Randomised controlled trial of analgesia for the management of acute severe pain from traumatic injury: study protocol for the paramedic analgesia comparing ketamine and morphine in trauma (PACKMaN)

BACKGROUND

Prehospital analgesia is often required after traumatic injury, currently morphine is the strongest parenteral analgesia routinely available for use by paramedics in the United Kingdom (UK) when treating patients with severe pain. This protocol describes a multi-centre, randomised, double blinded trial comparing the clinical and cost-effectiveness of ketamine and morphine for severe pain following acute traumatic injury.

METHODS

A two arm pragmatic, phase III trial working with two large NHS ambulance services, with an internal pilot. Participants will be randomised in equal numbers to either (1) morphine or (2) ketamine by IV/IO injection. We aim to recruit 446 participants over the age of 16 years old, with a self-reported pain score of 7 or above out of 10. Randomised participants will receive a maximum of 20 mg of morphine, or a maximum of 30 mg of ketamine, to manage their pain. The primary outcome will be the sum of pain intensity difference. Secondary outcomes measure the effectiveness of pain relief and overall patient experience from randomisation to arrival at hospital as well as monitoring the adverse events, resource use and cost-effectiveness outcomes.

DISCUSSION

The PACKMAN study is the first UK clinical trial addressing the clinical and cost-effectiveness of ketamine and morphine in treating acute severe pain from traumatic injury treated by NHS paramedics. The findings will inform future clinical practice and provide insights into the effectiveness of ketamine as a prehospital analgesia.

TRIAL REGISTRATION

ISRCTN, ISRCTN14124474. Registered 22 October 2020, https://www.isrctn.com/ISRCTN14124474.

Dosimetry Reconstruction in Radiopharmaceutical Therapy Using a Sparse Network of External γ-Sensors

PURPOSE/OBJECTIVE(S)

Radiopharmaceutical therapy (RPT) has demonstrated promise in the treatment of neuroendocrine and prostate cancer. Due to the highly varied biodistribution and non-homogeneity of total integrated dose across cancer patients, a system for real-time dosimetry based on continuous measurement is desirable to deliver sufficient dose for tumor ablation while preventing toxicity from off-target uptake by organs at risk (OAR). Single time point imaging (mostly SPECT)-based dosimetry offers a snapshot of the body-wide dose distribution at a given time point, but even single SPECT imaging is generally limited in availability, often leading to significant inaccuracies in estimating total integrated dose. Therefore, accurate personalized dosimetry in RPT is an unmet need and requires continuous dosimetry measurements of tumors and OARs across multiple half-lives of the therapeutic radiopharmaceutical. Using a priori knowledge of tumor and OAR locations from pretherapy imaging, we have developed a novel algorithm that utilizes a network of custom uncollimated, optical fiber-based γ-counting probes to isolate the real-time in vivo tumor and OAR uptake in 177Lu-PSMA-617 and 225Ac-MACROPA-YS5 therapy.

MATERIALS/METHODS

The proposed system was successfully validated in athymic mice models bearing varying numbers of tumors from two human prostate cancer cell lines (PC3-pip, PC3-flu). Uncollimated γ counts using the developed probes were acquired outside of the mice for 10 minutes, starting at 0 hr, 6 hrs, 12 hrs, 24 hrs, and 48 hrs after the injection of 177Lu-PSMA-617. The percent injected activity per mL of tissue (%IA/mL) of each tumor and OAR was reconstructed at every time point and compared to the %IA/mL extracted from SPECT/CT immediately after the recording.

RESULTS

The developed system's %IA/mL reconstruction in PC3-pip tumors, PC3-flu tumors, kidneys, and bladders is highly correlative with the %IA/mL extracted from state-of-art in vivo dosimetry techniques, with %IA/mL ranging from 0.1% to 160% assuming a 29.6 MBq 177Lu-PSMA-617 administration. The least squares linear regression fit between the reconstructed activity and the activity measured from SPECT/CT is given by Estimated %IA/mL = 0.91 x SPECT %IA/mL, with an R2 of 0.991, and Pearson's r of 0.9975. There is a nearly 1:1 mapping between the proposed model and SPECT/CT.

