Development of an infection prevention and control pathway to facilitate high-throughput cataract surgery in Scotland

INTRODUCTION

Cataract surgery offers significant improvement to quality of life for patients with cataracts. However, there are growing waiting lists and challenges in providing this type of surgery in a timely manner. Feedback from stakeholders had previously indicated infection prevention and control (IPC) as a potential barrier to high-throughput surgery. Antimicrobial Resistance and Healthcare Associated Infection Scotland was asked to support the implementation of high-throughput cataract surgery aimed at addressing these challenges.

AIM

To develop an IPC pathway to facilitate high-throughput surgery. This would be based on best practice, and would address any barriers identified by stakeholders.

METHODS

A short life working group with input from key stakeholders, including clinical teams, was established. A rapid literature review was also undertaken.

RESULTS

An agreed patient pathway was developed, with the aim of helping to facilitate high-throughput surgery. Pre-, intra- and postoperative phases were considered. Where literature was unavailable, expert/consensus opinion was utilized. Facilities for high-throughput surgery were also considered, including the Jack and Jill theatre arrangement which lends itself well to this concept.

CONCLUSION

Through collaboration with stakeholders, an IPC pathway was developed to facilitate high-throughput cataract surgery and address any potential IPC barriers to implementation. The process and the output described could be utilized to develop similar pathways for other surgeries that lend themselves well to high throughput, improving quality of life for patients and reducing waiting times. This study highlights the importance of establishing surveillance for postoperative endophthalmitis following implementation.

Becoming the temporary surgeon: A grounded theory examination of anaesthetists performing emergency front of neck access in inter-disciplinary simulation-based training

The time-critical 'can't intubate, can't oxygenate' [CICO] emergency post-induction of anaesthesia is rare, but one which, should it occur, requires Anaesthetists to perform rapid emergency front of neck access [FONA] to the trachea, restoring oxygenation, and preventing death or brain hypoxia. The UK Difficult Airway Society [DAS] has directed all Anaesthetists to be trained with surgical cricothyroidotomy [SCT] as the primary emergency FONA method, sometimes referred to as 'Cric' as a shorthand. We present a longitudinal analysis using a classical approach to Grounded Theory methodology of ten Specialist Trainee Anaesthetists' data during a 6-month training programme delivered jointly by Anaesthetists and Surgeons. We identified with a critical realist ontology and an objectivist epistemology meaning data interpretation was driven by participants' narratives and accepted as true accounts of their experience. Our theory comprises three themes: 'Identity as an Anaesthetist'; 'The Role of a Temporary Surgeon'; and 'Training to Reconcile Identities', whereby training facilitated the psychological transition from a 'bloodless Doctor' (Anaesthetist) to becoming a 'temporary Surgeon'. The training programme enabled Specialist Trainees to move between the role of control and responsibility (Identity as an Anaesthetist), through self-described 'failure' and into a role of uncertainty about one's own confidence and competence (The Role of a Temporary Surgeon), and then return to the Anaesthetist's role once the airway had been established. Understanding the complexity of an intervention and providing a better insight into the training needs of Anaesthetic trainees, via a Grounded Theory approach, allows us to evaluate training programmes against the recognised technical and non-technical needs of those being trained.

Addressing Unintentional Exclusion of Vulnerable and Mobile Households in Traditional Surveys in Kathmandu, Dhaka, and Hanoi: a Mixed-Methods Feasibility Study

The methods used in low- and middle-income countries' (LMICs) household surveys have not changed in four decades; however, LMIC societies have changed substantially and now face unprecedented rates of urbanization and urbanization of poverty. This mismatch may result in unintentional exclusion of vulnerable and mobile urban populations. We compare three survey method innovations with standard survey methods in Kathmandu, Dhaka, and Hanoi and summarize feasibility of our innovative methods in terms of time, cost, skill requirements, and experiences. We used descriptive statistics and regression techniques to compare respondent characteristics in samples drawn with innovative versus standard survey designs and household definitions, adjusting for sample probability weights and clustering. Feasibility of innovative methods was evaluated using a thematic framework analysis of focus group discussions with survey field staff, and via survey planner budgets. We found that a common household definition excluded single adults (46.9%) and migrant-headed households (6.7%), as well as non-married (8.5%), unemployed (10.5%), disabled (9.3%), and studying adults (14.3%). Further, standard two-stage sampling resulted in fewer single adult and non-family households than an innovative area-microcensus design; however, two-stage sampling resulted in more tent and shack dwellers. Our survey innovations provided good value for money, and field staff experiences were neutral or positive. Staff recommended streamlining field tools and pairing technical and survey content experts during fieldwork. This evidence of exclusion of vulnerable and mobile urban populations in LMIC household surveys is deeply concerning and underscores the need to modernize survey methods and practices.

Intra-operative anaesthetic management of older patients undergoing liver surgery

Older patients represent a growing proportion of the general surgical caseload. This includes those undergoing liver resection, with figures rising faster than the rate of population ageing. The physiology of ageing leads to changes in all body systems which may render the provision of safe anaesthesia more challenging than in younger patients. Anaesthesia for liver surgery has specific principles, largely aimed at reducing venous bleeding from the liver, and those related to complex major surgery. This review explores the principles of anaesthesia for liver resection and describes how they may require modification in the older patient. The traditional approach of low central venous pressure anaesthesia in order to reduce bleeding may need to be altered in the presence of a cardiovascular system less able to tolerate hypotension and hypoperfusion. These changes in physiology should also lower the threshold for invasive monitoring. The provision of effective analgesia perioperatively should be tailored to minimise the surgical stress response and opiate use. Careful consideration of general principles of intra-operative care for older patients, such as positioning, drug dosing, avoidance of excessively deep anaesthesia, and maintenance of normothermia are also important given the prolonged, complex nature of liver surgery. This individualised approach, with careful attention to changes in physiology allows liver resections to be undertaken in older patients without increases in mortality.

