA map is, it is important to choose an optimal cut off value to maximize the sensitivity and specificity of the test. ROC methodology allows users to follow a prescriptive method to obtain ideal cut-off values for gamma analysis, and to assess improvements in sensitivity and specificity for higher performing beam delivery system.

Good communication in psychiatry--a conceptual review

BACKGROUND

The communication between clinician and patient is the basis of psychiatric treatment. However, there has been little practical attention to training in it, and no specific theory of what constitutes good communication in psychiatry has been developed. This review aims to identify principles that guide good communication.

METHODS

A conceptual review of guiding principles for how clinicians should communicate with patients to achieve clinical objectives in psychiatry.

RESULTS

Five guiding principles for clinicians were identified: a focus on the patient's concerns; positive regard and personal respect; appropriate involvement of patients in decision making; genuineness with a personal touch; and the use of a psychological treatment model.

CONCLUSIONS

The principles are mostly generic, but their implementation can be particularly challenging in psychiatry. They may guide further empirical research on effective communication in psychiatry and be utilised using different personal skills of clinicians.

Measuring patients' views: a bifactor model of distinct patient-reported outcomes in psychosis

BACKGROUND

Patient-reported outcomes (PROs) are widely used for evaluating the care of patients with psychosis. Previous studies have reported a considerable overlap in the information captured by measures designed to assess different outcomes. This may impair the validity of PROs and makes an a priori choice of the most appropriate measure difficult when assessing treatment benefits for patients. We aimed to investigate the extent to which four widely established PROs [subjective quality of life (SQOL), needs for care, treatment satisfaction and the therapeutic relationship] provide distinct information independent from this overlap.

METHOD

Analyses, based on item response modelling, were conducted on measures of SQOL, needs for care, treatment satisfaction and the therapeutic relationship in two large samples of patients with psychosis.

RESULTS

In both samples, a bifactor model matched the data best, suggesting sufficiently strong concept factors to allow for four distinct PRO scales. These were independent from overlap across measures due to a general appraisal tendency of patients for positive or negative ratings and shared domain content. The overlap partially impaired the ability of items to discriminate precisely between patients from lower and higher PRO levels. We found that widely used sum scores were strongly affected by the general appraisal tendency.

CONCLUSIONS

Four widely established PROs can provide distinct information independent from overlap across measures. The findings may inform the use and further development of PROs in the evaluation of treatments for psychosis.

Patients' subjective initial response and the outcome of inpatient and day hospital treatment

OBJECTIVE

This study aimed to establish whether psychiatric patients' subjective initial response (SIR) to hospital and day hospital treatment predicts outcomes over a one-year follow-up period.

METHOD

We analysed data from 765 patients who were randomised to acute psychiatric treatment in a hospital or day hospital. SIR was assessed on day 3 after admission. Outcomes were psychiatric symptom levels and social disability at discharge, and at 3 and 12 months after discharge.

RESULTS

After controlling for socio-demographic and clinical characteristics, a more positive SIR was significantly associated with lower symptom levels at discharge and 3 months after discharge and lower social disability at 3 months and 12 months after discharge.

CONCLUSION

SIR can predict outcomes of complex interventions over a one-year period. Patients' initial views of acute hospital and day treatment should be elicited and considered as important.

What works for whom in a computer-mediated communication intervention in community psychiatry? Moderators of outcome in a cluster randomized trial

OBJECTIVE

An intervention to structure patient-key worker communication has been tested in a randomized controlled trial. The aim of this paper was to investigate effectiveness of the intervention in terms of moderators of effectiveness.

METHOD

A total of 507 patients with schizophrenia were included. Moderators of effectiveness were investigated using two-way anovas.

RESULTS

Patients with a better relationship with their key worker and a shorter duration of illness at baseline benefited more from the intervention in terms of quality of life. Patients who received the intervention who were in competitive employment or had a shorter duration of illness showed greater reduction of unmet needs. Older patients receiving the intervention had better treatment satisfaction.

CONCLUSION

Outcome of the intervention was moderated by patient characteristics. Moreover, the moderating characteristics varied depending on the specific outcome. Evidence on moderators is very limited, even though, they are significant for understanding, targeting and implementing complex interventions.

The therapeutic relationship in psychiatric settings

OBJECTIVE

To discuss the current climate of research on the therapeutic relationship (TR) in mainstream psychiatric settings.

METHOD

Consideration of theoretical frameworks, quantitative and qualitative research methods, along with potentials for interventions.

