A comparison of two primary care trials on tennis elbow: issues of external validity

OBJECTIVE

To assess clinical heterogeneity across two studies with respect to study population, interventions, and outcome measures, and to evaluate the influence of these sources of heterogeneity on the results of the studies.

METHODS

The individual patient data were used from two randomised controlled trials investigating the effectiveness of conservative treatments in patients with tennis elbow in primary care. Patients were allocated at random to treatment with steroid injection, wait and see policy, non-steroidal anti-inflammatory drugs, placebo tablets, or physiotherapy. Outcome measures included severity of the main complaint, inconvenience of the elbow complaints, pain during the day, elbow disability, pain-free grip strength, and global improvement. All outcomes were assessed at 1, 6, and 12 months after randomisation.

RESULTS

The two study populations were similar with respect to age, sex, comorbid neck/shoulder complaints, and baseline scores for the severity of pain. However, significant differences were observed for employment status, duration of elbow complaints, dominant side affected, previous history of elbow complaints, and use of analgesics. Local injections differed between the two studies with respect to volume, number, and steroid preparation. However, after 1, 6, and 12 months, the treatment effects of steroid injections were very similar between the study populations.

CONCLUSIONS

Despite large differences in study population at baseline, the responses to steroid injections were remarkably similar. Also the responses to other conservative interventions and the placebo treatment were very consistent, suggesting a uniform course of a tennis elbow and a lack of influence of clinical heterogeneity.

Molecular replacement using genetic algorithms

A new molecular replacement (MR) strategy is introduced which features a continuous transform and a genetic algorithm (GA) for search optimization. This strategy uses a GA to simultaneously search the rotational and translational parameters of a test model while maximizing the correlation coefficient between the observed and calculated diffraction data. This has distinct advantages over conventional MR strategies which require a cross-rotation signal. An important feature of this method is its capability to simultaneously search the overall rotation/translation of the test model in the unit cell while refining the relative orientation/position of internal subdomains. This identifies molecular replacement solutions which would otherwise be completely missed using just a static model, and greatly improve the signal-to-noise contrast.

Using genetic algorithms for solving heavy-atom sites

A novel procedure has been developed for locating heavy-atom positions in crystals of macromolecules. This method used genetic algorithms (GA's) to search for heavy-atom sites that are consistent with an observed difference Patterson function. The procedure is straightforward to apply, space-group independent, and particularly powerful for cases involving non-crystallographic symmetry of multiple heavy atoms in the asymmetric unit. In this paper, we introduce how GA's are used for determining the heavy-atom positions and show how this method is more efficient than a sequential search.

Use of a preprinted sticker to improve the prescribing of prophylactic antibiotics for hip fracture surgery

PROBLEM

Antibiotic prophylaxis has been shown to reduce the number of postoperative infections following surgery for hip fracture. At Auckland Hospital the policy for antibiotic prophylaxis for hip fracture surgery is for the patient to receive the first dose of antibiotic at the induction of anaesthesia followed by two more doses at 8 hour intervals. A previous audit found that patients often received too many doses of antibiotic. A retrospective audit was performed of 100 patients undergoing surgery for a hip fracture. The primary problem was over-prescribing; 68 patients (68%) received more than three doses. The number of patients who received three doses according to the guidelines was 29 (29%, 95% CI 21 to 40).

SETTING

Auckland Hospital which provides acute orthopaedic services for a population of 500,000.

STRATEGY FOR CHANGE

A sticker was introduced with the prescription printed on it. The sticker was applied to the medication chart by the anaesthetist when the initial dose of antibiotic was given. Charts of a further 100 patients were reviewed after the introduction of the sticker and compared with those from another hospital in Auckland where the sticker was not used.

EFFECTS OF CHANGE

The number of patients who received three doses, in accordance with the guidelines, improved to 74 (74%, 95% CI 64 to 82, p<0.001). These changes were observed even though the sticker was only used in 44 patients (44%, 95% CI 34 to 54). At the other hospital the number of patients who received three doses was 10 (20%, 95% CI 10 to 42) and 13 (26%, 95% CI 15 to 40, p = 0.37) for the same two periods.

LESSONS LEARNT

The use of a preprinted sticker is a simple intervention which improves the use of antibiotic prophylaxis at the time of surgery. This improvement occurred even though the sticker was used in slightly fewer than half the cases.

Use of a preprinted sticker to improve the prescribing of prophylactic antibiotics for hip fracture surgery

PROBLEM

Antibiotic prophylaxis has been shown to reduce the number of postoperative infections following surgery for hip fracture. At Auckland Hospital the policy for antibiotic prophylaxis for hip fracture surgery is for the patient to receive the first dose of antibiotic at the induction of anaesthesia followed by two more doses at 8 hour intervals. A previous audit found that patients often received too many doses of antibiotic. A retrospective audit was performed of 100 patients undergoing surgery for a hip fracture. The primary problem was over-prescribing; 68 patients (68%) received more than three doses. The number of patients who received three doses according to the guidelines was 29 (29%, 95% CI 21 to 40).

SETTING

Auckland Hospital which provides acute orthopaedic services for a population of 500,000.

STRATEGY FOR CHANGE

A sticker was introduced with the prescription printed on it. The sticker was applied to the medication chart by the anaesthetist when the initial dose of antibiotic was given. Charts of a further 100 patients were reviewed after the introduction of the sticker and compared with those from another hospital in Auckland where the sticker was not used.