Attack rate and prey preference of Lasioseius subterraneous and Protogamasellus mica on four nematode species

Plant parasitic nematodes are common and important global pests, causing over US$150 billion in crop losses across the agricultural sector worldwide. Meloidogyne javanica and Pratylenchus zeae are two of the most damaging plant-parasitic nematodes and there are limited options for their control. We evaluated the potential of a large (Lasioseius subterraneous) and a small (Protogamasellus mica) mesostigmatan mite as biological control agents of plant-parasitic nematodes. We tested the attack rate and reproductive potential of these two mite species on four nematode species: M. javanica (eggs), Pra. zeae (adults) and two microbivorous nematodes, Mesorhabditis sp. and Aphelenchus avenae (adults for both species). Each mite/nematode combination (1 mite:100 nematodes) was tested in six replicate arenas. In a separate trial, each mite species was presented with 50 A. avenae and 50 Pra. zeae in the same arena to determine prey preference. Both mite species significantly reduced the abundance of all nematode species used in the trials when compared to nematode-only controls. Lasioseius subterraneous consumed all available M. javanica eggs within 72 h. The larger mite had a significantly higher overall attack rate than the smaller mite, each consuming an average of 96 and 72 nematodes, respectively, within 72 h. However, both mites had a similar reproductive rate. Protogamasellus mica displayed a positive preference towards the plant parasitic nematode Pra. zeae over the fungal feeding A. avenae whereas L. subterraneous did not display a prey preference. Our results highlight the potential of these two predators to control plant parasitic nematodes, although further trials under field conditions are needed.

Under-use of appropriate blood pressure-lowering and lipid-lowering therapy in the Busselton baby boomer population

BACKGROUND AND OBJECTIVES

Data are sparse on how well the absolute risk approach is implemented in primary healthcare. The aim of this study was to quantify absolute cardiovascular disease (CVD) risk, appropriate use of blood pressure (BP)-lowering and lipid-lowering therapy, and clinical target responses in the Busselton baby boomer population.

METHOD

This was a cross-sectional study of 5107 people aged 45-69 years (54.6% female) who participated in the 2010-2015 Busselton Healthy Ageing Study.

RESULTS

Overall, 16.1% of participants had prior CVD (5.8%) or a high primary CVD risk (10.3%). The frequency of use of a guideline-recommended combination of BP-lowering and lipid-lowering therapy was 46.2% in participants with prior CVD, compared with only 16.8% in those with high primary CVD risk (P <0.001). Among the high-risk participants who were receiving recommended combination therapy, only 42.7% achieved target systolic BP levels and 42.1% achieved target total cholesterol levels.

DISCUSSION

These data confirm substantial under treatment of Australian adults who are at high CVD risk. Enhanced implementation of absolute CVD risk assessment and evidence-based treatment in high-risk adults has potential for substantial health gains.

A mixed-methods pilot study to evaluate a collaborative anaesthetic and surgical training package for emergency surgical cricothyroidotomy

In a ‘can’t intubate, can’t oxygenate’ scenario, success of emergency front-of-neck access is dependent upon a clinician’s skill, competence and confidence to initiate the procedure. Surgical cricothyroidotomy is an important airway skill, as it can be employed as both the primary method of emergency front-of-neck access or as a rescue approach if a needle technique should fail. We designed a collaborative surgical and anaesthetic training package to address perceived anaesthetic reluctance to perform surgical cricothyroidotomy and undertook a pilot study of the package using a mixed-methods approach. The package consisted of three elements: theory teaching, surgical experience and repeated high-fidelity simulation. Ten anaesthetic trainees were trained using the package. Training comprised face-to-face tuition on the 2015 Difficult Airway Society guidelines, the Vortex cognitive aid, manikin-based surgical cricothyroidotomy instruction and surgical experience gained from an elective surgical tracheostomy. A standardised, high-fidelity in situ ‘can’t intubate, can’t oxygenate’ simulation was used to assess performance at baseline and at two weeks and six months after training. Participants scored their self-efficacy, underwent qualitative semi-structured interviews and had their performance quantitatively assessed to evaluate this training. Six months following training, participants’ performance had improved. They reported significantly increased self-efficacy and demonstrated significantly reduced deliberation time to initiate surgical cricothyroidotomy in the simulated ‘can’t intubate, can’t oxygenate’ emergency. Thematic framework analysis of interview transcripts revealed that reluctance to perform surgical cricothyroidotomy was related to fear and anxiety in regard to performing the procedure. These results support wider adoption of collaborative educational training packages, including hands-on surgical teaching, to improve trainees’ efficacy and confidence with surgical cricothyroidotomy and front-of-neck access in an emergency ‘can’t intubate, can’t oxygenate’ scenario.

Improving household surveys and use of data to address health inequities in three Asian cities: protocol for the Surveys for Urban Equity (SUE) mixed methods and feasibility study

INTRODUCTION

As rapid urbanisation transforms the sociodemographic structures within cities, standard survey methods, which have remained unchanged for many years, under-represent the urban poorest. This leads to an overly positive picture of urban health, distorting appropriate allocation of resources between rural and urban and within urban areas. Here, we present a protocol for our study which (i) tests novel methods to improve representation of urban populations in household surveys and measure mental health and injuries, (ii) explores urban poverty and compares measures of poverty and 'slumness' and (iii) works with city authorities to understand, and potentially improve, utilisation of data on urban health for planning more equitable services.

METHODS AND ANALYSIS

We will conduct household surveys in Kathmandu, Hanoi and Dhaka to test novel methods: (i) gridded population sampling; (ii) enumeration using open-access online maps and (iii) one-stage versus two-stage cluster sampling. We will test reliability of an observational tool to categorise neighbourhoods as slum areas. Within the survey, we will assess the appropriateness of a short set of questions to measure depression and injuries. Questionnaire data will also be used to compare asset-based, consumption-based and income-based measures of poverty. Participatory methods will identify perceptions of wealth in two communities in each city. The analysis will combine quantitative and qualitative findings to recommend appropriate measures of poverty in urban areas. We will conduct qualitative interviews and establish communities of practice with government staff in each city on use of data for planning. Framework approach will be used to analyse qualitative data allowing comparison across city settings.