RESULTS

Most of the concepts and methods used to investigate the TR in conventional psychiatric settings have been imported from psychotherapy and, despite significant differences between the two, there is little specific research. A distinction is suggested between therapeutic relationships and patient-clinician interactions. Relationships predict outcome and may be assessed with operationalized methods. Specific communicative skills may be helpful in the treatment of particular illnesses. The feasibility and effectiveness of potential interventions in the TR have rarely been studied.

CONCLUSION

Specific conceptual and methodological work is required to develop a better understanding of TRs in psychiatric settings. Further research should include intervention studies and might support a stronger emphasis on TRs in training and supervision.

Do people with schizophrenia display theory of mind deficits in clinical interactions?

BACKGROUND

Having a 'theory of mind' (ToM) means that one appreciates one's own and others' mental states, and that this appreciation guides interactions with others. It has been proposed that ToM is impaired in schizophrenia and experimental studies show that patients with schizophrenia have problems with ToM, particularly during acute episodes. The model predicts that communicative problems will result from ToM deficits.

METHOD

We analysed 35 encounters (> 80 h of recordings) between mental health professionals and people with chronic schizophrenia (out-patient consultations and cognitive behaviour therapy sessions) using conversation analysis in order to identify how the participants used or failed to use ToM relevant skills in social interaction.

RESULTS

Schizophrenics with ongoing positive and negative symptoms appropriately reported first and second order mental states of others and designed their contributions to conversations on the basis of what they thought their communicative partners knew and intended. Patients recognized that others do not share their delusions and attempted to reconcile others' beliefs with their own but problems arose when they try to warrant their delusional claims. They did not make the justification for their claim understandable for their interlocutor. Nevertheless, they did not fail to recognize that the justification for their claim is unconvincing. However, the ensuing disagreement did not lead them to modify their beliefs.

CONCLUSIONS

Individuals with schizophrenia demonstrated intact ToM skills in conversational interactions. Psychotic beliefs persisted despite the realization they are not shared but not because patients cannot reflect on them and compare them with what others believe.

Are therapeutic relationships in psychiatry explained by patients' symptoms? Factors influencing patient ratings

OBJECTIVE

To investigate the therapeutic relationship and how it is influenced by sociodemographic and clinical factors.

METHOD

This study analysed self-ratings of the therapeutic relationship in 90 first-admitted, 72 long-term hospitalised and 41 out-patients with schizophrenia along with 249 alcoholic and 42 depressive in-patients and their association with sociodemographic and clinical variables. In all the patients, the therapeutic relationship was assessed using a simple scale based on three items.

RESULTS

The therapeutic relationship differed significantly across groups. It was rated most positively by alcoholic patients and least positively by long-term hospitalised schizophrenia patients. Increased observer-rated psychopathology was significantly associated with a poorer therapeutic relationship in all groups except the hospitalised schizophrenia patients. In this group, increased self-rated symptoms were associated with a poorer relationship. In multiple regression analyses, 3-28% of the relationship variance was explained by psychopathology. CONCLUSIONS; Patient ratings of the therapeutic relationship were partially explained by psychopathology, leaving the greater part of the variance to be explained by factors other than sociodemographic and clinical characteristics.

Ammonia uptake and its effects on ionoregulation in the freshwater crayfish Pacifastacus leniusculus (Dana)

Exposure of adult crayfish Pacifastacus leniusculus to Artificial Freshwater (AFW) media containing 1.5 m and 0.15 mmol x l(-1) total ammonia [Tamm; 0.1 x acute lethal concentration (24 h LC50) and 0.01 x 24 h LC50] and adjusted to pH 6.5, pH 8.2 and pH 10.5 resulted in significant increases in haemolymph ammonia over a 24-h period. Ammonia accumulated most rapidly at pH 10.5. These media were chosen to expose animals to a range of different un-ionised ammonia (UIA) [NH3] and ionised ammonia [NH4+] concentrations. From comparisons of measured transepithelial potential differences (PDte) with calculated Nernst potentials (PDNH4+) for the known haemolymph-to-medium gradients of [NH4+], it was deduced that, in pH 8.2 and pH 6.5 AFW, NH4+ was not in thermodynamic equilibrium across the integument (presumably gill epithelium). In pH 10.5 AFW with 1.5 mmol x l(-1) Tamm (predominantly NH3), the accumulation of ammonia in the haemolymph was in the NH4+ form due to haemolymph pH regulation by the crayfish in this alkaline external medium. Measured net fluxes of ammonia (Jamm(net)) were inwardly directed and maximal when [NH3] was the main component externally, but were also significant at pH 8.2 with high [NH4+] ([NH4+]:[NH3] approximately 20:1). Haemolymph Na+ depletion was significant and, over the 24-h exposure period, most rapid in high [NH3] medium but [Cl-] was unaffected. However, paradoxically, sodium uptake (measured JNa(in) on immediate transfer to high Tamm medium) was not significantly inhibited when [NH3] was the predominant ammonia species. In 1.5 mmol x l(-1) Tamm (mainly [NH4+), VNa(in) (the active component of JNa(in)) was significantly inhibited, particularly at low external [Na+]. This inhibition could not be demonstrated as one of competition at an Na+/NH4+ apical gill exchange site. The resultant net efflux of sodium from the animal showed that the ability of the animals to balance sodium losses at low external [Na+] was severely affected. Longer exposure to pH 10.5 AFW with high [NH3] (12 h) resulted in significantly increased JNa(out), while not significantly affecting JNa(in). Analysis of urinary Na+ losses showed that, while urinary flow rate and water reabsorption was most likely unaffected by ammonia exposure, final urine [Na+] was significantly elevated. The resulting urinary Na+ loss accounted for 63% of the increased JNa(out) in high [NH3] medium.

