Sonographers' perspectives on research - A worldwide online questionnaire study

INTRODUCTION

Research has been performed by sonographers (also known as ultrasound reporting radiographers) for many years for improving diagnosis of disease, developing new imaging approaches, and enhancing patient outcomes. Despite this, sonographers' perspectives on research have not been well studied. To understand the views of sonographers is essential, as they have an important role in the successful implementation of research outcomes during their daily work. The study aimed to explore sonographers' perspectives on research.

METHODS

This cross-sectional online questionnaire was developed, and pilot tested, before distribution on social media platforms by the research group to sonographers or reporting radiographers in ultrasound worldwide. The questionnaire included 21-items. The link was open for 8 weeks in the spring of 2023. A mix of closed, open and scale questions were used. Informed consent was mandatory, and information about the study and anonymity was presented.

RESULTS

A total of 165 sonographers participated in the questionnaire of which 66.1 % were from Europe (n = 109), 6.1 % from North America (n = 10), 0.6 % from South America (n = 1), 2.4 % from Asia (n = 4), 13.3 % from Africa (n = 22) and 11.5 % from Oceania (n = 19). A total of 32 % of the participants had performed research. Also, 68.5 % would like to become more involved in research.

CONCLUSION

Most sonographers work in large hospitals, and half of them have obtained academic level 7 education. A limited number of sonographers have published peer reviewed papers. Many sonographers expressed an interest in research. This suggests a potential for future development of the sonographers' role in research.

IMPLICATIONS FOR PRACTICE

The findings for this study provide insight that could be used to improve research practice for sonographers.

Ultrasound education across European Federation of Radiographers Societies (EFRS) countries: Similarities and differences

INTRODUCTION

Ultrasound education varies greatly across European healthcare systems. This paper focuses on ultrasound academic education as a part of wider suite of surveys on radiographers working in ultrasound. The aim was to investigate sonography educational levels, methods of training, course duration and other factors in European Federation of Radiographers Societies (EFRS) member countries.

METHOD

In 2019 an online survey was sent to the 38 EFRS member societies to distribute to higher education institutions within their own country. The survey was in English and contained different types of questions such as closed questions, free text options, and scale responses, to investigate sonography education including academic course types and duration, curriculum content, learning and teaching methods.

RESULTS

A total of 45 responses were received, showing wide variation in the duration of training between the respective countries. Academic level 7 (part-time) ultrasound education was most frequently reported (n = 13), followed by direct entry ultrasound courses (n = 9) and bachelor's degree programmes at EQF level 6 (n = 7). The duration of part-time courses ranged from nine months up to four years.

CONCLUSION

Sonography training and education varies among EFRS member countries ranging from short focused courses to postgraduate awards. Few countries offer sonography education leading to an award. The majority of clinical teaching and learning takes place in the learner's workplace.

IMPLICATIONS FOR PRACTICE

High quality academic and clinical education for radiographers extending their role into ultrasound is important to ensure safe, effective sonography practice and good patient care.

What makes a good clinical practice experience in radiography and sonography? An exploration of qualified clinical staff and student perceptions

INTRODUCTION

Clinical practice can be a challenging experience for some healthcare students. The quality of the clinical experience can have a profound effect on the overall student learning experience in clinical practice and attrition. The aim of the study was to explore the perceptions of an optimal clinical practice experience by radiography and sonography students and qualified clinical staff.

METHODS

A qualitative research design was adopted utilising focus groups (n = 5). The study population comprised of qualified radiography/sonography staff (n = 10) from across a number of placement sites used by City, University of London and radiography and sonography students (n = 15) from the same institution. Full verbatim transcriptions were analysed thematically.

RESULTS

Four key themes emerged: 1) favourable/unfavourable traits, 2) creating an optimal learning environment 3) challenges and 4) considerations for clinical education. Key factors for a positive learning experience included clinical supervisors being approachable, whilst encouraging and empowering students. Qualified radiography/sonography clinical staff highlighted student motivation as an important aspect for successful placement learning.

CONCLUSION

The study has provided an insight into a number of positive attributes that enhance student learning experiences whilst on clinical placement. Unhelpful attributes and challenges, such as student motivation and time limitations, were also revealed. It is important that supervisors within the clinical departments actively work towards the provision of a positive learning experience.

IMPLICATIONS FOR PRACTICE

This study can better inform clinical staff regarding the importance of enhancing the student learning experience and facilitating high quality learning within the clinical department. Moreover, to encourage clinical staff to ensure robust "support" is established for students on placement.

"It's not just the medical aspects that are important": A qualitative exploration of first-time parents' experiences of antenatal imaging and their influence on parent-fetal bonding

INTRODUCTION

Antenatal imaging provides clinical information regarding fetal growth and development. The additional benefit afforded by imaging for expectant parents in developing an emotional connection (bond) to the unborn baby is also acknowledged. However, the relationship between imaging and bonding is not fully understood, particularly where there are differing parental and pregnancy circumstances, for example use of advanced imaging techniques or the prenatal diagnosis of a congenital fetal condition. This study aimed to explore the role of antenatal imaging in enhancing the developing parent-fetal bond in first-time parents.

METHODS

A descriptive, qualitative methodology was used. Semi-structured telephone interviews were conducted with first-time expectant parents attending a London hospital for clinical ultrasound (n = 20) or research MRI (n = 8) imaging during pregnancy. The sample included parents receiving specialist antenatal care for a diagnosed fetal cardiac condition (n = 8). Thematic analysis was conducted.

RESULTS

The analysis generated three themes: 1) Our baby, our scan too; 2) Destination parenthood; and 3) Being in the dark, then finding the light. These themes highlight the important, but transient role of antenatal imaging in enhancing parent-fetal bonding, as well as the differing care needs of expectant parents. The integral role of healthcare professionals in providing a personalised, supportive, imaging experience to facilitate bonding is also reflected.

CONCLUSION

Adopting parent-centred care approaches which involve expectant parents in fetal imaging influences bonding by helping parents to consider the reality of their impending parenthood. Knowledge acquired during scans is used to create an identity for the unborn baby, which parents can develop an emotional connection to.

IMPLICATIONS FOR PRACTICE

To optimise the potential for enhanced parent-fetal bonding, care provision in fetal imaging should be tailored to the individual needs of expectant parents.