ETHICS AND DISSEMINATION

Ethical approvals have been granted by ethics committees from the UK, Nepal, Bangladesh and Vietnam. Findings will be disseminated through conference papers, peer-reviewed open access articles and workshops with policy-makers and survey experts in Kathmandu, Hanoi and Dhaka.

Ephrin-A2 affects wound healing and scarring in a murine model of excisional injury

Ephrin ligand/Eph receptor signaling is important in both tissue development and homeostasis. There is increasing evidence that Ephrin/Eph signaling is important in the skin, involved in hair follicle cycling, epidermal differentiation, cutaneous innervation and skin cancer. However, there is currently limited information on the role of Ephrin/Eph signaling in cutaneous wound healing. Here we report the effects of the Ephrin-A2 and A5 ligands on wound healing. Using Ephrin-A2^-/-, Ephrin-A5^-/- and Ephrin-A2A5^-/- transgenic mice, in vitro wound healing assays were conducted using isolated keratinocytes and fibroblasts. Ephrin-A2^-/-, Ephrin-A2A5^-/- and wild type mice with excisional wounds were used to analyze the impact of these ligands on wound closure, scar outcome, collagen orientation and re-innervation in vivo. The absence of the Ephrin-A2 and A5 ligands did not have any effect on dermal fibroblast proliferation or on fibroblast or keratinocyte migration. The loss of Ephrin-A2 and A5 ligands did not impact on the rate of wound closure or re-innervation after injury. However, changes in the gross morphology of the healed scar and in collagen histology of the scar dermis were observed in transgenic mice. Therefore Ephrin-A2 and A5 ligands may play an important role in final scar appearance associated with collagen deposition and structure.

Protocol to develop sustainable day care for children aged 1-4 years in disadvantaged urban communities in Dhaka, Bangladesh

INTRODUCTION

Lack of safe, stimulating and health-promoting environments for children under-5 hinders their physical, social and cognitive development, known as early childhood development (ECD). Improving ECD impacts on children, and can improve educational attainment for girls, who often care for younger siblings, and employment prospects for mothers. Developing and evaluating the impacts of ECD programmes within childcare needs to assess a range of social, health, educational and economic impacts, including women's empowerment.Children living in slums are at high risk of poor early development and holistic, sustainable interventions are needed to address ECD in these contexts. This study will be undertaken in Dhaka, Bangladesh, a city where over 8.5 million inhabitants live in slums. In collaboration with government, non-governmental organisations and communities, we are developing and testing a sustainable day-care model for low-income communities in Dhaka.

METHODOLOGY AND ANALYSIS

A sequential mixed methods approach is being used in the study, with qualitative work exploring quantitative findings. Two hundred households with children under-5 will be surveyed to determine day-care needs and to assess ECD (parent-reported and direct assessment). The feasibility of four ECD measuring tools Caregiver-Reported Early Development Index, Measuring Early Learning Quality and Outcomes, The Early Human Capability Index and International Development and Early Learning Assessment will be assessed quantitatively and qualitatively. Qualitative methods will help understand demand and perceptions of day care while mothers work. Participatory action research will be used to develop a locally appropriate and potentially sustainable model of day care for under-5 children. A ward in the south of Dhaka has been selected for the study as this typifies communities with slum and non-slum households living next to each other, allowing us to explore potential for better-off household to subsidise day care for poorer households.

ETHICS AND DISSEMINATION

Findings will be published and inform decision makers at the national, regional and the local actors in order to embed the study into the policy and practice on childcare and ECD. Ethical approvals for this study were obtained from the School of Medicine Research Ethics Committee at the Faculty of Medicine and Health at the University of Leeds (ref: MREC16-106) and the Bangladesh Medical Research Council (ref: BMRCAIREC/20 I 6-20 I 9 I 250).

Public Health Risks in Urban Slums: Findings of the Qualitative 'Healthy Kitchens Healthy Cities' Study in Kathmandu, Nepal

BACKGROUND

Communities in urban slums face multiple risks to their health. These are shaped by intermediary and structural determinants. Gaining a clear understanding of these determinants is a prerequisite for developing interventions to reduce the health consequences of urban poverty. With 828 million people living in slum conditions, the need to find ways to reduce risks to health has never been greater. In many low income settings, the kitchen is the epicentre of activities and behaviours which either undermine or enhance health.

METHODS

We used qualitative methods of semi-structured interviews, observation and participatory workshops in two slum areas in Kathmandu, Nepal to gain women's perspectives on the health risks they faced in and around their kitchens. Twenty one women were interviewed and four participatory workshops with a total of 69 women were held. The women took photographs of their kitchens to trigger discussions.

FINDINGS

The main health conditions identified by the women were respiratory disease, gastrointestinal disease and burn injuries. Women clearly understood intermediary (psychosocial, material and behavioural) determinants to these health conditions such as poor ventilation, cooking on open fires, over-crowding, lack of adequate child supervision. Women articulated the stress they experienced and clearly linked this to health conditions such as heart disease and uptake of smoking. They were also able to identify protective factors, particularly social capital. Subsequent analysis highlighted how female headed-households and those with disabilities had to contend with greater risks to health.

CONCLUSIONS

Women living in slums are very aware of the intermediary determinants-material, behavioural and psycho-social, that increase their vulnerability to ill health. They are also able to identify protective factors, particularly social capital. It is only by understanding the determinants at all levels, not just the behavioural, that we will be able to identify appropriate interventions.

Soil phosphorus constrains biodiversity across European grasslands

Nutrient pollution presents a serious threat to biodiversity conservation. In terrestrial ecosystems, the deleterious effects of nitrogen pollution are increasingly understood and several mitigating environmental policies have been developed. Compared to nitrogen, the effects of increased phosphorus have received far less attention, although some studies have indicated that phosphorus pollution may be detrimental for biodiversity as well. On the basis of a dataset covering 501 grassland plots throughout Europe, we demonstrate that, independent of the level of atmospheric nitrogen deposition and soil acidity, plant species richness was consistently negatively related to soil phosphorus. We also identified thresholds in soil phosphorus above which biodiversity appears to remain at a constant low level. Our results indicate that nutrient management policies biased toward reducing nitrogen pollution will fail to preserve biodiversity. As soil phosphorus is known to be extremely persistent and we found no evidence for a critical threshold below which no environmental harm is expected, we suggest that agro-environmental schemes should include grasslands that are permanently free from phosphorus fertilization.