EFFECTS OF CHANGE

The number of patients who received three doses, in accordance with the guidelines, improved to 74 (74%, 95% CI 64 to 82, p<0.001). These changes were observed even though the sticker was only used in 44 patients (44%, 95% CI 34 to 54). At the other hospital the number of patients who received three doses was 10 (20%, 95% CI 10 to 42) and 13 (26%, 95% CI 15 to 40, p = 0.37) for the same two periods.

LESSONS LEARNT

The use of a preprinted sticker is a simple intervention which improves the use of antibiotic prophylaxis at the time of surgery. This improvement occurred even though the sticker was used in slightly fewer than half the cases.

A comparison of four shoulder-specific questionnaires in primary care

OBJECTIVES

To compare the validity, responsiveness to change, and user friendliness of four self completed, shoulder-specific questionnaires in primary care.

METHODS

A cross sectional assessment of validity and a longitudinal assessment of responsiveness to change of four shoulder questionnaires was carried out: the Dutch Shoulder Disability Questionnaire (SDQ-NL); the United Kingdom Shoulder Disability Questionnaire (SDQ-UK); and two American instruments, the Shoulder Pain and Disability Index (SPADI) and the Shoulder Rating Questionnaire (SRQ). 180 primary care consulters with new shoulder region pain each completed two of the questionnaires, as well as EuroQoL and 10 cm visual analogue scales (VAS) for overall pain and difficulty due to the shoulder problem. Each participant was assessed by a standardised clinical schedule. Postal follow up at 6 weeks included baseline measures and self rated assessment of global change of the shoulder problem (seven point Likert scale).

RESULTS

Strongest correlations were found for SDQ-UK with EuroQoL 5 score, and for SPADI and SRQ with shoulder pain and difficulty VAS. All shoulder questionnaires correlated poorly with active movement at the painful shoulder. SPADI and SRQ performed better on ROC analysis than SDQ-NL and SDQ-UK (areas under the curve of 0.87, 0.85, 0.77, and 0.77, respectively). However, SRQ scores changed significantly over time in stable subjects.

CONCLUSIONS

Cross sectional comparison of the four shoulder questionnaires showed they had similar overall validity and patient acceptability. SPADI and SRQ were most responsive to change. Additionally, SPADI was the quickest to complete and scores did not change significantly in stable subjects.

Using fragment chemistry data mining and probabilistic neural networks in screening chemicals for acute toxicity to the fathead minnow

The paper is illustrating how the general data mining methodology may be adapted to provide solutions to the problem of high throughput virtual screening of organic chemicals for possible acute toxicity to the fathead minnow fish. The present approach involves mining fragment information from chemical structures and is using probabilistic neural networks to model the relationship between structure and toxicity. Probabilistic neural networks implement a special class of multivariate non-linear Bayesian statistical models. The mathematical principles supporting their use for value prediction purposes are clarified and their peculiarities discussed. As part of the research phase of the data mining process, a dataset consisting of 800 structures and associated fathead minnow (Pimephales promelas) 96-h LC50 acute toxicity endpoint information is used for both the purpose of identifying an advantageous combination of fragment descriptors and for training the neural networks. As a result, two powerful models are generated. Model 1 implements the basic PNN with Gaussian kernel (statistical corrections included) while Model 2 implements the PNN with Gaussian kernel and separated variables. External validation is performed using a separate dataset consisting of 86 structures and associated toxicity information. Both learning and generalization capabilities of the two models are investigated and their limitations discussed.

Type 2 diabetes mellitus--genes or intrauterine environment? An embryo transfer paradigm in rats

AIMS/HYPOTHESIS

The familial predisposition to Type 2 diabetes mellitus is mediated by both genetic and intrauterine environmental factors. In the normal course of events, maternal genes always develop in the same uterus, thus restricting studies aimed at investigating the relative contribution of these factors. We have developed an embryo transfer paradigm in rats to overcome this difficulty.

METHODS

Euglycaemic female Wistar rats were superovulated and mated with male Wistar rats. The following day, fertilised eggs were transferred into pseudo-pregnant female Wistar rats or hyperglycaemic Goto Kakizaki (GK) rats. Pregnancies were allowed to go to term. Offspring were weighed at 6 weeks, 3 months and 6 months of age and an intravenous glucose tolerance test was carried out at 6 months of age.

RESULTS

Offspring from Wistar into Wistar embryo transfers (n=20) were not significantly hyperglycaemic compared to the non-manipulated Wistar stock colony (n=26). However, offspring from Wistar gametes reared in hyperglycaemic GK mothers (n=51) were significantly lighter at 6 weeks of age (156+/-4.1 g vs 180+/-6.1 g [mean +/- SEM], p<0.01) and significantly more hyperglycaemic at 6 months of age (fasting glucose 6.6+/-0.18 mmol/l vs 4.8+/-0.21 mmol/l, mean blood glucose during glucose tolerance test 14.3+/-0.31 mmol/l vs 11.1+/-0.28 mmol/l, p<0.01) than Wistar gametes transferred back into euglycaemic Wistar mothers. When GK rats were superovulated and mated together, transfer of 1-day-old embryos into pseudo-pregnant Wistar dams did not alleviate hyperglycaemia in adult offspring.

CONCLUSIONS/INTERPRETATION

In GK rats, a euglycaemic intrauterine environment cannot overcome the strong genetic predisposition to diabetes. However, in Wistar rats with a low genetic risk of diabetes, exposure to hyperglycaemia in utero significantly increases the risk of diabetes in adult life.