CONCLUSION

A novel dose reconstruction algorithm for personalized dosimetry in RPT that utilizes a sparse set of external γ-counters and a priori knowledge of tumor and OAR locations was developed and validated in in vivo human prostate cancer murine models. The proposed system enables continuous dosimetry measurements of multiple tumors and OAR noninvasively, with high accessibility, high temporal resolution, and across multiple classes of ɑ and β-based RPT. Similar experiments using 225Ac-MACROPA-YS5 are ongoing and additional results will be reported.

Sugar or salt ("SOS"): A protocol for a UK multicentre randomised trial of mannitol and hypertonic saline in severe traumatic brain injury and intracranial hypertension

Hyperosmolar solutions are widely used to treat raised intracranial pressure following severe traumatic brain injury. Although mannitol has historically been the most frequently administered, hypertonic saline solutions are increasingly being used. However, definitive evidence regarding their comparative effectiveness is lacking. The Sugar or Salt Trial is a UK randomised, allocation concealed open label multicentre pragmatic trial designed to determine the clinical and cost-effectiveness of hypertonic saline compared with mannitol in the management of patients with severe traumatic brain injury. Patients requiring intensive care unit admission and intracranial pressure monitoring post-traumatic brain injury will be allocated at random to receive equi-osmolar boluses of either mannitol or hypertonic saline following failure of routine first-line measures to control intracranial pressure. The primary outcome for the study will be the Extended Glasgow Outcome Scale assessed at six months after randomisation. Results will inform current clinical practice in the routine use of hyperosmolar therapy as well as assess the impact of potential side effects. Pre-planned longer term clinical and cost effectiveness analyses will further inform the use of these treatments.

Individual patient data analysis of tidal volumes used in three large randomized control trials involving patients with acute respiratory distress syndrome

Background.

The acute respiratory distress syndrome (ARDS) is a condition with a high mortality and morbidity. Mechanical ventilation prevents immediate mortality but may further damage patients' lungs. Low tidal volume lung-protective strategies have been shown to increase survival by reducing this iatrogenic damage. Current guidelines recommend tidal volumes of 6-8 ml kg -1 of predicted body weight. We used data from three large randomized controlled trials of treatments for ARDS to determine compliance with these recommendations.

Methods.

We used the tidal volume recorded at randomization for all patients in the OSCAR, HARP-2, and BALTI-2 studies. In addition, we used the ventilation data for control arm patients in OSCAR and all patients in HARP-2 at days 1 and 7 after randomization.

Results.

The three trials enrolled 1660 patients, with tidal volume data available at least at one time point in 1412 patients. Compliance with the 6-8 ml kg -1 recommendation for tidal volume ranged from 20 to 39% of patients across all time points in all three trials.

Conclusion.

Poor compliance with the guidelines for tidal volume in patients with ARDS has been demonstrated before in case series, but not in clinical trials where the patient population is specifically selected against standard ARDS diagnostic criteria and the investigators were encouraged to use low tidal volumes. This study may indicate a need to improve implementation and compliance with protective lung ventilation.

Post-admission outcomes of participants in the PARAMEDIC trial: A cluster randomised trial of mechanical or manual chest compressions

BACKGROUND

The PARAMEDIC cluster randomised trial evaluated the LUCAS mechanical chest compression device, and did not find evidence that use of mechanical chest compression led to an improvement in survival at 30 days. This paper reports patient outcomes from admission to hospital to 12 months after randomisation.

METHODS

Information about hospital length of stay and intensive care management was obtained through linkage with Hospital Episode Statistics and the Intensive Care National Audit and Research Centre. Patients surviving to hospital discharge were approached to complete questionnaires (SF-12v2, EQ-5D, MMSE, HADS and PTSD-CL) at 90days and 12 months. The study is registered with Current Controlled Trials, number ISRCTN08233942.

RESULTS

377 patients in the LUCAS arm and 658 patients in the manual chest compression were admitted to hospital. Hospital and intensive care length of stay were similar. Long term follow-up assessments were limited by poor response rates (53.7% at 3 months and 55.6% at 12 months). Follow-up rates were lower in those with worse neurological function. Among respondents, long term health related quality of life outcomes and emotional well-being was similar between groups. Cognitive function, measured by MMSE, was marginally lower in the LUCAS arm mean 26.9 (SD 3.7) compared to control mean 28.0 (SD 2.3), adjusted mean difference -1.5 (95% CI -2.6 to -0.4).