Evidence for sensitivity of dune wetlands to groundwater nutrients

Dune slacks are seasonal wetlands, high in biodiversity, which experience considerable within-year and between-year variations in water-table. They are subject to many pressures including climate change, land use change and eutrophication. Despite their biological importance and the threats facing them, the hydrological and nutrient parameters that influence their soil properties and biodiversity are poorly understood and there have been no empirical studies to date testing for biological effects in dune systems resulting from groundwater nutrients at low concentrations. In this study we examined the impact of groundwater nutrients on water chemistry, soil chemistry and vegetation composition of dune slacks at three distance classes (0-150 m, 150-300 m, 300-450 m) away from known (off-site) nutrient sources at Aberffraw dunes in North Wales, whilst accounting for differences in water-table regime. Groundwater nitrate and dissolved inorganic nitrogen (DIN) and soil nitrate and nitrite all had significantly higher concentrations closest to the nutrient source. Multivariate analysis showed that although plant species composition within this site was primarily controlled by water table depth and water table fluctuation, nitrogen from groundwater also influenced species composition, independently of water table and soil development. A model containing all hydrological parameters explained 17% of the total species variance; an additional 7% was explained following the addition of NO3 to this model. Areas exposed to elevated, but still relatively low, groundwater nutrient concentrations (mean 0.204 mg/L+/-0.091 of DIN) had greater abundance of nitrophilous species and fewer basipholous species than in areas with lower concentrations. This shows that clear biological impact occurs below previously suggested DIN thresholds of 0.20-0.40 (mg/L).

Eco-hydrological requirements of dune slack vegetation and the implications of climate change

Dune slacks are a seasonal coastal wetland habitat, whose plant assemblages and soil properties are strongly linked to a fluctuating water table. Climate change is predicted to cause major shifts in sand dune hydrological regimes, yet we know remarkably little about the tolerance of these communities to change, and their precise hydrological requirements are poorly quantified. Dune slack vegetation and soils were sampled within five vegetation types across four west coast UK sites. Relationships between vegetation assemblages, and parameters of soil development (moisture, loss on ignition, pH, KCl extractable ions) and groundwater hydrological regime (annual maximum and minimum water levels and range, duration of flooding) were established to define the environmental tolerances of different communities. In multivariate analysis of the vegetation, the dominant gradient was hydrological: dry to wet, followed by a secondary soil development gradient: young calcareous organic-poor soils to acidic/neutral soils with greater organic matter contents. Most measured hydrological and soil variables explained a significant proportion of observed variation in species composition when tested individually, with the exception of soil nitrate and soil calcium concentrations. Maximum water level was the key hydrological variable, and soil moisture and soil pH were the key soil variables. All hydrological and soil parameters together explained 22.5% of the total species variation. There were significant differences in hydrological and soil parameters between community types, with only 40 cm difference in mean annual minimum water levels (averaged over 4 years) separating the wettest and the driest dune slack communities. Therefore, predicted declines in water level exceeding 100 cm by 2080 are likely to have a major impact on the vegetation of these priority conservation habitats.

Establishment of scatter factors for use in shielding calculations and risk assessment for computed tomography facilities

The specification of shielding for CT facilities in the UK and many other countries has been based on isodose scatter curves supplied by the manufacturers combined with the scanner's mAs workload. Shielding calculations for radiography and fluoroscopy are linked to a dose measurement of radiation incident on the patient called the kerma-area product (KAP), and a related quantity, the dose-length product (DLP), is now employed for assessment of CT patient doses. In this study the link between scatter air kerma and DLP has been investigated for CT scanners from different manufacturers. Scatter air kerma values have been measured and scatter factors established that can be used to estimate air kerma levels within CT scanning rooms. Factors recommended to derive the scatter air kerma at 1 m from the isocentre are 0.36 µGy (mGy cm)(-1) for the body and 0.14 µGy (mGy cm)(-1) for head scans. The CT scanner gantries only transmit 10% of the scatter air kerma level and this can also be taken into account when designing protection. The factors can be used to predict scatter air kerma levels within a scanner room that might be used in risk assessments relating to personnel whose presence may be required during CT fluoroscopy procedures.

Complete resolution of recurrent calciphylaxis with long-term intravenous sodium thiosulfate

A 35-year-old morbidly obese woman on home haemodialysis presented with painful indurated subcutaneous nodules histologically characteristic of calciphylaxis. After failing to respond to conventional treatment, she was commenced on an intravenous infusion of 25 g of sodium thiosulfate three times per week. Two weeks after commencing sodium thiosulfate, the pain resolved completely. By 12 weeks, the lesions had healed and the infusions were ceased. Two months later, skin lesions recurred, but resolved again within 3 months of recommencement of sodium thiosulfate treatment, which was continued for 8 months. The treatment was well tolerated. There has been no recurrence of lesions in the 18 months since the cessation of sodium thiosulfate. Clinical trials to determine the optimum dose and duration of therapy for sodium thiosulfate treatment of calciphylaxis should be given priority because of its high rate of success in treating what is otherwise a severe and mostly lethal condition.

'Carers' of people with mental health problems: proposals in current public mental health policy in nine countries

This study investigates how public mental health policy addresses the role and needs of those who care for people with mental health problems. Public mental health policy recognises that carers are at increased risk of poor health. Countries want to ensure that mental health services are responsive to the needs of "carers", that carers participate in the planning and implementation of services and that more information should be made available to carers. Respite care is recommended as a way to improve the health of both carers and service users. Unfortunately, policies only identify possibilities for intervention, and rarely identify specific actions to be taken or clarify who has responsibility for delivering interventions. Further the financial implications of the proposals and the need for additional trained staff are seldom discussed. Current proposals for helping carers are inadequate.