Phosphate glasses for tissue engineering: Part 1. Processing and characterisation of a ternary-based P2O5-CaO-Na2O glass system

This paper presents the results of a study of the thermal properties, X-ray powder diffraction (XRPD), NMR and solubility of a range of phosphate-based glasses. Ion release and pH measurements were also obtained. The compositions were limited by fixing the P2O5 mol% content at 45, 50 and 55 mol%, and varying the CaO mol% at 30, 35 and 40 mol%. Initial data collected from thermal analysis showed an increase in the Tg values, with increasing CaO mol%, as expected. An increase in crystallisation temperatures with increasing CaO mol% was also observed, with sharp peaks indicating the presence of single and/or double phases. Initial XRPD data revealed that the 45 mol% P2O5 precipitated a calcium bridged trimetaphosphate (Na4Ca[PO3]6) at the sodium oxide contents of 25 and 20 mol%, but at the 15 mol% level two phases formed, NaCa[PO3]3 and Ca2P2O7. The 50 mol% P2O5 compositions showed two sodium phosphate-rich phases [NaCa(PO3)3 and NaPO3] for the lower calcium containing compositions, and a calcium phosphate phase [CaP2O6] for compositions with higher CaO mol%. The 55 mol% P2O5 compositions, exhibited similar phases for the lower calcium containing compositions, and a single calcium phosphate phase (CaP2O6) was identified for the higher calcium containing composition. NMR analysis revealed the presence of Q1 and Q2 species in the 45 mol% P2O5 compositions, and Q2 species present in the 50 and 55 mol% P2O5 compositions. The non-linear data obtained from the thermal and solubility analyses conducted were attributed to the packing density of the 45 mol% P2O5 compositions. The solubility was seen to decrease with increasing CaO mol%, for all the glasses investigated, and all the compositions showed a gradual decrease in pH with time, and this was accounted for by the release of Na+ and Ca2+ ions into solution.

Phosphate glasses for tissue engineering: Part 2. Processing and characterisation of a ternary-based P2O5-CaO-Na2O glass fibre system

This paper presents the results of a study of the thermal properties, solubility and dimensions of a range of phosphate-based glass fibres (PB-GFs). The glass compositions were limited by fixing the P2O5 content to 45, 50 and 55 mol%, and varying the CaO mol% at 30, 35 and 40. PB-GFs were obtained from the 50 and 55 mol% P2O5 compositions; however, we were unable to obtain fibres from the 45 mol% compositions. This was linked to the cross-linked density, network connectivity and average chain length of the compositions studied. With regards to thermal parameters investigated, initial data showed an increase of the Tg and crystallisation temperatures with increasing CaO mol% at each fixed phosphate content. A decrease in Tg temperatures was also observed with increasing P2O5 content to 55 mol%. The crystallisation temperatures obtained for compositions with fixed phosphate at 55 mol%, showed a reverse pattern, with a decrease in values as compared to the fixed 50 mol% phosphate compositions. The diameters of the fibres all decreased with increasing RPMs as expected, and the solubility also increased with increasing RPMs. This was related to the increased surface area of the higher RPM fibres. There was also a decrease seen in solubility with increasing CaO mol%.

A novel in situ assay for the identification and characterization of soluble nuclear mobility factors

The development of green fluorescent protein (GFP) technology combined with live cell microscopy techniques have revealed the dynamic properties of GFP-tagged proteins in the nucleus. The mobility of a GFP-tagged protein can be assessed using a quantitative photobleaching technique, fluorescence recovery after photobleaching (FRAP) analysis. FRAP experiments demonstrate that many nuclear proteins are highly mobile within the nucleus. However, the factors within the nucleus that regulate this mobility are not known. This is partly due to an absence of protocols that can be used to identify such nuclear mobility factors. We developed a novel in situ assay that combines a biochemical permeabilization and extraction procedure with a quantitative FRAP technique, a method we used to uncover a new functional role for molecular chaperones in the nuclear mobility of steroid receptors. This assay can readily be adapted to identify and characterize other nuclear mobility factors.

Prophylactic aspirin use in the adult general population

BACKGROUND

The aim of the study was to establish the prevalence and patterns of aspirin use in people with vascular problems.

METHODS

A cross-sectional population survey was carried out on a stratified random sample of 10,000 adults aged 35 and over in North Staffordshire.

RESULTS

A total of 6322 adults replied to the questionnaire (adjusted response 67 percent). The prevalence of vascular problems was 12.9 percent, and 67.6 per cent of respondents were using aspirin. The main association with aspirin use was previous advice about aspirin: adults who recalled being given advice were more likely to be using aspirin. Increasing age, disease severity and level of deprivation were also associated with increased aspirin use. Of adults without vascular problems, 7.1 percent also reported using aspirin regularly.

CONCLUSIONS

There is still potential to increase aspirin use in those with vascular problems. The extent and quality of health care professionals' advice may be an important area to target. The reasons why some people without vascular problems take regular aspirin is an area for further investigation.

Sex determination by PCR analysis of DNA extracted from incinerated, deciduous teeth

Establishing the biological sex of human remains is a very important part of identifying victims of fire when severe soft tissue destruction has occurred. Deciduous (children's) teeth were exposed to a range of incineration temperatures 100-500 degrees C for 15 minutes. Polymerase Chain Reaction (PCR) amplification was used to identify specific human amelogenin regions. There was successful identification of human biological sex, from deciduous teeth exposed to incineration temperatures of 200 degrees C and below, using standard ethidium bromide gel staining. There was greater sensitivity using fragment analysis by laser induced fluorescence which achieved sex identification from some teeth heated to 400 degrees C.

Consent for regional anaesthesia in the United Kingdom: what is material risk?