“It has been the most difficult time in my career”: A qualitative exploration of UK obstetric sonographers’ experiences during the COVID-19 pandemic

Introduction

Substantial changes were made to the provision of pregnancy ultrasound services during the COVID-19 pandemic with the intention of minimising virus transmission and maintaining service continuity. Published literature describing the impact of the pandemic on obstetric sonographers is predominantly quantitative in nature, however statistics cannot fully convey sonographers’ voices. This study aimed to gain a deeper understanding of the lived experiences of UK obstetric sonographers performing pregnancy ultrasound scans during the pandemic.

Methods

A UK-wide, online, anonymous cross-sectional survey on Qualtrics XM^TM was open to responses between 9^th March and 6^th May 2021. Whilst this survey contained some quantitative elements, open questions were included to capture additional qualitative detail from respondents about their perceptions and experiences of scanning during the pandemic. Key themes were generated from free text responses using thematic analysis.

Results

Written responses were received from 111/138 sonographers participating in the survey. Five themes were generated, depicting the impact of the pandemic on obstetric sonographers: 1) continuity in a crisis; 2) decisions about me, without me; 3) battle scars – the lasting damage of COVID-19; 4) what people think I do vs. what I really do; and 5) the human touch. A cross-cutting theme was sonographers’ feelings of disconnection from senior figures and expectant parents which created a sense of abandonment and distrust.

Conclusion

Survey respondents’ self-reported experiences of ineffective leadership and management, and perceived lack of understanding of the complexity of the sonographer role are potential contributory factors in the high levels of moral injury and occupational burnout reported within the workforce during the pandemic.

Implications for practice

Moral injury support and healing must be prioritised to enable the recovery of the obstetric ultrasound workforce in the post-pandemic era.

Radiographers' individual perspectives on sonography - A survey of European Federation of Radiographer Societies (EFRS)

INTRODUCTION

Radiographers can elect to work within many different modalities, one being ultrasound. Within Europe there are differing opinions about how much of a role radiographers should take in relation to the ultrasound examination, particularly report writing. This paper provides findings exploring the radiographer's views on working within sonography.

METHODS

In 2019 an electronic survey was disseminated to radiographer members by European Federation of Radiographer Societies (EFRS) national radiographer societies, following a pilot study. A mix of closed questions, free text, and scale responses aimed to investigate radiographers' practice, legal responsibilities, report writing, educational level and experiences of support and mentoring.

RESULTS

Of 561 radiographers participating, most (92%) reported performing ultrasound scans. Challenges with legislation, medical protectionism and lack of high-quality education restricted other radiographers. On average, the respondents have practiced ultrasound for 13.5 years. A total of 60% had postgraduate education and carried out a wide range of examinations. A full interpretative report, including advice on further investigations is performed by 52%, whilst 22% provide a checklist or descriptive report. Over 55% of radiographers took legal responsibility for the examination and the majority had clear protocols, good mentoring and support in the workplace. Peer review of their work was less common.

CONCLUSION

The result shows that in 21 (n = 25) countries radiographers perform ultrasound, however not without challenges. Educational levels range from no formal education or short courses to an MSc in ultrasound. Report writing practice differs across the EFRS countries responding to the survey, as does peer review to enhance skills and clinical practice.

IMPLICATIONS FOR PRACTICE

National Radiographer societies could review findings to support campaigning for a change in legislation and improvements to educational offerings in ultrasound.

Radiographers in ultrasound: Motivation and role expansion. A survey of European Federation of Radiographer Societies (EFRS)

INTRODUCTION

Variability in non-medical ultrasound practice across Europe has been highlighted in studies. Meanwhile, advanced practice in radiography has undergone rapid development in the United Kingdom (UK). This survey aimed to review results relating to extended role and advanced practice skills, motivation and job satisfaction from a wider survey of radiographers undertaking ultrasound examinations across the European Federation of Radiographer Societies' (EFRS) community.

METHODS

Following a pilot study, a SurveyMonkey™ on-line questionnaire was disseminated to EFRS member societies to share with their members, and via social media platforms. Quantitative questions for this article related to extended and advanced practice skills, communication of results, job satisfaction, motivation and career development. Theme analysis was used to assess qualitative feedback concerning priorities for future developments within the ultrasound role.

RESULTS

There were 561 responses, mainly from the UK, Ireland and Spain (81%). The majority (83.4%) of UK sonographers communicate findings to patients, compared with 27.1% in other EFRS countries. More engage with teaching (UK = 90.1%, non-UK 72.9%) compared with activities in the other advanced practice domains. The lowest involvement was the research domain, with only 33% actively involved in research. Radiographers were motivated to undertake ultrasound to develop their knowledge and skills and assume more responsibility.

CONCLUSION

Wide variations in ultrasound practice were seen across respondent countries. Generally, radiographers are happy with their ultrasound roles, although priorities include legislation for the sonographer role, remuneration, respect or support from medical colleagues, high quality education and role progression opportunities.

IMPLICATIONS FOR PRACTICE

The findings provide a better understanding of radiographer views which can assist radiographer societies and local teams to develop strategies to enhance advanced practice skills development and career prospects in ultrasound.

Evaluation of automated tool for two-dimensional fetal biometry

OBJECTIVE

To evaluate whether an automated tool can recognize a structure of interest and measure fetal head circumference (HC), abdominal circumference (AC) and femur length (FL) on frozen two-dimensional ultrasound images.

METHODS

Ultrasound examinations were performed in 100 singleton pregnancies between 20 and 40 weeks of gestation, ensuring an even distribution throughout gestational age. In each pregnancy, three standard biometric variables (HC, AC, FL) were measured each in three different images obtained for this purpose (i.e. nine independent image acquisitions). An algorithm (Philips Research) was used to detect the structure of interest and automatically place calipers for measurement. Caliper placement was assessed in two ways. First, subjective clinical assessment was performed to determine whether the caliper placement was correct, and caliper position was classified as 'acceptable for clinical use', 'minor adjustment required' or 'major adjustment required'. Second, the resulting automatic measurements were compared with manual measurements, taken in real time. Mean difference errors were calculated and expressed as percentages to correct for fetal growth with advancing gestation.