How do public health policies tackle alcohol-related harm: a review of 12 developed countries

AIMS

To identify how current public health policies of 12 developed countries assess alcohol-related problems, the goals and targets that are set and the strategic directives proposed.

METHODS

Policy documents on alcohol and on general public heath were obtained through repeated searches of government websites. Documents were reviewed by two independent observers.

RESULTS

All the countries studied state that alcohol causes substantial harm to individual health and family well-being, increases crime and social disruption, and results in economic loss through lost productivity. All are concerned about consumption of alcohol by young adults and by heavy and problem drinkers. Few aim to reduce total consumption. Only five of the countries set specific targets for changes in drinking behaviour. Countries vary in their commitment to intervene, particularly on taxation, drink-driving, the drinking environment and for high-risk groups. Australia and New Zealand stand out as having coordinated intervention programmes in most areas.

CONCLUSIONS

Policies differ markedly in their organization, the goals and targets that are set, the strategic approaches proposed and areas identified for intervention. Most countries could improve their policies by following the recommendations in the World Heath Organization's European Alcohol Action Plan.

A review of major influences on current public health policy in developed countries in the second half of the 20th century

Public health policy underwent substantial transformation during the latter half of the 20th century. The landmark statement was the 1948 World Health Organization (WHO) constitution, which identified good health as a fundamental right and gave the responsibility to governments to achieve it for all their people. However, following World War II, developed countries made substantial investment in health care with less attention paid to public health. The importance of public health was slowly recognised over the period from 1970 to 2000 with the publication of several reports from different organisations. The first authoritative policy statement that the important determinants of health lay outside health care was in the Lalonde Report from Canada. These ideas were subsequently expressed in the WHO Alma-Ata declaration and were emphasised a year later by the US Surgeon General. The idea of setting goals for health improvement also began in the 1970s. The Lalonde Report and the United Kingdom Black Report recommended that targets be used, but the first explicitly stated health targets were set by the US in 1979. WHO also identified the need for such targets at this time, but did not introduce them until 1984. Since then health targets have become a central feature of public health policy in developed countries. The Ottawa Conference on Health Promotion in 1986 championed the view that health promotion was central to achieving health goals internationally. It helped clarify the types of actions needed: that individuals need to be provided with the supportive environment and economic resources to be able to lead healthy lives. In a further development, the Healthy Cities Project was launched with the specific aim of involving political decision-makers in building a strong lobby for public health at the local level. The Healthy Cities Project illustrates how to provide means and opportunity for interventions to be implemented in communities. Concerns with inequalities in health were emphasised in the WHO declaration of Alma-Ata, and were the focus of the United Kingdom Black Report. The Jakarta Conference on Health Promotion in 1997 urged international action on poverty, as it is the major threat to health. International acceptance of the need to tackle inequalities took longer than the acceptance of health targets, but it is now an important feature of public health policy. The advent of the 21st century marked the coming of age of public health. The renewed version of 'Health for All', 'Health for All in the 21st Century', emphasised the one constant goal of WHO that all individuals should achieve their full health potential. Public health is now regarded internationally as being a priority with this WHO goal being adopted as the overarching goal of policy. The challenges it faces in tackling problems such as obesity, inequalities in health, smoking, alcohol and substance abuse are great and will require policies which tackle the economic, social and environmental determinants of health.

Synaptonemal complex karyotype of zebrafish

Meiotic cells of zebrafish have been prepared to show synaptonemal complexes (SCs) by light and electron microscopy. Completely paired SCs from both spermatocytes and oocytes were measured to produce an SC karyotype. The SC karyotype resembles the somatic karyotype of zebrafish and has no recognisable sex bivalent. Measurements of total SC length indicate that SCs grow longer and develop centromeres during pachytene. Oocytes consistently have longer SCs than spermatocytes, presumably correlated with the reported higher recombination frequency in females than in males.

Body surface area estimation in children using weight alone: application in paediatric oncology

The majority of chemotherapy regimens and trials specify doses of cytotoxic drugs normalized to body surface area. Estimation of BSA in paediatric patients is particularly problematic, as conventional nomograms require accurate determination of both height and weight. The chemotherapy standards group of the UKCCSG (United Kingdom Children's Cancer Study Group) has evaluated a method for calculation of body surface area (BSA) estimation, based solely on patient weight. In comparison with BSA estimations using 2 commonly used methods, which require both weight and height measurements, deviation in the estimate of BSA was less than 10%. This method may be extended to the dosing of chemotherapeutic agents in infants of body weight less than 10 kg, with appropriate recommendations for dose modification. Until better correlates of drug clearance, such as GFR for carboplatin, are identified BSA is used to standardize doses for most chemotherapeutic agents. The formula presented here provides a more robust and reliable method of calculation of BSA from weight alone. Although this approach has been shown to be equivalent to other currently used methods, care should be taken extending this calculation of BSA to children less than 10 kg, to obese patients and to those with cachexia.

The role of cortical activity in experience-dependent potentiation and depression of sensory responses in rat barrel cortex

The role of cortical activity in experience-dependent cortical plasticity was studied in the rat barrel cortex. Plasticity was induced by depriving every other whisker in a chessboard pattern, which is known to cause depression of responses to deprived whisker stimulation and potentiation of responses to spared whisker stimulation. Postsynaptic activity was blocked by muscimol released from elvax slow-release polymer located under the dura and over the barrel field. Spared whisker responses potentiated 2.5-fold in layer II/III and 2.9-fold in layer IV of the near-neighbor barrel in animals implanted with saline-elvax. In contrast, in whisker-deprived animals implanted with muscimol-elvax, responses were indistinguishable from those in undeprived animals. Similarly, in the spared barrel itself, spared whisker responses potentiated 1.3-fold in layer IV in animals implanted with saline-elvax but not at all in muscimol-treated animals. Whiskers that were deprived and then allowed to regrow showed depressed responses in saline-elvax-treated animals, in which 40% of the cells in layer II/III and 26% in layer IV were unresponsive to their principal whisker. These values fell to 17 and 3% for layers II/III and IV, respectively, in muscimol-treated animals, and the response magnitude distributions were indistinguishable from undeprived cases. Cortical activity block had no acute effect on the ventroposteriomedial nucleus responses and had a transient facilitatory effect after 4 d of muscimol treatment, which returned to baseline as the muscimol treatment wore off. We conclude from these studies that cortical activity is required for potentiation and depression of sensory responses in barrel cortex.