Legal principles that apply to the process of informed consent have changed in recent years. Patients should now be given the information that they wish to receive, not the information that health professionals may consider reasonable for them. In obstetric practice informed consent is especially important as young, fit patients may request and receive non-essential but potentially life-threatening interventions. The quantity and detail of information parturients desire do not remain static. They vary over time and from country to country. Our paper examines current opinion amongst parturients in the United Kingdom. We asked 100 obstetric patients to choose the complications of regional anaesthesia that they would like to learn about during informed consent. Nearly all women (82-94%) wished to know about common, less severe side effects. A substantial majority (70-77%) also wished to know about rarer but more severe complications, such as permanent neurological deficit, meningitis and high spinal block. Despite the availability of information for patients from sources such as the Obstetric Anaesthetists' Association and the National Electronic Library for Health, there remains little consensus amongst anaesthetists about what information to provide. Frequently some complications that patients would consider important are not discussed. Changing legal and public expectations demand that we adapt our current practice and improve the accuracy and timing of information provided.

Structure-function of human 3 alpha-hydroxysteroid dehydrogenases: genes and proteins

Four soluble human 3 alpha-hydroxysteroid dehydrogenase (HSD) isoforms exist which are aldo-keto reductase (AKR) superfamily members. They share 86% sequence identity and correspond to: AKR1C1 (20 alpha(3 alpha)-HSD); AKR1C2 (type 3 3 alpha-HSD and bile-acid binding protein); AKR1C3 (type 2 3 alpha-HSD and type 5 17 beta-HSD); and AKR1C4 (type 1 3 alpha-HSD). Each of the homogeneous recombinant enzymes are plastic and display 3-, 17- and 20-ketosteroid reductase and 3 alpha- 17 beta- and 20 alpha-hydroxysteroid oxidase activities with different k(cat)/K(m) ratios in vitro. The crystal structure of the AKR1C2.NADP(+).ursodeoxycholate complex provides an explanation for this functional plasticity. Ursodeoxycholate is bound backwards (D-ring in the A-ring position) and upside down (beta-face of steroid inverted) relative to the position of 3-ketosteroids in the related rat liver 3 alpha-HSD (AKR1C9) structure. Transient transfection indicates that in COS-1 cells, AKR1C enzymes function as ketosteroid reductases due to potent inhibition of their oxidase activity by NADPH. By acting as ketosteroid reductases they may regulate the occupancy of the androgen, estrogen and progesterone receptors. RT-PCR showed that AKRs are discretely localized. AKR1C4 is virtually liver specific, while AKR1C2 and AKR1C3 are dominantly expressed in prostate and mammary gland. AKR1C genes are highly conserved in structure and may be transcriptionally regulated by steroid hormones and stress.

Immunoassay for wild-type protein in lymphocytes predicts germline mutations in patients at risk for hereditary colorectal cancer

Using colorectal cancer (CRC) as an example, we present the hypothesis that quantitative immunoassays for wild-type (full-length) proteins can be used to identify carriers of traits for hereditary diseases. In the case of hereditary CRC, this involves identifying individuals with germline mutations in a mismatch-repair (MMR) gene (mainly hMSH2 or hMLH1) or in the adenomatous polyposis coli (APC) gene. Because expression of wild-type protein should reflect wild-type gene dosage, we predicted that individuals harboring a germline mutation will have a reduction of approximately 50% in expression in lymphocytes of the corresponding full-length protein. In this pilot study, we tested lymphoblastoid cell lines that had been established from controls and individuals with, or at high risk for, hereditary CRC: 9 lines from healthy, unaffected individuals; 4 from affected members in familial adenomatous polyposis families (with known germ-line APC mutation); 42 from CRC patients in our Familial CRC Registry (increased risk of hereditary nonpolyposis colon cancer as assessed by family history, age at adenoma or carcinoma diagnosis, and other clinical criteria). For MSH2 and MLH1 we used western blots; for APC we used immunoprecipitation. All familial adenomatous polyposis lines had about 50% less immunoprecipitable full-length APC protein. Some cell lines (7 of 42) from Familial CRC Registry patients showed on western blots a reduction (mean 46%) in either MSH2 or MLH1 (relative to the other protein). All 7 subsequently were proved to contain a germline MMR mutation. We conclude that (1) because most of the expected CRC-causing germ line mutations are truncation-causing, immunoassays for wild-type protein should be able to identify most individuals with hereditary CRC-causing traits; (2) these assays, which are more practical and inexpensive than current mutation-detecting tests for hereditary CRC traits, have the potential for commercial development into broad-based population screens of high-risk patients and their families and the potential to save both lives and health-care dollars; (3) this strategy may be useful for other hereditary cancers and even other hereditary diseases; (4) our approach has the potential to greatly benefit public-health programs for cancer control.

Predicting the biodegradation products of perfluorinated chemicals using CATABOL

Perfluorinated chemicals (PFCs) form a special category of organofluorine compounds with particularly useful and unique properties. Their large use over the past decades increased the interest in the study of their environmental fate. Fluorocarbons may have direct or indirect environmental impact through the products of their decomposition in the environment. It is a common knowledge that biodegradation is restricted within non-perfluorinated part of molecules: however, a number of studies showed that defluorination can readily occur during biotransformation. To evaluate the fate of PFCs in the environment a set of principal transformations was developed and implemented in the simulator of microbial degradation using the catabolite software engine (CATABOL). The simulator was used to generate metabolic pathways for 171 perfluorinated substances on Canada's domestic substances list. It was found that although the extent of biodegradation of parent compounds could reach 60%, persistent metabolites could be formed in significant quantities. During the microbial degradation a trend was observed where PFCs are transformed to more bioaccumulative and more toxic products. Perfluorooctanoic acid and perfluorooctanesulfonate were predicted to be the persistent biodegradation products of 17 and 27% of the perfluorinated sulphonic acid and carboxylic acid containing compounds, respectively.