RESULTS

After exclusion of one pregnancy due to missing images, a total of 891 images (297 for each biometric variable) from 99 pregnancies were analyzed. The algorithm failed to place calipers for the AC in nine images, whereas there were no failures in caliper placement for measurement of HC and FL. On subjective quality assessment of automatic caliper placement, in 475 (53.3%) images position of the calipers was judged to be clinically acceptable and did not require any adjustment, while in 317 (35.6%) and 90 images (10.1%) minor and major adjustments were required, respectively. The mean error between manual and automatic measurement of HC was -0.21 cm corresponding to a percentage error of -0.81% with 95% limits of agreement (LOA) between -3.73% and 2.12%. For AC and FL measurements, the mean error was, respectively, 0.72 cm (percentage error, 2.40%) with LOA between -9.48% and 14.27%, and 0.21 cm (percentage error, 3.76%) with LOA between -8.38% and 15.91%.

CONCLUSIONS

The automated tool identified correctly the biometric variable of interest in 99% of frozen images. The resulting measurements had a high degree of accuracy and compared well with previously published manual-to-manual agreement. The measurements exhibited bias, with the automated tool underestimating biometry; this could be overcome by further improvements in the algorithm. Nevertheless, adjustable calipers for manual correction remains a requirement. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Neurosurgery videos on online video sharing sites: The next best teacher?

Background

E-learning platforms, especially the online neurosurgical video sharing sites, are playing a key role in the dissemination of knowledge related to the essential steps of operative neurosurgery.

Aim

A national survey was undertaken to assess the utility of neurosurgical operative videos exhibited on the online video-sharing sites.

Materials and Methods

Resident trainees in neurosurgery, as well as junior and senior consultant neurosurgeons practicing in India were provided, on the Google platform, a questionnaire consisting of nine multiple-choice questions and a space for remarks. 520 people were contacted using e mail and/or whattsapp modalities, out which 98 responses were considered valid.

Results

Majority (n = 87, 88.8%) of the responders voted that internet videos have helped them in improving their surgical skills. There was no statistically significant difference between people working in rural and urban areas in this regard (P = 0.517). Both senior and junior neurosurgeons were utilizing these online videos for enhancing their surgical skills, and there was no statistically significant difference regarding the perception of the usefulness of these online video channels between the two groups (P = 0.660). However, the response rate to the questionnaires sent was only 18.84%.

Conclusions

Online video-sharing platforms are useful, especially in a country like India with diverse neurosurgical infrastructure. The need for the development and maintenance of a dedicated, high-quality, structured video bank through collaboration and cooperation of high volume centers and institutes of repute in India is strongly advocated.

Understanding hepatitis C intervention success-Qualitative findings from the HepCATT study

The United Kingdom has committed to eliminating viral hepatitis as a public health threat. Innovative interventions for marginalized populations are required to realize this goal. In 2016, the HepCATT study team implemented a complex hepatitis C (HCV) intervention in three English drug treatment services, with five controls. We report qualitative study findings from two intervention sites to explore intervention success and transferability potential. The intervention comprised multiple components, including a nurse facilitator, peer support and education initiatives. Qualitative data were generated at baseline (2014) and post-intervention (2016) at two sites through in-depth interviews, focus groups and observations. The 96 participants comprised drug service and intervention providers and clients with an injecting history. Data were triangulated and thematically analysed. Client engagement with a HCV treatment service rose from 16 at baseline to 147 in 2016. There was no comparable increase at the five control sites. Baseline testing and treatment barriers included the following: limited HCV knowledge; fear of diagnosis and treatment; precarious living circumstances and service-specific obstacles. Treatment engagement was aided by intervention timeliness; improved communication structures; personalized care; streamlined testing and treatment pathways; peer support. Multiple interrelated components influenced the increased levels of treatment engagement documented in HepCATT. The nurse facilitator, involved in implementation and innovation, was key to intervention success. Baseline barriers correspond with international literature-indicating transferability potential. Control data indicate that biomedical innovation alone is not sufficient to increase engagement among the most marginalized. Sustainable resourcing of community services is crucial to effect change.

Second-trimester Down's syndrome serum screening: double, triple or quadruple marker testing?

Background: The recommendations of the UK National Screening Committee (NSC) are based on the findings of the Serum, Urine and Ultrasound Screening Study (SURUSS). Our study sought to establish if the SURUSS findings, in terms of detection rates (DR) and false-positive rates (FPR) for various second-trimester marker combinations, could be replicated in a local setting.

Methods: We investigated the effects of adding inhibin-A and unconjugated oestriol to our existing double test protocol. This retrospective study examined 1000 control pregnancies and 128 affected pregnancies.

Results: The inhibin-A method was associated with considerable assay drift and very marked within-batch imprecision (intrabatch percent coefficient of variation [CV] = 17%). At a cut-off of 1 in 250, the quadruple test showed a DR of 72%, the triple test 70% and the double test 63%. There were no significant differences between the FPRs for any of the combinations, which were all between 6.6% and 7.0% for a 1 in 250 cut-off.

Conclusions: In our view, the current inhibin-A assay is unacceptable as a screening marker due to poor assay performance. We have reviewed the NSC benchmark programme outcomes, and would suggest that the 2005 target of a DR of at least 60% with an FPR of less than 5% is achievable using triple testing in the second trimester in conjunction with universal scan dating. Our results suggest that the April 2007 target of a DR of 75% with an FPR of less than 3% is unachievable using current second-trimester maternal serum screening.

Uterine artery pulsatility and resistivity indices in pregnancy: Comparison of MRI and Doppler US

OBJECTIVE

The aim of this work was to evaluate whether the uterine arteries (UtA) could be identified and their flow profiles measured during a fetal MRI examination. A comparison was performed against same day sonographic Doppler assessment.

METHODS

35 normal, healthy, singleton pregnancies at 28-32 weeks gestation underwent routine Doppler examination, followed by MRI examination. The resistivity index (RI) and pulsatility index (PI) of the left and right UtA were measured using phase contrast MRI. Bland Altman statistics were used to compare MRI and ultrasound results.

RESULTS

Sixty-nine comparable vessels were analysed. Six vessels were excluded due to artefact or technical error. Bland-Altman analysis demonstrated the ultrasound indices were comparable, although systematically lower than the MRI indices; Right UtA RI bias -0.03 (95% limits of agreement (LOA) -0.27 to +0.20), and left UtA RI bias -0.06 (95% LOA -0.26 to +0.14); Right UtA PI bias -0.06 (95% LOA -0.50 to +0.38), Left UtA PI bias -0.11 (95% LOA -0.54 to +0.32). The inter-rater agreement for the MRI derived PI and RI analysis was good.