Theoretical frameworks for understanding and investigating the therapeutic relationship in psychiatry

BACKGROUND

Mental health care is delivered through a relationship between a clinician and a patient. Although this therapeutic relationship is of central importance for mental health care, it appears to be relatively neglected in psychiatric research. Empirical research has for the most part adopted concepts and methods developed in psychotherapy and general medical practice. Hence, unpacking the presuppositions that have informed research on the therapeutic relationship to date may be a useful first step in developing this field.

METHOD

A review of the literature was carried out.

RESULTS

Six central theories are identified as framing the definitions and methods on this topic: role theory, psychoanalysis, social constructionism, systems theory, social psychology and cognitive behaviourism. To date, role theory, psychoanalysis and systems theory appear to be the frameworks most often applied in research in this field. Each perspective offers a unique emphasis in the analysis of the therapeutic relationship, which is reflected in the empirical work from each perspective discussed herein.

CONCLUSIONS

None of the theories identified have been fully specified and comprehensively investigated in psychiatric settings. However, more than one approach may be used for thinking about relationships, depending on the treatment situation. Further specification and testing of the theories in psychiatric practice--taking account of the specific context--is warranted to underpin more pragmatic research. A stronger link between fundamental psychological and sociological research and applied health care research would advance our understanding of which elements of positive therapeutic relationships are instrumental in improving patient outcome and ultimately contribute to improving mental health care.

Arthrodesis of the equine proximal interphalangeal joint: a biomechanical comparison of three 4.5-mm and two 5.5-mm cortical screws

OBJECTIVE

To compare the biomechanical characteristics and mode of failure of 2 parallel-screw techniques for proximal interphalangeal joint arthrodesis in horses.

STUDY DESIGN

Randomized block design, blocking for horse (1-5), method of screw fixation (three 4.5-mm vs two 5.5-mm), side (left limb vs right limb), and end (front limb vs hind limb). Constructs were loaded to failure in 3-point bending in a dorsal-to-palmar (plantar) direction.

SAMPLE POPULATION

Twenty limbs (10 limb pairs) from 5 equine cadavers.

METHODS

A combined aiming device was used to facilitate consistent screw placement. Three parallel 4.5-mm cortical screws were placed in lag fashion in 1 limb of a pair, and 2 parallel 5.5-mm cortical screws were placed in lag fashion in the contralateral limb. Arthrodesis constructs were tested in 3-point bending in a dorsal-to-palmar (plantar) direction using a materials-testing machine. Loading rate was 19 mm/s. Maximal bending moment at failure and composite stiffness were obtained from bending moment-angular deformation curves. Data were analyzed using ANOVA and chi(2) analysis.

RESULTS

There were no significant differences in bending moment (P >.05, power = 0.8 @ delta = 19%) or composite stiffness (P >.05, power = 0.8 @ delta = 19%) between the 2 fixation techniques. Higher maximal bending moment was found in front limbs than hind limbs, and front limbs with two 5.5-mm screws than hind limbs with two 5.5-mm screws. In all cases, constructs completely failed. A greater number of 4.5-mm cortical screws failed than 5.5-mm cortical screws. CONCLUSIONS-In pastern arthrodesis constructs loaded in 3-point bending, end (front limb vs hind limb) affected maximal bending moment at failure of constructs. There was no significant effect of horse, treatment, or side on maximal bending moment or stiffness. Two 5.5-mm cortical screws should provide a surgically simpler pastern arthrodesis than three 4.5-mm cortical screws while maintaining similar biomechanical characteristics.