Psychological interventions for non-ulcer dyspepsia

BACKGROUND

Studies have also shown that NUD patients have higher scores of anxiety, depression, neurotism, chronic tension, hostility, hypochondriasis, and tendency to be more pessimistic when compared with the community controls. However, the role of psychological interventions in NUD remains uncertain.

OBJECTIVES

This review aims to determine the effectiveness of psychological interventions including psychotherapy, psychodrama, cognitive behavioral therapy, relaxation therapy and hypnosis in the improvement of either individual or global dyspepsia symptom scores and quality of life scores patients with NUD.

SEARCH STRATEGY

Trials were located through electronic searches of the Cochrane Controlled Trials Register (CCTR), MEDLINE, EMBASE, CINAHL and PsycLIT, using very broad subject headings and text words. Bibliographies of retrieved articles were also searched and experts in the field were contacted.

SELECTION CRITERIA

All randomised controlled trials (RCTs) or quasi-randomised studies assessing the effectiveness of psychological interventions (including psychotherapy, psychodrama, cognitive behavioural therapy, relaxation therapy and hypnosis) for non-ulcer dyspepsia (NUD) were identified.

DATA COLLECTION AND ANALYSIS

Data collected included individual, global dyspepsia symptom scores and quality of life (QoL) scores.

MAIN RESULTS

We identified only four trials, each using different psychological interventions and three presenting results in a manner, that did not allow synthesis of the data to form a meta-analysis. All trials suggest that psychological interventions benefit dyspepsia symptoms and this effect persists for one year. However, all trials use statistical techniques that adjusted for baseline differences between groups. This should not be necessary for a randomised trial that is adequately powered suggesting that the sample size of these papers was too small. Unadjusted data was not statistically significant. The other problem of psychological intervention include low recruitment and high drop out rate which has been shown to be greater in patients receiving group therapy.

REVIEWERS' CONCLUSIONS

There is currently insufficient evidence from this review to confirm the efficacy of psychological intervention in NUD. There is also no evidence on the combined effects of pharmacological and psychological therapy. Nevertheless, if there are any benefits of psychological therapies, they are likely to persist long-term and NUD is a chronic relapsing and remitting disorder. Psychological therapies may therefore be offered to patients with severe symptoms that have not responded to pharmacological therapies.

Psychological interventions for non-ulcer dyspepsia

BACKGROUND

Studies have also shown that NUD patients have higher scores of anxiety, depression, neurotism, chronic tension, hostility, hypochondriasis, and tendency to be more pessimistic when compared with the community controls. However, the role of psychological interventions in NUD remains uncertain.

OBJECTIVES

This review aims to determine the effectiveness of psychological interventions including psychotherapy, psychodrama, cognitive behavioral therapy, relaxation therapy and hypnosis in the improvement of either individual or global dyspepsia symptom scores and quality of life scores patients with NUD.

SEARCH STRATEGY

Trials were located through electronic searches of the Cochrane Controlled Trials Register (CCTR), MEDLINE, EMBASE, CINAHL and PsycLIT, using very broad subject headings and text words. Bibliographies of retrieved articles were also searched and experts in the field were contacted.

SELECTION CRITERIA

All randomised controlled trials (RCTs) or quasi-randomised studies assessing the effectiveness of psychological interventions (including psychotherapy, psychodrama, cognitive behavioural therapy, relaxation therapy and hypnosis) for non-ulcer dyspepsia (NUD) were identified.

DATA COLLECTION AND ANALYSIS

Data collected included individual, global dyspepsia symptom scores and quality of life (QoL) scores.

MAIN RESULTS

We identified only four trials, each using different psychological interventions and three presenting results in a manner, that did not allow synthesis of the data to form a meta-analysis. All trials suggest that psychological interventions benefit dyspepsia symptoms and this effect persists for one year. However, all trials use statistical techniques that adjusted for baseline differences between groups. This should not be necessary for a randomised trial that is adequately powered suggesting that the sample size of these papers was too small. Unadjusted data was not statistically significant. The other problem of psychological intervention include low recruitment and high drop out rate which has been shown to be greater in patients receiving group therapy.

REVIEWER'S CONCLUSIONS

There is currently insufficient evidence from this review to confirm the efficacy of psychological intervention in NUD. There is also no evidence on the combined effects of pharmacological and psychological therapy. Nevertheless, if there are any benefits of psychological therapies, they are likely to persist long-term and NUD is a chronic relapsing and remitting disorder. Psychological therapies may therefore be offered to patients with severe symptoms that have not responded to pharmacological therapies.

Multiple microaneurysms of the superior hemorrhoidal artery: unusual recurrent massive rectal bleeding: report of a case

A case of massive rectal bleeding in a 38-year-old male patient from a previously unreported source is presented. Multiple microaneurysms affecting the rectum were demonstrated on an inferior mesenteric artery angiogram. The importance of angiography both for diagnosis and potential therapy in patients with continuous active lower gastrointestinal bleeding is emphasized.

Neurologic defects and selective disruption of basement membranes in mice lacking entactin-1/nidogen-1

Entactin-1 (nidogen-1) is an ubiquitous component of basement membranes. From in vitro experiments, entactin-1 was assigned a role in maintaining the structural integrity of the basement membrane because of its binding affinity to other components, such as type IV collagen and laminin. Entactin-1 also interacts with integrin receptors on the cell surface to mediate cell adhesion, spreading, and motility. Targeted disruption of the entactin-1 gene in the mouse presented in this study revealed a duplication of the entacin-1 locus. Homozygous mutants for the functional locus lacked entactin-1 mRNA and protein and often displayed seizure-like symptoms and loss of muscle control in the hind legs. The behavior patterns suggested the presence of neurologic deficits in the central nervous system, thus providing genetic evidence linking entactin-1 to proper functions of the neuromuscular system. In homozygous mutants, structural alterations in the basement membranes were found only in selected locations including brain capillaries and the lens capsule. The morphology of the basement membranes in other tissues examined superficially appeared to be normal. These observations suggest that the lost functions of entactin-1 result in pathologic changes that are highly tissue specific.