CONCLUSION

This study demonstrates that in the majority of early third trimester pregnancies, the uterine arteries can be identified, and their flow profiles measured using MRI, and that the derived PI and RI values are comparable with Doppler ultrasound values.

Educating the future sonographic workforce: membership survey report from the British Medical Ultrasound Society

The British Medical Ultrasound Society (BMUS), the Consortium for the Accreditation of Sonographic Education (CASE), education providers and the NHS are working together to review how best to develop education for the future sonographic workforce. There is currently a national vacancy rate of approximately 12% across NHS Trusts. Education course placements are often limited to the number of clinical training places available within departments, resulting in a disparity between vacancies and the numbers of qualified sonographers graduating. Clearly there is a need for education to match the service demand. A term often used as a solution to the workforce problem is 'direct entry' ultrasound education. Anecdotally this term has caused confusion amongst health care professionals and as such the aim of this work was to gain an understanding of the views and opinions of BMUS members and interested professionals about direct entry training and subsequent development of any future training programmes. BMUS undertook an online survey with 286 responses. The survey provided insight into the opinions of ultrasound practitioners and the complexities of developing a relevant educational programme for the future sonographer workforce. The results suggested a number of concerns with direct entry ultrasound programmes, including insufficient training places, lack of health care background knowledge, lack of imaging knowledge and no state registration specific to sonographers. Benefits of direct entry to ultrasound training were perceived to be increasing the number of sonographers trained each year, whilst training people in their first choice profession with skills developed specific to the sonographer role. Support for direct entry ultrasound training was limited to 51% of respondents who would advocate this form of ultrasound training if it led to qualified sonographers with the same skills as sonographers exiting from current CASE accredited programmes.

Mycotoxins that affect the North American agri-food sector: state of the art and directions for the future

This paper summarises workshop discussions at the 5th international MYCORED meeting in Ottawa, Canada (June 2012) with over 200 participants representing academics, government and industry scientists, government officials and farming organisations (present in roughly equal proportions) from 27 countries. Workshops centred on how mycotoxins in food and feed affect value chains and trade in the region covered by the North American Free Trade Agreement. Crops are contaminated by one or more of five important mycotoxins in parts of Canada and the United States every year, and when contaminated food and feed are consumed in amounts above tolerable limits, human and animal health are at risk. Economic loss from such contamination includes reduced crop yield, grain quality, animal productivity and loss of domestic and export markets. A systematic effort by grain producers, primary, transfer, and terminal elevators, millers and food and feed processers is required to manage these contaminants along the value chain. Workshops discussed lessons learned from investments in plant genetics, fungal genomics, toxicology, analytical and sampling science, management strategies along the food and feed value chains and methods to ameliorate the effects of toxins in grain on animal production and on reducing the impact of mycotoxins on population health in developing countries. These discussions were used to develop a set of priorities and recommendations.

Persistence of brodifacoum in cockroach and woodlice: implications for secondary poisoning during rodent eradications

When planning rodent eradications, that normally involve the use of the anticoagulant poison brodifacoum, it is imperative to minimise impacts on other "non-target" species that dwell alongside the targeted rodents and may indeed be the intended beneficiaries of the eradication. Such impacts can arise either from primary poisoning when the non-target species ingest bait pellets containing toxicant or by secondary poisoning when the non-target species eats prey that has itself eaten brodifacoum. Cockroaches and woodlice, likely to scavenge bait pellets, are widely distributed on tropical and sub-tropical islands where they are eaten by ground-dwelling birds. Combining work on Henderson Island, South Pacific, site of a recent rat eradication project, and UK laboratory experiments, our study first measured brodifacoum concentrations in cockroaches given temporary ad lib access to poison bait pellets, approximately mimicking the aftermath of bait distribution for a rodent eradication. In two separate experiments using different species/exposure times, the mean brodifacoum concentrations among cockroaches immediately after bait exposure was 262±s.e. 131 and 477±168µgkg(-1) wet weight. Values decreased quickly in the following 2 weeks, and then continued to decline at a slower rate over the following 4 weeks in the more prolonged laboratory experiment. A supplementary experiment with woodlice recorded a similar brodifacoum concentration in the animals at the end of the exposure period, 223±66µgkg(-1), and a similar time course for the post-exposure decline. In the context of rails (Rallidae), a group of birds known to be particularly susceptible to primary brodifacoum poisoning, these results suggested that, in terms of acute exposure, individual birds would need to eat a minimum of their own body weight (and more commonly 2-5 times that) of live cockroaches before facing a 50% risk of death. Therefore, we conclude that in eradication scenarios, acute secondary poisoning is of lower concern for these birds than primary poisoning.

Anatomic site variability in rat skeletal uptake and desorption of fluorescently labeled bisphosphonate

OBJECTIVES

Bisphosphonates commonly used to treat osteoporosis, Paget's disease, multiple myeloma, hypercalcemia of malignancy and osteolytic lesions of cancer metastasis have been associated with bisphosphonate-associated jaw osteonecrosis (BJON). The underlying pathogenesis of BJON is unclear, but disproportionate bisphosphonate concentration in the jaw has been proposed as one potential etiological factor. This study tested the hypothesis that skeletal biodistribution of intravenous bisphosphonate is anatomic site-dependent in a rat model system.

MATERIALS AND METHODS

Fluorescently labeled pamidronate was injected intravenously in athymic rats of equal weights followed by in vivo whole body fluorimetry, ex vivo optical imaging of oral, axial, and appendicular bones and ethylenediaminetetraacetic acid bone decalcification to assess hydroxyapatite-bound bisphosphonate.

RESULTS

Bisphosphonate uptake and bisphosphonate released per unit calcium were similar in oral and appendicular bones but lower than those in axial bones. Hydroxyapatite-bound bisphosphonate liberated by sequential acid decalcification was the highest in oral, relative to axial and appendicular bones (P < 0.05).

CONCLUSIONS

This study demonstrates regional differences in uptake and release of bisphosphonate from oral, axial, and appendicular bones of immune deficient rats.