Tongue-base hamartoma in tuberous sclerosis

This paper describes the case of a 41-year-old female with tuberous sclerosis who presented with a large tongue-base hamartoma. The surgical management of the patient was complicated by the presence of a large thyroid goitre. Awake fibre-optic intubation, thyroidectomy then tracheostomy were necessary before the tongue-base hamartoma could be safely resected. To the best of our knowledge, this is the first reported case of a tongue-base hamartoma in a patient with tuberous sclerosis.

Control of influenza A on a bone marrow transplant unit

In January 1998, an outbreak of influenza A occurred on our adult bone marrow transplant unit. Aggressive infection control measures were instituted to halt further nosocomial spread. A new, more rigorous approach was implemented for the 1998/99 influenza season and was extremely effective in preventing nosocomial influenza at our institution.

Sex reversal of the newt Triturus cristatus reared at extreme temperatures

Crested newt larvae were reared at defined temperatures, either from uncleaved eggs or from early feeding larvae, until metamorphosis when sexual differentiation had occurred. Trials at 18-24 degrees C showed a 1:1 sex ratio. A higher temperature trial produced more males than females, including some XX neomales. Lower temperatures resulted in a significant excess of females, including XY neofemales. Sex reversal only occurred in about half the possible cases on average. Extreme temperatures must perturb the normal XX/XY system of sex determination, to reveal either an ancestral ZZ/ZW system or a still more primitive environmental control. It is suggested that neofemales (but not neomales) could occur in nature.

Pre-selection of integration sites imparts repeatable transgene expression

Variable gene expression amongst transgenic lines occurs due to copy number and to random associations of incoming DNA with chromosomal elements at the site of integration. Here we describe a method of identifying sites permissive for transgene expression and their use for efficient introduction of single copy transgenes by homologous recombination. ES clones were selected in HAT medium for expression of a randomly integrated HPRT marker lying 5' to an Oct4/ lacZ transgene. 794 clones were assessed in vitro for appropriate down-regulation of lacZ following differentiation. Two clones were chosen for further analysis which displayed appropriate and inappropriate gene regulation (clones 710 and 91, respectively). Three developmental promoters (thyroglobulin, Hox2.6 and Myf5) were then sequentially introduced into the original insertion sites in each clone (710 and 91) by homologous recombination, to drive expression of lacZ. Transgenic embryos were assessed for their ability to direct lacZ expression to tissues in which the respective promoter sequences are normally active. The site which appropriately down-regulated lacZ in vitro (710) also showed appropriate in vivo regulation of lacZ from the three developmental promoters. Site 91, however, directed an additional pattern of ectopic expression, which was common to all four promoters. Pre-selection of genomic sites for the introduction of transgenes by gene targeting improves the repeatability of transgene expression and provides an efficient means of single copy transgene introduction by homologous recombination.

Inhibin-B as a test of ovarian reserve for infertile women

The objective of the study was to compare a standard clomiphene citrate challenge test with inhibin-B serum concentrations also obtained on cycle days 3 and 10 as a negative predictor of pregnancy in a group of 106 women at risk for compromised ovarian function. Mean duration of follow-up was 8.25 months in 95 patients with 30 pregnancies recorded (plus one biochemical). Inhibin-B concentrations on cycle days 3 and 10 were correlated only with each other and not with serum oestradiol, follicle stimulating hormone (FSH) and/or pregnancy rates. Pregnancy occurred in 34.5% (10/29) of all patients with inhibin-B values >/=45 pg/ml on cycle day 3 and in 31.8% (21/66) of those with values <45 pg/ml. For FSH >11 mIU/ml on either day, pregnancy rate was 13.6% versus 38.4% for FSH of </=9 mIU/ml (P = 0.03). This study reconfirmed the usefulness of a clomiphene citrate challenge test as an indication of ovarian reserve but failed to find clinical value for inhibin-B testing.

Local cortical interactions determine the form of cortical plasticity

Competitive interactions between left and right eye inputs to visual cortex during development are usually explained by the thalamocortical axons competing more or less well for cortical territory during retraction into eye specific domains. Here we review the evidence for competitive and co-operative interactions between cortical columns in barrel cortex which are present several weeks after retraction of thalamocortical axons into barrels. Sensory responses in barrel cortex can be altered by a period of vibrissa deprivation. It was found that responses to previously deprived vibrissae (that had been allowed to regrow) were depressed more if neighboring vibrissae were spared than if all vibrissae were removed simultaneously. Depression of the deprived vibrissa response was greater the closer the cell lay to a spared barrel. It was also found that spared vibrissae responses were potentiated more if several neighboring vibrissae were left intact than if only a single vibrissae was spared. These results suggest a mechanism of cooperative potentiation, perhaps due to intracortical summation of excitation evoked by neighbouring vibrissa stimulation. Thalamic responses to vibrissa stimulation were unaffected by deprivation indicating a cortical origin. One of the consequences of deprivation was that the speed of transmission between barrels was increased for spared and decreased for deprived vibrissa. These results imply that inherent interactions between cortical columns give rise to a property of competition and co-operativity which amplify the effects of sensory deprivation.