Health status in patients awaiting hip replacement for osteoarthritis

BACKGROUND

Hip osteoarthritis is a major cause of pain and disability, especially in the elderly. As part of a study investigating factors that could be associated with advanced osteoarthritis of the hip, we compared the health status of patients awaiting arthroplasty for hip osteoarthritis with controls. We further investigated the interaction of hip osteoarthritis with other variables (age, gender, social class and concurrent pain) in relation to health status.

METHODS

A case-control study was performed in two English health districts (Portsmouth and North Staffordshire) during 1993-1995. A total of 611 patients (210 men and 401 women) listed for hip replacement because of osteoarthritis over an 18-month period formed the case group and were compared with an equal number of controls selected from the general population and individually matched for age, gender and general practice. Cases and controls completed a structured interviewer-administered questionnaire, which included queries about their medical condition, occupation (from which a measure of social class was derived), and general health status using the SF36.

RESULTS

Physical function (t=32.1, P<0.001), social function (t=16.8, P<0.001) and perceived general health (t=4.1, P<0.001) were worse in the case group, but energy/vitality and mental health showed little difference between cases and controls. Cases were more likely to report knee pain than controls, but case-control status was not associated with pain in the fingers or shoulders, or with social class. However, differences in physical and social function between cases and controls did vary with socio-demographic factors and concurrent knee pain status.

CONCLUSION

Patients awaiting hip-replacement because of osteoarthritis were more likely to be restricted in their physical and social life than adults in the general population, but mental state and vitality appear unimpaired in this group. This contrasts with findings from other chronic pain disorders. Manual social class is not linked to being on a waiting list for osteoarthritic hip replacement but does add to the burden on health status, particularly social functioning in those with osteoarthritis of the hip.

Management of pregnancy in women with pulmonary hypertension secondary to SLE and anti-phospholipid syndrome

Pulmonary hypertension is found in about 10% of patients with systemic lupus erythematosis (SLE). Pulmonary hypertension may be present at the time of diagnosis or may develop after the diagnosis of SLE or anti-phospholipid syndrome (APS). It often presents in the reproductive years and has a significant impact on pregnancy outcome, being a significant cause of indirect maternal deaths. In our observational case series of three patients there were two deaths (66%). In cases 1 and 2 the pulmonary hypertension developed during pregnancy and deteriorated rapidly with markedly abnormal mean pulmonary artery pressures of 80 and 70 mmHg respectively prior to death. Both patients died within 48 hours of delivery. In case 3 the pulmonary hypertension was milder and was diagnosed very early in pregnancy. The patient received multidisciplinary care from the first trimester and the management of the pregnancy, delivery and the early puerperium was planned. Careful epidural anaesthesia was used and the patient had invasive monitoring on the intensive therapy unit (ITU) for 72 hours. Women with pulmonary hypertension need to be aware of the high risk of maternal mortality associated with pregnancy but we believe that an improvement in outcome can be achieved by careful assessment and the use of a multidisciplinary approach from early in pregnancy.

Central nerve block and coagulation: a survey of obstetric anaesthetists

We conducted a survey amongst anaesthetists in 264 obstetric units in the UK to examine their practice in relation to potential clotting abnormalities. The survey was conducted between July and November 1998 and shows a varied opinion and practice. We received a return of 226 (86%) with 64-78% of respondents willing to perform a central nerve block at a platelet count of 80 x 10(9)/L or more. Patients on aspirin alone or aspirin and heparin would be given a central nerve block by up to 96% and 43% of respondents respectively. Following administration of heparin, up to 22% of respondents would perform a central nerve block within 2 h while up to 64% would wait beyond 4 h. Eighty-five units had departmental policies on the removal of epidural catheters but only 15 differentiated between unfractionated and low molecular weight heparin.

The impact of sporadic campylobacter and salmonella infection on health and health related behaviour: a case control study

The aim of the work was to explore the impact on general and psychological health of those with a proven bacterial gastrointestinal infection and to compare this with controls from whom no bacterial pathogen was identified. A case control study was conducted using an interviewer-administered questionnaire. Thirty-nine cases from whose faeces salmonella or campylobacter had been cultured were compared with matched controls. Reported gastrointestinal symptoms, general health and self-reported hygiene practices were compared. At the time of acute illness the General Household Questionnaire suggested similar levels of morbidity, though by follow up the controls were substantially more likely to be distressed. Cases were more likely to have changed their food preparation practices, to avoid certain eating places and to have been given advice about food preparation. In this small study a positive diagnosis of salmonella or campylobacter seems to have had a reassuring effect when compared with those for whom no diagnosis was made.

Bleeding angiodysplasia: should we concentrate more on the aortic valve than on the bowel?

A case of bleeding from angiodysplasia in association with aortic stenosis is presented. The particular interest in this patient is that the bleeding ceased immediately after the insertion of a bioprosthetic valve and recurred when the valve restenosed. Furthermore, the bleeding again promptly resolved when the valve was exchanged for a metallic prosthesis despite long-term anticoagulation. The implications of these observations are discussed.

Chronic shoulder pain in the community: a syndrome of disability or distress?