The prevalence and trends of overweight, obesity and nutrition-related non-communicable diseases in the Arabian Gulf States

This paper reviews studies on the prevalence of overweight, obesity and related nutrition-related non-communicable diseases in Bahrain, Kuwait, Qatar, Oman, Saudi Arabia and the UAE. Obesity is common among women; while men have an equal or higher overweight prevalence. Among adults, overweight plus obesity rates are especially high in Kuwait, Qatar and Saudi Arabia, and especially among 30-60 year olds (70-85% among men; 75-88% among women), with lower levels among younger and elderly adults. The rate of increase in obesity was pronounced in Saudi Arabia and Kuwait. Prevalence of obesity is high among Kuwaiti and Saudi pre-schoolers (8-9%), while adolescent overweight and obesity are among the highest in the world, with Kuwait having the worst estimates (40-46%); however, comparison of child data is difficult because of differing standards. Among nutrition-related non-communicable diseases, hypertension and diabetes levels are very high and increase with age, with the UAE performing the worst because of a rapid rate of increase between 1995 and 2000. Additional monitoring of the prevalence of metabolic syndrome and cancers is necessary. Nationally representative longitudinal surveys with individual, household and community-level information are needed to determine the importance of various factors that contribute to these troubling trends.

A prospective observational study of attention-deficit hyperactivity disorder in Asia: baseline characteristics of symptom severity and treatment options in a paediatric population

OBJECTIVES

To better understand the burden and management of attention-deficit hyperactivity disorder in East Asia, this subanalysis of the baseline characteristics of a large prospective, observational, nonrandomized study investigating the relationships between symptom severity, treatments, co-morbidities, and health outcomes provides information about the diagnosis of, and treatment patterns for, attention-deficit hyperactivity disorder in this region.

METHODS

Outpatients with attention-deficit hyperactivity disorder symptoms participated in this 12-month study performed in China, Korea, and Taiwan. Patients were grouped according to whether they received conventional treatment or no or other treatment. Attention-deficit hyperactivity disorder symptom severity and co-morbidities were assessed using the Clinical Global Impressions-Attention-deficit Hyperactivity Disorder-Severity scale and Child Symptom Inventory-4: Parent Checklist (categories B to J) / Adolescent Symptom Inventory-4: Parent Checklist (categories L and O), respectively.

RESULTS

A total of 502 patients aged 6 to 18 years were enrolled. Investigators were psychiatrists (69%) and paediatricians (31%), who used the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders (86%), the 10th revision of the International Classification of Diseases (6%), and other attention-deficit hyperactivity disorder diagnostic criteria (8%) for diagnosis. Pharmacotherapy was the most commonly prescribed treatment (n = 251; 50%), and treated patients were older (9.1 vs. 8.2 years; p < 0.001) and more severely ill (Clinical Global Impressions-Attention-deficit Hyperactivity Disorder- Severity scale, 4.6 vs. 4.2; p < 0.001) than those who were not treated. Anxiety and oppositional co-morbidities were commonly reported.

CONCLUSIONS

These data provide an insight into the demographics, diagnosis, and treatment of paediatric patients with attention-deficit hyperactivity disorder in East Asia, and provide a baseline for assessing changes in treatment practices in this population.

The Hepatitis A Virus Cellular Receptor, HAVcR-1, Reduces the Integrity of Human Endothelial Tight Junctions

Background: Disruption of Tight Junctions (TJ's) in endothelial cells can cause a leaky vascular bed and may therefore lead to vascular spread of cancer cells. Hepatitis A virus (HAV) cellular receptor HAVcR-1, also known as KIM-1/TIM-1, is the cellular receptor for the hepatotropic picornavirus that causes acute hepatitis-A in humans. Although HAVcR-1 is expressed in every human organ, the natural function of HAVcR-1 remains unknown. In the current study, we investigated the location, association and possible functionality of HAVcR-1 in human endothelial cells.Methods: HAVcR-1 protein in human endothelial cells was visualised using immunohistochemistry and mRNA transcript by RT-PCR. A hammerhead ribozyme transgene that specifically targeted human HAVcR-1 was constructed and used to knockdown endogenously expressed HAVcR-1 (HECVHKD); moreover, forced expression was obtained by insertion of a transgene into wild type endothelial cells (HECVHEX).TJ function was assessed using trans-endothelial resistance (TER) and paracellular permeability assays under the influence of HGF (40ng/ml) a cytokine we have previously shown to modulate TJs in human endothelial cells.Results: Human endothelial cells expressed HAVcR-1 at low levels. The location of both endogenous and forcibly expressed HAVcR-1 was at the cell-cell junction, at the region of the TJ. In this study, one of the first to examine the location and binding partners of HAVcR-1, expression of this receptor was targeted to the vicinity of intercellular junctions, via ZO-1, which further was demonstrated to be at the site of the TJ by its co-localisation with ZO-2. This was true of both endogenously and forcibly expressed protein. Moreover, HAVcR-1 was co-precipitated with the regulatory factor Rho C. Although there was no change in function of HECVHEX cells, the TJ function of the HECVHKD cells exhibited significantly reduced response to HGF over 2h (p&lt;0.01). Interestingly, there was no concurrent response in PCP.Conclusion: These results demonstrate for the first time that HAVcR-1 may have a previously undiscovered role in the regulation of TJ integrity in human endothelial cells.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 2158.

Is the incidence of psychotic disorder in decline? Epidemiological evidence from two decades of research

BACKGROUND

It is unclear whether the incidence of first episode psychoses is in decline. We had the opportunity to determine whether incidence had changed over a 20-year period in a single setting, and test whether this could be explained by demographic or clinical changes.

METHODS

The entire population at-risk aged 16-54 in Nottingham over three time periods (1978-80, 1993-95 and 1997-99) were followed up. All participants presenting with an ICD-9/10 first episode psychosis were included. The remainder of the population at-risk formed the denominator. Standardized incidence rates were calculated at each time period with possible change over time assessed via Poisson regression. We studied six outcomes: substance-induced psychoses, schizophrenia, other non-affective psychoses, manic psychoses, depressive psychoses and all psychotic disorders combined.

RESULTS

Three hundred and forty-seven participants with a first episode psychosis during 1.2 million person-years of follow-up over three time periods were identified. The incidence of non-affective or affective psychoses had not changed over time following standardization for age, sex and ethnicity. We observed a linear increase in the incidence of substance-induced psychosis, per annum, over time (incidence rate ratios: 1.15; 95% CI 1.05-1.25). This could not be explained by longitudinal changes in the age, sex and ethnic structure of the population at-risk.