CLINICAL RELEVANCE

Three 4.5-mm screws or two 5.5-mm screws will provide similar biomechanical characteristics in bending when performing equine pastern arthrodesis.

Therapeutic relationships and quality of life: association of two subjective constructs in schizophrenia patients

Subjective quality of life is an important criterion in outcome evaluation that has been well-researched in psychiatry. By comparison, the therapeutic relationship which may also be subjectively assessed has been relatively neglected as an outcome criterion although it has predictive power in relation to outcome. This exploratory study investigated subjective quality of life and therapeutic relationships in first-admission (N = 90) and long-term (N = 168) schizophrenia patients, each at two points of time. The follow-up period was 9 months for the first-admission sample and 1.5 years for the long-term sample. A significant relationship was found between global assessments of quality of life and therapeutic relationships in long-term, but not in first-admission patients. This finding was consistent at both assessments, suggesting that therapeutic relationships may become more central to quality of life in long-term care situations and that patients' views of this relationship are increasingly embedded in their overall appraisal of life.

Tissue matrix protein expression in human osteoblasts, osteosarcoma tumors, and osteosarcoma cell lines

Treatment for osteosarcoma is problematic because there are no prognostic markers. Diagnosis is primarily limited to cytologic grading. Oncogenesis alters cell structure therefore osteoblast tissue matrix proteins (extracellular matrix, cytoskeletal, intermediate filament, and nuclear matrix proteins), components of the cell substructure, are candidates for osteosarcoma markers. Structural proteins of the extracellular matrix, e.g. the collagens, are useful for diagnosis but not for tumors that produce little osteoid. To identify principal cellular tissue matrix proteins that distinguish normal from transformed human osteoblasts, their expression in normal osteoblasts, two osteosarcoma cell lines, and three primary osteosarcoma tumors were compared. The tumors were graded as (i) intermediate, (ii) high, and (iii) high grade recurrent. The 1-D SDS/PAGE profiles of the major components of the nuclear matrix and intermediate filament fractions from normal osteoblasts did not vary with biopsy site, age, or sex of patients. These profiles included known cytoskeletal proteins and OB250, a approximately 250 kD protein(s) observed in the intermediate filament fraction. A loss of protein bands, including OB250, was observed in the osteosarcoma cell lines and tumors. The intermediate and high grade tumors exhibited nearly identical protein profiles including potential tumor-specific proteins and collagen, consistent with the presence of intracellular collagen fibers in osteosarcoma. A microsequence was obtained for OT25, a novel low molecular weight protein observed in osteosarcoma cell lines. Fibrinogen gamma-chain, a protein that mediates cell adhesion was recovered from the high grade recurrent tumor.

Posterior lumbar interbody fusion. A biomechanical comparison, including a new threaded cage

STUDY DESIGN

In vitro biomechanical testing was performed on eight lumbar calf spines.

OBJECTIVES

To compare the initial stiffness of a standard method of posterior lumbar interbody fusion using structural autograft with the same procedure using additional posterior instrumentation. These constructs also were compared to a new titanium implant.

SUMMARY OF BACKGROUND DATA

Posterior lumbar interbody fusion is gaining wide acceptance for the treatment of segmental spinal instability, spondylolisthesis, and discogenic pain. Many methods have been described, including use of autograft or allograft bone, in either structural or nonstructural form, with or without additional fixation. A new threaded titanium interbody implant has been designed to increase initial stability while allowing bony ingrowth for fusion.

METHODS

Eight lumbar calf spines were subjected to axial compression, sagittal moments (flexion-extension), and axial torque while displacement was measured. Stiffness was calculated from the load displacement curves for each construct under each load pattern.

RESULTS

The posterior lumbar interbody fusion by bone graft alone was the least stiff construct of all modes tested. In two of eight specimens the bone graft dislodged posteriorly into the canal during torsional testing. The titanium interbody implant was similar in stiffness to the bone graft posterior lumbar interbody fusion with posterior instrumentation group in all three modes. They were both significantly stiffer than the normal spine, the destabilized spine, and the posterior lumbar interbody fusion by bone graft alone (P < 0.05).

CONCLUSIONS

In this model, the posterior lumbar interbody fusion with bone graft alone had less initial stiffness than that of the intact spine. The addition of posterior instrumentation or interbody implants can increase initial stiffness significantly.