OBJECTIVES

To investigate two questions in a community based population of people with chronic shoulder pain. Firstly, does chronic pain lead to impaired psychological health over time? Secondly, how does restriction of daily activity influence pain perception and psychological health?

METHODS

Two postal surveys, two years apart, were carried out to identify a group of subjects with chronic shoulder pain. The first survey was sent to a random sample of adults (n=40026) registered with a primary care practice, and included a pain manikin, demographic information, and the Hospital Anxiety and Depression scale (HAD). The second survey was sent to those subjects who reported unilateral shoulder region pain in the first survey and it included a shoulder-specific disability scale, pain severity score, and the HAD.

RESULTS

2606 (65.1%) people responded to the initial survey. Of these, 304 (11.7%) reported unilateral shoulder region pain at baseline. In the subsequent survey, there were 234 responders (83.3% adjusted response): 142 of these reported shoulder pain and formed our study group of "subjects with chronic shoulder pain". Within this group there was no significant change in psychological distress scores between baseline and follow up. Both the disability score and psychological distress scores correlated significantly with pain severity (disability v pain r=0.536, p<0.001; psychological distress v pain r=0.269, p=0.002). When the correlation between disability and pain severity was corrected for possible confounders, it remained significant (r=0.490, p<0.001). This was not the case for the correlation between psychological distress and pain (p>0.05). Disability was significantly correlated with psychological distress on univariate (r=0.445, p<0.001) and multivariate analysis (r=0.341, p=0.002).

CONCLUSION

In those with chronic shoulder pain the relation between pain and psychological health seems to be linked to disability. Psychological distress was not explained by persistent pain itself.

[Trends of OC use 1980-1999 in a German cohort of women]

INTRODUCTION

There is no doubt, oral contraceptives are a safe, reversible and commonly used method of contraception. Ever use is about 80 % in developed countries and current use of OCs about 40 %. Almost all information about prevalence of OC use came from cross-sectional studies and did not distinguish between high- and low-dose OCs. This paper deals with the prevalence of OC use as it was observed during lifetime of a large cohort of German women by calendar year and estrogen content.

METHODS

The prevalence of OC use between 1980 to 1999 was analysed on occasion of an interim analysis of the German cohort study on women's health. This analysis is based on more than 10 000 women with about 390 000 women-years of observation.

RESULTS

The proportion of women under the age of 50, that ever used OCs, increased steeply from 1980, i. e. from 62 % (1980) to about 90 % from 1996 onward. The proportion of current users in a given calendar year rose from 44 % (1980) to 49 % (1991-95) and dropped after the "pill crisis 1995". The percentage of current users who used high-estrogen-dose OCs dropped from 32 % (1980) to 5 % (1999). In contrast, the percentage of users of low-dose OCs of the 2nd generation steeply increased as was the percentage of users of the 3rd generation pills, however the latter dropped after 1995.

CONCLUSION

The high acceptance of oral contraceptives despite many "pill crises" underlines the continuously high appreciation of their efficacy on the one hand, but underscores also the high responsibility of physicians and industry concerning surveillance or reduction of discussed side effects.

A comparative study of the effects of carbamazepine and the NMDA receptor antagonist remacemide on road tracking and car-following performance in actual traffic

RATIONALE

Antiepileptic drugs are known to produce side effects which may impair driving performance. Performance effects, however, may differ substantially between individual antiepileptic drugs.

OBJECTIVE

To compare the effects of carbamazepine, remacemide, and placebo on actual driving performance during a 12-day incremental dosing regimen.

METHODS

Twenty-two healthy volunteers participated in a three-way, double-blind, cross-over driving study. Treatment effects were assessed in two actual driving tests carried out on days 8, 10, and 12 of each treatment period. The Road Tracking Test involved driving an instrumented vehicle at a constant speed and steady lateral position between the delineated lane boundaries. Standard deviation of lateral position (SDLP) was measured to indicate precision of road tracking control. The Car-Following Test involved driving the same vehicle behind a leading car and maintaining that distance while the latter executed a series of deceleration/acceleration maneuvers. Time to speed adaptation (TSA) and brake reaction time were the primary measures.

RESULTS

Remacemide did not affect the subjects' driving performance. Carbamazepine increased SDLP throughout treatment and lengthened TSA on day 8. Changes in SDLP relative to placebo were comparable to those previously seen in drivers conducting the same test with blood alcohol concentrations of 0.05 g/dl.

CONCLUSION

Remacemide, at the given dose regimen, does not affect driving performance. Carbamazepine, at the given dose regimen, can produce mild but sufficient impairment to put epileptic patients at risk when driving, at least during initiation therapy.

Crystal structure of the lambda repressor C-terminal domain octamer

The three-dimensional structure of the lambda repressor C-terminal domain (CTD) has been determined at atomic resolution. In the crystal, the CTD forms a 2-fold symmetric tetramer that mediates cooperative binding of two repressor dimers to pairs of operator sites. Based upon this structure, a model was proposed for the structure of an octameric repressor that forms both in the presence and absence of DNA. Here, we have determined the structure of the lambda repressor CTD in three new crystal forms, under a wide variety of conditions. All crystals have essentially the same tetramer, confirming the results of the earlier study. One crystal form has two tetramers bound to form an octamer, which has the same overall architecture as the previously proposed model. An unexpected feature of the octamer in the crystal structure is a unique interaction at the tetramer-tetramer interface, formed by residues Gln209, Tyr210 and Pro211, which contact symmetry-equivalent residues from other subunits of the octamer. Interestingly, these residues are also located at the dimer-dimer interface, where the specific interactions are different. The structures thus indicate specific amino acid residues that, at least in principle, when altered could result in repressors that form tetramers but not octamers.