CONCLUSIONS

Our findings suggest psychotic disorders are not in decline, though there has been a change in the syndromal presentation of non-affective disorders, away from schizophrenia towards other non-affective psychoses. The incidence of substance-induced psychosis has increased, consistent with increases in substance toxicity over time, rather than changes in the prevalence or vulnerability to substance misuse. Increased clinical and popular awareness of substance misuse could also not be excluded.

Investigating whether adverse prenatal and perinatal events are associated with non-clinical psychotic symptoms at age 12 years in the ALSPAC birth cohort

BACKGROUND

Non-clinical psychosis-like symptoms (PLIKS) occur in about 15% of the population. It is not clear whether adverse events during early development alter the risk of developing PLIKS. We aimed to examine whether maternal infection, diabetes or pre-eclampsia during pregnancy, gestational age, perinatal cardiopulmonary resuscitation or 5-min Apgar score were associated with development of psychotic symptoms during early adolescence.

METHOD

A longitudinal study of 6356 12-year-old adolescents who completed a semi-structured interview for psychotic symptoms in the Avon Longitudinal Study of Parents and Children (ALSPAC) birth cohort. Prenatal and perinatal data were obtained from obstetric records and maternal questionnaires completed during pregnancy.

RESULTS

The presence of definite psychotic symptoms was associated with maternal infection during pregnancy [adjusted odds ratio (OR) 1.44, 95% confidence interval (CI) 1.11-1.86, p=0.006], maternal diabetes (adjusted OR 3.43, 95% CI 1.14-10.36, p=0.029), need for resuscitation (adjusted OR 1.50, 95% CI 0.97-2.31, p=0.065) and 5-min Apgar score (adjusted OR per unit decrease 1.30, 95% CI 1.12-1.50, p<0.001). None of these associations were mediated by childhood IQ score. Most associations persisted, but were less strong, when including suspected symptoms as part of the outcome. There was no association between PLIKS and gestational age or pre-eclampsia.

CONCLUSIONS

Adverse events during early development may lead to an increased risk of developing PLIKS. Although the status of PLIKS in relation to clinical disorders such as schizophrenia is not clear, the similarity between these results and findings reported for schizophrenia indicates that future studies of PLIKS may help us to understand how psychotic experiences and clinical disorders develop throughout the life-course.

Association of measures of fetal and childhood growth with non-clinical psychotic symptoms in 12-year-olds: the ALSPAC cohort

BACKGROUND

Previous studies have suggested that impaired fetal and childhood growth are associated with an increased risk of schizophrenia, but the association of pre-adult growth with non-clinical psychotic symptoms (psychosis-like symptoms) in children is not known.

AIMS

To explore the associations of body size at birth and age 7.5 years with childhood psychosis-like symptoms.

METHOD

Prospective cohort of children followed up from birth to age 12: the ALSPAC cohort.

RESULTS

Data on 6000 singleton infants born after 37 weeks of gestation. A one standard deviation increase in birth weight was associated with an 18% reduction in the risk of definite psychosis-like symptoms after adjusting for age and gestation (Odds ratio (OR) = 0.82, 95% CI = 0.73-0.92, P = 0.001). This association was partly confounded by maternal anthropometry, smoking during pregnancy, socioeconomic status and IQ. A similar association was seen for birth length and psychosis-like symptoms, which disappeared after controlling for birth weight. There was little evidence for an association of 7-year height or adiposity with psychosis-like symptoms.

CONCLUSIONS

Measures of impaired fetal, but not childhood, growth are associated with an increased risk of psychosis-like symptoms in 12-year-olds.

The DEBIT trial: an intervention to reduce antipsychotic polypharmacy prescribing in adult psychiatry wards - a cluster randomized controlled trial

BACKGROUND

Clinical guidelines advise against prescribing more than one antipsychotic with limited exceptions. Despite this, surveys continue to report high antipsychotic polypharmacy rates. The aim of the study was to investigate the effectiveness of a multi-faceted intervention in reducing prescribing of antipsychotic polypharmacy on general adult psychiatry wards, compared with guidelines alone.

METHOD

A pragmatic cluster randomized controlled trial recruited 19 adult psychiatric units (clusters) from the South West of England. Participants were all ward doctors and nurses. The multi-faceted intervention comprised: an educational/CBT workbook; an educational visit to consultants; and a reminder system on medication charts.

RESULTS

The odds of being prescribed antipsychotic polypharmacy in those patients prescribed antipsychotic medication was significantly lower in the intervention than control group when adjusted for confounders (OR 0.43, 95% CI 0.21-0.90, p=0.028). There was considerable between-unit variation in polypharmacy rates and in the change in rates between baseline and follow-up (5 months after baseline).

CONCLUSION

The intervention reduced levels of polypharmacy prescribing compared to guidelines alone although the effect size was relatively modest. Further work is needed to elicit the factors that were active in changing prescribing behaviour.

A modified fascia iliaca compartment block has significant morphine-sparing effect after total hip arthroplasty

We assessed whether a modified fascia iliaca compartment block in unilateral total hip arthroplasty provides a morphine-sparing effect in the first 24 hours. This involved a randomised, double blind study of 44 patients. Both groups received a modified fascia iliaca block with the trial group receiving 30 ml 0.5% bupivacaine with 1:200,000 adrenaline, 150 microg clonidine and 9 ml 0.9% saline and the control group receiving 40 ml 0.9% saline. Otherwise both groups received identical care with a subarachnoid block for operative anaesthesia. Patient-controlled morphine analgesia was commenced postoperatively and data were collected at three, six, 12 and 24 hours post commencement of surgery. We found that the trial group used less morphine at 12 and 24 hours (P < 0.001). The median morphine usage at 24 hours was 37.5 mg in the control patients and 22 mg in the trial patients. Pain scores were similar between groups. We conclude that a modified fascia iliaca compartment block has a significant morphine-sparing effect in unilateral total hip arthroplasty.

Minor physical anomalies in patients with first-episode psychosis: their frequency and diagnostic specificity

BACKGROUND

An increased prevalence of minor physical anomalies (MPAs) has been extensively documented in schizophrenia but their specificity for the disorder remains unclear. We investigated the prevalence and the predictive power of MPAs in a large sample of first-episode psychotic patients across a range of diagnoses.

METHOD

MPAs were examined in 242 subjects with first-episode psychosis (50% schizophrenia, 45% affective psychosis and 5% substance-induced psychosis) and 158 healthy controls. Categorical principal components analysis and analysis of variance were undertaken, and individual items with the highest loading were tested using the chi2 test.