Prolactin and growth hormone stimulation of lactation in mice requires thyroid hormones

This experiment tested the hypothesis that thyroid hormones are essential for a milk production response to growth hormone (GH) and prolactin (PRL). Prior to breeding, female transgenic mice expressing the herpes simplex type-I thymidine kinase in the thyroid were treated with ganciclovir to ablate thyroid follicular cells. To provide for normal gestation, thyrocyte-ablated mice were supplied thyroxine (T4) in drinking water (0.2 microgram/ml) until 7 days before parturition. Litter size was adjusted to 9 pups, hormone administration began on Day 2 of lactation, and mice were sacrificed on Day 12. There were 5-6 mice in each of 7 treatments that included nonablated controls, thyrocyte-ablated controls, and thyrocyte-ablated mice treated with T4, GH, PRL, GH + T4, and PRL + T4. Thyroxine was administered in drinking water, and GH and PRL (20 microgram/d) were administered by subcutaneous injection. Compared with thyrocyte-ablated controls, litter weight gain was unaffected when dams were treated with GH, PRL, or T4 alone. However, when dams were treated with GH or PRL in combination with T4, litter weight gain increased 13% compared with thyrocyte-ablated controls and 18% compared with GH or PRL-treated mice. Concentration of T4 in serum of pups averaged 62 ng/ml and did not differ among treatments. Concentration of T4 in serum of dams averaged 76 ng/ml when T4-treated. Thyroxine 5'-deiodinase (5'D), the enzyme that converts T4 to triiodothyronine, was quantitated in liver, kidney, and mammary gland. Quantity of 5'D was lower in liver and kidney of thyrocyte-ablated dams without T4 than in respective tissues of mice treated with T4, and there was no effect of GH or PRL. However, in mammary gland, 5'D was increased by treatment with GH, PRL, or T4. Data show that thyroid hormones are necessary for a galactopoietic response to GH and PRL and demonstrate a unique organ-specific regulation of 5'D by galactopoietic hormones.

The effect of vibrissa deprivation pattern on the form of plasticity induced in rat barrel cortex

Plasticity was induced in the barrel cortex of adolescent rats by depriving every second vibrissa on the contralateral vibrissa pad. This produced a chessboard pattern of barrels in the cortex where each barrel receiving its principal input from a spared vibrissa was surrounded by barrels for which the principal vibrissa had been deprived and conversely, each barrel receiving its principal input from a deprived vibrissa was surrounded by barrels for which the principal vibrissa had been spared. After 7 days' deprivation, responses to the regrown vibrissae were depressed in layers II/III (49% of control levels) and IV (60%). Depression was far greater than that seen with "all vibrissa" deprivation, suggesting that activity in the spared vibrissae accentuated the depression of the deprived vibrissae. Depression was not due to subcortical changes as thalamic Ventral Posterior Medial (VPM) responses to deprived vibrissa were unchanged. The short latency responses in layer IV (5-7 ms) were unaffected by deprivation, but the number of cells responding at intermediate latencies (8-13 ms) was markedly reduced (to 66% of control). Potentiation of the spared vibrissa response was substantial in the near side of the neighbouring barrel (2.2-fold increase in layers II/III, 2.9-fold in layer IV) but had not spread to the far side after 7 days' deprivation. Sparing multiple vibrissae may increase the rate of potentiation since 7 days is insufficient time for potentiation in single vibrissa spared animals. Potentiation was not due to subcortical changes as thalamic VPm responses to the spared vibrissa were normal. However, in the spared barrel the response latency decreased by 1-2 ms. Only the cells responding at short latency exhibited potentiated responses (39% increase) suggesting that some thalamocortical plasticity is still possible at P28-35. These results show that chessboard pattern deprivation is capable of inducing substantial plasticity over a wide area of barrel cortex. All the major forms of plasticity seen with other vibrissa deprivation patterns were present, although no other single deprivation pattern studied so far causes the complete repertoire seen with chessboard deprivation.

Amphibian sex determination and sex reversal

Amphibians employ a genetic mechanism of sex determination, according to all available information on sex chromosomes or breeding tests. Sex reversal allows breeding tests to establish which sex is heterogametic and provides an indication of the mechanism of sex determination. Cases of spontaneous and experimental sex reversal (by temperature, hormones or surgery) are reviewed and illustrated by previously unpublished studies on crested newts. These newts respond conventionally to temperature and hormone treatment but provide anomalous results from breeding tests. It is suggested that both the evolution from temperature dependency to a genetic switch and from ZZ/ZW to XX/XY are superimposed on a generally uniform mechanism of sex determination in all vertebrates.

Impaired experience-dependent plasticity in barrel cortex of mice lacking the alpha and delta isoforms of CREB

The transcription factor cyclic-AMP response element binding protein (CREB) has been implicated in long-term plasticity processes in vertebrate and invertebrate species. In the absence of the alpha/delta CREB isoforms, performance is impaired in long-term memory tasks and the long-term maintenance of long-term potentiation (LTP) is impaired in the hippocampus. However, it is not known whether CREB plays a role in neocortical plasticity. Antibodies to CREB revealed that CREB-immunoreactive nuclei are present in all cortical layers but are more numerous in layers II/III, where they composed at least two-thirds the total population of cells. CREB-immunopositive cells were therefore present and densest in the very cortical layers that exhibit experience-dependent plasticity at this age. In order to assess the role of CREB in neocortical plasticity, we studied the effect of vibrissae deprivation on receptive field plasticity in the barrel cortex of mutant mice lacking the alpha/delta isoforms of CREB. A single vibrissa was spared and the others removed for 18 days. In wild-types this caused potentiation of the spared vibrissa response. However, in adult mutants (>6 months) spared vibrissa responses from homozygotes were potentiated less than in any adolescent animals or in adult wild-type littermates. Surround receptive field responses were abnormally large in homozygotes and failed to increase by the same amount as they did in wild-types. In contrast, the alpha/delta CREB mutation had no discernible effect on plasticity in cortical layers II/III of the younger adolescent age group (1-2 months), suggesting that different plasticity processes may operate at this age. Further tests showed that the beta isoform of CREB was up-regulated in the barrel cortex of the alpha/delta CREB knock-outs, suggesting that this subunit may have compensated partly for the loss of the alpha/delta isoforms. These studies suggests that CREB plays a role in experience-dependent plasticity in the adult neocortex.