Factors affecting over-the-counter use of aspirin in the secondary prophylaxis of cardiovascular disease

Little is known about the contribution of over-the-counter (OTC) aspirin to cardiovascular prophylaxis. To investigate this, a two-phase cross-sectional study was carried out in nine general practices in North Staffordshire. In the first phase, all patients with cardiovascular disease (CVD) were identified from computer searches using morbidity registers and drug searches. The search also identfied the subgroup receiving prescribed prophylactic aspirin. In the second phase, a questionnaire was posted to all patients with CVD who were not on prescribed aspirin to establish their current use of OTC aspirin. Overall, 69% of the CVD group used aspirin, with 26% of aspirin being OTC. OTC aspirin use was more common in those aged under 65 years, men, and the more affluent. Also, there were significant differences in OTC aspirin use between the various practices. This study shows that a considerable amount of aspirin is used OTC in those with CVD. Its use is influenced by several factors that could be addressed when considering attempts to improve the overall uptake of aspirin.

Use of a cross-sectional survey to estimate outcome of health care: the example of anxiety and depression

Our study proposes that a population-based cross-sectional survey can be used to estimate the outcome of health care by linking general practice morbidity records to the survey. Using the example of anxiety and depression to test this idea, we conducted a survey of an adult population registered with one general practice in the UK. The Hospital Anxiety and Depression (HAD) questionnaire was used to identify cases and controls. After mailing to a randomly selected adult population of 4002, there was an adjusted response rate of 66% (n = 2,606), with 416 (16%) high-score cases, 506 (19%) medium-score cases, and 1684 (65%) low-score controls. All cases were compared with a sample of controls (n = 450). In the 12 months before the survey, the high-score case group had experienced significantly higher GP contacts (n = 377 [91%] versus 354 [79%]), diagnoses for anxiety or depression (119 [29%] versus 21 [5%]), and related drug treatments (111 [27%] versus 22 [5%]) compared with the control sample. Most of the diagnoses and drug treatments had been initiated at least 9 months before the survey. The linkage between the survey and the clinical records suggested that the health outcome of previously identified anxious and depressed patients was poor, with an estimated two-thirds who will not have fully recovered within an average of 9 months. This study demonstrates the potential for using cross-sectional population surveys to estimate not only the need for health care but also the outcome of health care.

Method for qualifying microbial removal performance of 0.1 micron rated filters. Part III: bacterial challenge tests on 0.2/0.22 and 0.1 micron rated filter cartridges with Hydrogenophaga (formerly Pseudomonas) pseudoflava

We have previously reported on the preliminary characterization of Hydrogenophaga (formerly Pseudomonas) pseudoflava for potential use as a standard challenge organism to qualify 0.1 microm rated filters. This article reports on the retention efficiencies of a large panel of 0.2/0.22 microm and 0.1 microm rated filter cartridges for H. pseudoflava (ATCC 700892) versus the retention capabilities of the same filters for Brevundimonas diminuta (ATCC 19146). A total of thirty-two 0.2/0.22 microm rated filter cartridges, spanning nine different "sterilizing grade" filter types from four different filter manufacturers, were challenged with H. pseudoflava at challenge levels exceeding 10(7) cfu/cm2. H. pseudoflava was shown to penetrate every 0.2/0.22 microm rated filter tested, with log titer reduction (LTR) values ranging from 3.5 to 7.7 logs. H. pseudoflava was shown to be more penetrative than B. diminuta under the same challenge conditions. B. diminuta was fully retained by nineteen of the twenty 0.2/0.22 microm rated filters that were challenged with both organisms. In the case of 0.1 microm rated filters, eighteen filter cartridges, spanning five different filter types from three manufacturers were tested. H. pseudoflava was consistently retained by four out of the five filter types tested, with LTR values in excess of 11.5 to 12.2 logs. The 0.1 microm rated filter type that was penetrated by H. pseudoflava has been previously demonstrated to be not fully retentive for naturally occurring bacteria. The data show that H. pseudoflava penetrates 0.2/0.22 microm rated filters just as readily as B. diminuta penetrates 0.45 microm rated filters. In addition, titer reductions provided by 0.2/0.22 microm rated filters for H. pseudoflava are comparable to those reported for A. laidlawii mycoplasma, albeit under different conditions. This study demonstrates that H. pseudoflava meets all criteria for use as a standard organism for qualifying the microbial removal performance of 0.1 microm rated filters for enhanced sterility assurance.

Molecular evidence of mother-to-child transmission of HTLV-IIc in the Kararao Village (Kayapo) in the Amazon region of Brazil

Blood samples from native Indians in the Kararao village (Kayapo), were analysed using serological and molecular methods to characterize infection and analyse transmission of HTLV-II. Specific reactivity was observed in 3/26 individuals, of which two samples were from a mother and child. RFLP analysis of the pX and env regions confirmed HTLV-II infection. Nucleotide sequence of the 5' LTR segment and phylogenetic analysis showed a high similarity (98%) between the three samples and prototype HTLV-IIa (Mot), and confirmed the occurrence of the HTLV-IIc subtype. There was a high genetic similarity (99.9%) between the mother and child samples and the only difference was a deletion of two nucleotides (TC) in the mother sequence. Previous epidemiological studies among native Indians from Brazil have provided evidence of intrafamilial and vertical transmission of HTLV-IIc. The present study now provides molecular evidence of mother-to-child transmission of HTLV-IIc, a mechanism that is in large part responsible for the endemicity of HTLV in these relatively closed populations. Although the actual route of transmission is unknown, breast feeding would appear to be most likely.