Free-to-total prostate specific antigen ratio as a single test for detection of significant stage T1c prostate cancer

PURPOSE

We investigated whether impalpable, invisible (stage T1c) but significant prostate cancer can be detected better by determining the free-to-total prostate specific antigen (PSA) ratio of equivocal PSA serum levels.

MATERIALS AND METHODS

The specificity of free-to-total PSA ratio using research monoclonal enzyme immunoassays was compared to that of PSA greater than 4.0 ng./ml. in 117 consecutive patients with PSA 3 to 15 ng./ml. (Hybritech Tandem-R assay) due to untreated benign prostatic hypertrophy or prostate cancer. Of the patients 77% underwent adenectomy or radical prostatectomy with thorough pathological evaluation of surgical specimens.

RESULTS

Benign prostatic hypertrophy had a greater median free-to-total PSA ratio than stages T1c and T2 or greater prostate cancer (0.16 versus 0.09 and 0.11 ng./ml., p = 0.0001 and p = 0.0268, respectively). In stage T1c prostate cancer, areas under receiver operating characteristic curves were 0.58 and 0.84 for PSA and free-to-toal PSA ratio, and free-to-total PSA ratio correlated with prostate volume (r = 0.49, p = 0.005) and Gleason score (r = -0.37, p = 0.036). Pathologically, 84% of stage T1c cancers were significant and comparable to stage T2 or greater cancers.

CONCLUSIONS

Free-to-total PSA ratio enhances the efficacy of PSA measurement by improving specificity for detecting impalpable, invisible but significant stage T1c prostate cancer.

A new therapeutic option for the treatment of pneumonia

Patients with bacterial pneumonia often are treated empirically with parenteral broad-spectrum antimicrobials intended to cover potential gram-negative and gram-positive pathogens. However, beta-lactamase-mediated resistance has developed to many of these antimicrobials, particularly third-generation cephalosporins, and has led to the development of fourth-generation agents that are relatively beta-lactamase stable. The purpose of these studies was to compare the efficacy and safety of the fourth-generation agent, cefepime, with that of the third-generation agent, ceftazidime, in the treatment of hospitalized patients with moderate-to-severe bacterial pneumonia. A total of 336 (97 evaluable) patients were enrolled in an open-label study, and 99 (23 evaluable) patients were enrolled in a blinded study of patients with lower respiratory tract infections (LRTI) including pneumonia. Patients were randomized to receive either cefepime 1 g every 12 hours or ceftazidime 1 g every 8 hours given as an intravenous infusion over 30 minutes. Efficacy analysis included the evaluable patients while the safety analysis included all patients. The results in the open-label study were as follows: In patients with pneumonia, clinical response was satisfactory in 58 (85%) of 68 patients in the cefepime group and 21 (72%) of 29 patients in the ceftazidime group. Bacteriologic eradication occurred for 75 (93%) of 81 pathogens and 30 (94%) of 32 pathogens isolated from the 68 cefepime-treated patients and 29 ceftazidime-treated patients, respectively. The results in the blinded study were as follows: In patients with pneumonia, clinical response was satisfactory in 12 (80%) of 15 cefepime patients and in 7 (88%) of 8 ceftazidime patients, and the bacteriologic eradication rates were 85% (17/20 pathogens) and 73% (8/11 pathogens) isolated from the 15 cefepime-treated patients and the eight ceftazidime-treated patients, respectively. Among the most frequent adverse events in both groups were nausea, diarrhea, vomiting, and abdominal pain. Similar adverse events were noted in the 99 patients in the blinded study. These studies indicate that the efficacy and safety of cefepime administered at 1 g twice daily is comparable to that of ceftazidime administered at 1 g three times daily for treatment of hospitalized patients with pneumonia caused by susceptible pathogens.

Treatment goal-planning: outcome findings of a British prospective multi-centre study of adolescent inpatient units

A set of 16 treatment goals, related to 4 areas of adolescent functioning, were defined and employed in the initial and discharge assessments of 276 patients, admitted to 4 inpatient units, examined during a multi-centre prospective study of adolescent psychiatric hospitalizations. At discharge, subjects showed a substantial improvement across all treatment goals; least improvement was observed amongst those goals most frequently targeted. The clinical investigators consider the treatment goal definitions used in this study a meaningful way of measuring psychiatric disturbances in adolescence as well as a useful measure of change in an inpatient population. Further development of the treatment goal definitions would produce a robust clinical and audit tool.