RESULTS

Overall facial asymmetry, assymetry of the orbital landmarks, and frankfurt horizontal significantly differentiated patients with schizophrenia and affective psychosis from controls, as did a 'V-shaped' palate, reduced palatal ridges, abnormality of the left ear surface and the shape of the left and right ears. Patients with affective psychosis had significantly lowered eye fissures compared with control subjects.

CONCLUSIONS

MPAs are not specific to schizophrenia, suggesting a common developmental pathway for non-affective and affective psychoses. The topographical distribution of MPAs in this study is suggestive of an insult occurring during organogenesis in the first trimester of pregnancy.

Attenuated stress response to acute lipopolysaccharide challenge and ethanol administration in vasopressin V1b receptor knockout mice

The arginine vasopressin (Avp) 1b receptor (Avpr1b) present on anterior pituitary corticotrophs is involved in the stimulation of adrenocorticotrophic hormone (ACTH) secretion, especially during times of stress. Corticotrophin-releasing hormone (CRH) is considered the major ACTH secretagogue during acute stress whereas Avp appears to be the more dominant mediator of the hypothalamic-pituitary-adrenal (HPA) axis response during chronic stress situations. To investigate the role of the Avpr1b in the HPA axis response to acute stress, we measured ACTH and corticosterone (CORT) plasma levels in Avpr1b knockout (KO) mice and wild-type controls in response to bacterial lipopolysaccharide (LPS) challenge and ethanol (EtOH) administration. Mice deficient in Avpr1b had markedly compromised plasma ACTH and CORT responses to acute (30 min) LPS, but normal ACTH and CORT response to more extended exposure (4 h) to the immune system activator. The plasma ACTH and CORT levels stimulated by intoxicating, sedative doses of EtOH (3.2 and 4 g/kg) were significantly decreased in the Avpr1b KO mice compared to wild-type littermates. Significantly higher EtOH-induced plasma ACTH and CORT secretion was measured in female than in male Avpr1b wild-type mice. There were no differences in the blood alcohol levels following acute EtOH administration in Avpr1b KO or wild-type mice of either gender. Our results clearly suggest that Avpr1b plays a significant role in the HPA axis response to acute immune stress and EtOH intoxication.

The effect of timing of mineral supplementation of the ewe diet in late pregnancy on immunoglobulin G absorption by the lamb

Two experiments were carried out to examine the effects of the timing and duration of mineral supplementation of the ewe's diet in the final 6 weeks of gestation on immunoglobulin G (IgG) absorption by their progeny. In experiment 1, 60 single-bearing ewes were allocated to one of four dietary treatments (no. = 15) and offered a basal diet of grass silage ad libitum, containing 50 g/kg molassed sugar-beet pulp, which was supplemented with concentrates for the final 7 weeks of pregnancy and were additionally provided with a daily mineral/vitamin supplement for the final 6 weeks (W-6), 4 weeks (W-4), 2 weeks (W-2) or no mineral/vitamin supplement, (control; W-0). The supplement contained Ca, P, Na, Mg, Mn, Zn, Se, Co, I and vitamin E and was offered at the daily rate of 48 g per ewe. The ewes were milked at 1, 10 and 18 h post partum and measured quantities of colostrum, proportional to birth weight were fed back to the progeny via a stomach tube. At each milking, colostrum yield was recorded and colostrum samples taken to determine the concentration and yield of IgG. Treatment had no effect (P > 0.05) on the yields of colostrum or IgG to 18 h post partum. The efficiency of IgG absorption was lower (P < 0.001) in the progeny of ewes who received supplementary minerals (W-6, 0.069, W-4, 0.078, W-2, 0.072, W-0, 0.261; s.e. 0.0244. P < 0.001) regardless of the duration of the mineral/vitamin supplementation period and this resulted in a reduced concentration of IgG in the lamb's serum. In experiment 2, 40 twin-bearing ewes were allocated to one of four dietary treatments (no. = 10) and offered a basal diet of grass silage ad libitum which was supplemented initially with 500 g of a concentrate containing 140 g crude protein (CP) per kg from day 98 to 133 of gestation and then replaced with 700 g/day of a concentrate containing 180 g/kg CP from day 134 of gestation until lambing, in addition to one of the following mineral/vitamin supplementation treatments : no supplementary minerals, W0 (control); 48 g of supplement per ewe per day in weeks 6 and 5 pre- partum (W6–5), or weeks 4 and 3 pre-partum (W4–3), or for the final 2 weeks pre-partum (W2–1). The ewes were milked and the lambs fed as in experiment 1. Again, treatment had no effect (P > 0.05) on the yields of colostrum or IgG to 18 h post partum. When ewes were offered the mineral/vitamin supplement in the final 2 weeks of gestation their progeny had a lower (P < 0.01) serum IgG concentration (4.6 g/l) than in the control treatment (14.0 g/l) or when the supplement was offered either in weeks 3 and 4 (11.3 g/l) or weeks 5 and 6 pre-partum (14.3 g/l). IgG absorption efficiency followed the same pattern as lamb serum IgG concentration. We conclude that supplementation of the ewe's diet at the level used in these studies for the final 2 weeks of pregnancy results in the production of offspring with a reduced ability to absorb colostral IgG. Furthermore, in order for this impairment of the IgG absorptive ability of the lamb to manifest itself the supplementation must occur for the final 2 weeks of gestation and supplementation for a 2-weekly period earlier in gestation will not elicit the same effect.

Seasonal and interannual variability in grey seal diets on Sable Island, eastern Scotian Shelf

We studied seasonal and interannual variability in the diet of grey seals (Halichoerus grypus) using faecal samples collected from Sable Island, Nova Scotia between 1991 and 1998. More than 28,000 prey from at least 28 taxa were identified from 1,245 faecal samples collect mainly in spring, fall and winter. Sand lance (Ammodytes dubius) dominated the diet in all seasons and years, but the importance of this and other species varied over time. There was also evidence of seasonal and interannual variation in the size of prey consumed both within and among species. We compared diet composition with estimates of prey numbers and biomass from annual researchtrawl surveys conducted in March and July. Species-specific numerical corrections were applied to otolith counts to account for the complete digestion of otoliths, and fish catchability correction factors applied to trawl survey catches to account for trawl selectivity. Based on an odds ratio index of prey selectivity, grey seals positively selected sand lance in both seasons. Other species were either relatively avoided or eaten roughly in proportion to their estimated abundance.