The role of uncontrollable trauma in the development of PTSD and alcohol addiction

After a traumatic event, people often report using alcohol to relieve their symptoms of anxiety, irritability, and depression. Alcohol may relieve these symptoms because drinking compensates for deficiencies in endorphin activity following a traumatic experience. Within minutes of exposure to a traumatic event there is an increase in the level of endorphins in the brain. During the time of the trauma, endorphin levels remain elevated and help numb the emotional and physical pain of the trauma. However, after the trauma is over, endorphin levels gradually decrease and this may lead to a period of endorphin withdrawal that can last from hours to days. This period of endorphin withdrawal may produce emotional distress and contribute to other symptoms of posttraumatic stress disorder (PTSD). Because alcohol use increases endorphin activity, drinking following trauma may be used to compensate this endorphin withdrawal and thus avoid the associated emotional distress. This model has important implications for the treatment of PTSD and alcoholism.

Age-specific incidence and prevalence rates of treated epilepsy in an unselected population of 2,052,922 and age-specific fertility rates of women with epilepsy

BACKGROUND

There are no data on prevalence or incidence of treated epilepsy, and no data on fertility of women with epilepsy from an unselected UK population.

METHODS

We used the General Practice Research Database to ascertain the incidence and prevalence of people with treated epilepsy in an unselected population of 2,052,922 people in England and Wales, and also age-specific fertility rates. We defined period prevalence of treated epilepsy as the number of people with epilepsy taking an antiepileptic drug per 100,000 people during 1995. The incidence of treated epilepsy was defined as the number of new cases of treated epilepsy per 100,000 people during the same period. We calculated fertility rates among women with treated epilepsy between 1991 and 1995 and compared these rates with the population rates for England and Wales in 1993.

FINDINGS

The period prevalence of treated epilepsy in 1995 was 5.15 per 1000 people (95% CI 5.05-5.25). The prevalence was lower in children (age 5-9 years 3.16 [2.86-3.48]; 10-14 years 4.05 [3.70-4.42]), and higher in older people (65-69 years 6.01 [5.50-6.57]; 70-74 years 6.53 [5.97-7.14]; 75-79 years 7.39 [6.73-8.11]); 80-84 years 7.54 [6.78-8.39]; 85 years and older 7.73 [6.98-8.66]). The incidence of treated epilepsy was 80.8 per 100,000 people (76.9-84.7). The incidence was lower in children (5-9 years 63.2 [50.5-79.1]; 10-14 years 53.8 [42.4-68.3]) and higher in older people (65-69 years 85.9 [68.5-107.3]; 70-74 years 82.8 [65.0-105.2]; 75-79 years 114.5 [116.9-179.2]; 80-84 years 159 [125.2-202.6]; > or = 85 years 135.4 [100.4-178.7]). Fertility was lower among women with treated epilepsy, with an overall rate of 47.1 livebirths per 1000 women aged 15-44 per year (42.3-52.2), compared with a national rate of 62.6 in the same age-group. The standardised fertility ratios were significantly lower between the ages of 25 and 39 years in women with epilepsy (p<0.001).

INTERPRETATION

Compared with previous studies, we found that the incidence of epilepsy was higher in elderly people and lower in children. The prevalence rates also increase with age. Women aged 25-39 years with treated epilepsy have significantly lower fertility rates than those in the general population. Research is needed to identify any potentially preventable causes for the low fertility rates.

Effects of thyroid hormone deficiency on mice selected for increased and decreased body weight and fatness

A study was undertaken to test whether the elimination of metabolic pathways strongly involved in growth and fatness, comprising thyroid hormones (TH) and growth hormone (GH), is responsible for a substantial part of the genetic change produced by selection. Lines used in this study have been selected for about 50 generations for high (PH) and low (PL) body weight at 10 weeks and for high (F) and low fat content (L) at 14 weeks, producing a 3-fold difference in body weights and a 5-fold difference in fat content. Thyroid ablation was achieved by repeated backcrossing into the four selection lines of a transgene comprising the HSV1-tk gene coupled to the promoter of the thyroglobulin gene. Hemizygous pregnant dams were treated with ganciclovir leading to thyroid-ablated dams and offspring and therefore to a lack of TH and subsequently of GH. In the absence of TH and GH, lines still differ in body weight over the period studied (10 d to about 100 d; e.g. at the end PH = 32.1 g vs PL = 10.2 g) and in fat content (F = 16.2% vs L = 3.8%); the corresponding values for the wild-type controls were PH = 49.9 g vs PL = 17.4 g and F = 27.5% vs L = 4.8%. The effect of the transgene depended on the genetic background for body weights at most ages and for relative gonadal fat pad weights, but less for fat content. The L line showed the lowest growth depression. The lit gene, which causes GH but not TH deficiency, was also transferred by repeated backcrosses into three of these lines (PH, PL, F). The combined deficiency of TH and GH had bigger effects on body weights at earlier ages than did GH deprivation. The data show that changes in the TH- and GH-systems are not the only cause of line differences in growth and fatness resulting from long-term selection, but both are involved to a significant extent. The interactions between the effects of the transgene and of the lit gene and the genetic background were, nevertheless, relatively small and therefore these results support a polygenic model of selection response.

Ethanol, body temperature and thermoregulation

1. The effects of ethanol on body temperature (Tb) and on the regulator of Tb are reviewed. 2. The first section considers how ethanol affects cellular function and how temperature modifies these effects. 3. The next section reviews the effects of ethanol on Tb, covering both disruptive effects and effects on regulatory elements. 4. The final section covers recent work that has made use of genetic techniques to elucidate specific aspects of how ethanol affects temperature regulation.

Lampbrush chromosomes and chiasmata of sex-reversed crested newts

Triturus cristatus carnifex provides a particularly clear example of sexual dimorphism for chiasma frequency and localisation. Oocytes from normal XX females routinely carry one proximal chiasma on each arm of their lampbrush bivalents. Spermatocytes from normal XY males have more numerous and relatively distal chiasmata. Lampbrush chromosomes from the oocytes of sex-reversed XY neofemales are found to resemble those from normal oocytes in having one proximal chiasma on each bivalent arm. A comparison of particular markers on the heteromorphic long arm of chromosome 1 provides evidence to equate the lampbrush 1A to somatic 1A, and confirms previous reports that lampbrush chromosome 1A is slightly longer than 1B. The XY sex bivalent of neofemales does not show any obvious heteromorphy of recognised marker loops.