Performance during consecutive days of laboratory time-trials in young and veteran cyclists

AIM

There is a common belief amongst athletes and coaches that older athletes need longer recovery time between training sessions and following competition. This study was undertaken to investigate the influence of age on recovery from high intensity endurance exercise in well-trained cyclists.

METHODS

Nine young and 9 veteran cyclists (mean+/-SD: young 24+/-5 years, veteran 45+/-6 years) performed 3 consecutive days (T1-T3) of laboratory based cycling time trials of 30-min duration (TT30). Mean power output, heart rate (HR), and blood lactate were measured throughout each TT30. Non-specific performance tests of fatigue were undertaken before and after the TT30 on each test day. Non-specific tests included, a maximal voluntary isometric contraction of the quadriceps muscle (MVIF), a countermovement jump (CMJ), a 10-s cycle sprint (10ST), and serum creatine kinase activity (CK).

RESULTS

Statistical analysis revealed that there were no significant group differences between young and veteran subjects for initial fitness or training status. Over T1-T3 both groups maintained average power during the TT30 (young and veteran results combined; 3.49+/-0.38, 3.5+/-0.36 and 3.52+/-0.35 W x kg(-1), T1-T3, respectively). For both groups serum CK activity was significantly elevated at T2 and T3, and mean HR during the TT30 was significantly lower at T3 (approximately 3 b x min(-1)). There were no group differences or significant within group interactions across the 3 days for MVIF or 10ST but there was a significantly lower CMJ height by T3 in both young and veteran (approximately 3%). MVIF was significantly lower after TT30 each day but had fully recovered by the following day.

CONCLUSIONS

These findings suggest that high-intensity endurance performance is maintained in both well-trained young and veteran cyclists following 3 consecutive days of maximal 30-min laboratory time trials.

The cardiovascular and respiratory health of people with schizophrenia

OBJECTIVE

To examine the cardiovascular and respiratory health of people with severe mental illness (SMI) and compare findings with the Health Surveys for England.

METHOD

A prospective, multi-centre observational prevalence study of 602 patients with schizophrenia-related psychoses carried out in six locations across the UK over 24 months.

RESULTS

Compared with general population subjects, people with SMI reported higher rates of angina and respiratory symptoms and had poor lung function. Much of this increased risk could be explained by lifestyle risk factors; there were increased levels of obesity among younger people with SMI.

CONCLUSION

Key indicators of the cardiovascular and respiratory health of people with SMI are poor compared with those of the general population. Care plans should prioritize interventions to attenuate lifestyle risk factors. Evidence of increasing obesity in younger patients is of particular concern, predicting even greater health needs in the future.

Maintenance antipsychotic medication patterns in outpatient schizophrenia patients: a naturalistic cohort study

OBJECTIVE

Newer antipsychotics are increasingly used in schizophrenia maintenance. The UK change has been slow with little known on switching patterns. We aimed to investigate antipsychotic prescribing patterns in schizophrenia patients.

METHOD

A naturalistic six-site cohort sample of 600 patients were interviewed by researchers at 6-monthly intervals for 2 years to record their clinical and social functioning; use of services and medication for the preceding 6 months was obtained by structured extraction from clinical case notes.

RESULTS

Alterations in antipsychotic medication were frequent in this group, mainly during periods of inpatient care. Atypical prescribing increased steadily, though slowly, across the period. Polypharmacy was less than anticipated.

CONCLUSION

Inpatient care remains the main forum for switching of antipsychotics. The UK maintains a slow shift to atypical antipsychotics.

The association of fetal and childhood growth with risk of schizophrenia. Cohort study of 720,000 Swedish men and women

Previous investigations of the association of schizophrenia with patterns of pre- and post-natal growth have been based on small numbers of cases or have not taken account of the effects of prematurity on birthweight. We investigated the association of fetal growth with schizophrenia in a large cohort of Swedish males and females. We linked data from the Swedish Medical Birth Register (1973-1980), Inpatient and Discharge Register (1988-2002), Military Service Conscription Register (1990-1997), and the Population and Housing Censuses (1970 and 1990). Altogether 719,476 males and females were followed up from the age of 16 for a mean of 9.9 years. There were 736 incident cases of schizophrenia. Even in models that did not control for gestational age there was little evidence of an association between birthweight and schizophrenia (hazard ratio per kg increase in birthweight: 0.90 (95% CI 0.78 to 1.03); the hazard ratio in babies weighing <2.5 kg compared to 3.5-4.0 kg was 1.29 (95% CI 0.85 to 1.96). There was an inverse association of birth length with schizophrenia across the range of birth lengths. Short babies were at an increased risk (hazard ratio per 10 cm increase in birth length: 0.53, 95% CI 0.31 to 0.89 (fully adjusted model)). All associations were little changed when analyses were restricted to term (>36 week gestation) babies. In males, low body mass index and short height at age 18 were associated with increased risk. There is some evidence that patterns of risk in relation to fetal growth differ depending on post-natal growth patterns: the increased risk associated with low body mass index was restricted to long babies who became light adults. The exposures underlying these associations and the biological mechanisms mediating them require clarification.

Pathways to care and ethnicity. 1: Sample characteristics and compulsory admission. Report from the AESOP study

BACKGROUND

Many studies have found high levels of compulsory admission to psychiatric hospital in the UK among African-Caribbean and Black African patients with a psychotic illness.

AIMS

To establish whether African-Caribbean and Black African ethnicity is associated with compulsory admission in an epidemiological sample of patients with a first episode of psychosis drawn from two UK centres.

METHOD

All patients with a first episode of psychosis who made contact with psychiatric services over a 2-year period and were living in defined areas were included in the (AESOP) study. For this analysis we included all White British, other White, African-Caribbean and Black African patients from the AESOP sampling frame. Clinical, socio-demographic and pathways to care data were collected from patients, relatives and case notes.

RESULTS

African-Caribbean patients were significantly more likely to be compulsorily admitted than White British patients, as were Black African patients. African-Caribbean men were the most likely to be compulsorily admitted.

CONCLUSIONS

These findings suggest that factors are operating at or prior to first presentation to increase the risk of compulsory admission among African-Caribbean and Black African patients.