CONCLUSION

There were no clinically important differences identified in outcomes at long term follow-up between those allocated to the mechanical chest compression compared to those receiving manual chest compression.

Low-dose arsenic induces chemotherapy protection via p53/NF-κB-mediated metabolic regulation

Most chemotherapeutical drugs kill cancer cells chiefly by inducing DNA damage, which unfortunately also causes undesirable injuries to normal tissues, mainly due to p53 activation. We report a novel strategy of normal tissue-protection that involves p53/NF-κB coordinated metabolic regulation. Pretreatment of untransformed cells with low doses of arsenic induced concerted p53 suppression and NF-κB activation, which elicited a marked induction of glycolysis. Significantly, this metabolic shift provided cells effective protection against cytotoxic chemotherapy, coupling the metabolic pathway to cellular resistance. Using both in vitro and in vivo models, we demonstrated an absolute requirement of functional p53 in arsenic-mediated protection. Consistently, a brief arsenic-pretreatment selectively protected only normal tissues but not tumors from toxicity of chemotherapy. An indispensable role of glycolysis in protecting normal tissues was demonstrated by using an inhibitor of glycolysis, 2-deoxyglucose, which almost totally abolished low-dose arsenic-mediated protection. Together, our work demonstrates that low-dose arsenic renders normal cells and tissues resistance to chemotherapy-induced toxicity by inducting glycolysis.

A multicentred randomised controlled trial of a primary care-based cognitive behavioural programme for low back pain. The Back Skills Training (BeST) trial

OBJECTIVES

To estimate the clinical effectiveness of active management (AM) in general practice versus AM plus a group-based, professionally led cognitive behavioural approach (CBA) for subacute and chronic low back pain (LBP) and to measure the cost of each strategy over a period of 12 months and estimate cost-effectiveness.

DESIGN

Pragmatic multicentred randomised controlled trial with investigator-blinded assessment of outcomes.

SETTING

Fifty-six general practices from seven English regions.

PARTICIPANTS

People with subacute and chronic LBP who were experiencing symptoms that were at least moderately troublesome.

INTERVENTIONS

Participants were randomised (in a ratio of 2:1) to receive either AM+CBA or AM alone.

MAIN OUTCOME MEASURES

Primary outcomes were the Roland Morris Disability Questionnaire (RMQ) and the Modified Von Korff Scale (MVK), which measure LBP and disability. Secondary outcomes included mental and physical health-related quality of life (Short Form 12-item health survey), health status, fear avoidance beliefs and pain self-efficacy. Cost-utility of CBA was considered from both the UK NHS perspective and a broader health-care perspective, including both NHS costs and costs of privately purchased goods and services related to LBP. Quality-adjusted life-years (QALYs) were calculated from the five-item EuroQoL.

RESULTS

Between April 2005 and April 2007, 701 participants were randomised: 233 to AM and 468 to AM+CBA. Of these, 420 were female. The mean age of participants was 54 years and mean baseline RMQ was 8.7. Outcome data were obtained for 85% of participants at 12 months. Benefits were seen across a range of outcome measures in favour of CBA with no evidence of group or therapist effects. CBA resulted in at least twice as much improvement as AM. Mean additional improvement in the CBA arm was 1.1 [95% confidence interval (CI) 0.4 to 1.7], 1.4 (95% CI 0.7 to 2.1) and 1.3 (95% CI 0.6 to 2.1) change points in the RMQ at 3, 6 and 12 months respectively. Additional improvement in MVK pain was 6.8 (95% CI 3.5 to 10.2), 8.0 (95% CI 4.3 to 11.7) and 7.0 (95% CI 3.2 to 10.7) points, and in MVK disability was 4.3 (95% CI 0.4 to 8.2), 8.1 (95% CI 4.1 to 12.0) and 8.4 (95% CI 4.4 to 12.4) points at 3, 6 and 12 months respectively. At 12 months, 60% of the AM+CBA arm and 31% of the AM arm reported some or complete recovery. Mean cost of attending a CBA course was 187 pounds per participant with an additional benefit in QALYs of 0.099 and an additional cost of 178.06 pounds. Incremental cost-effectiveness ratio was 1786.00 pounds. Probability of CBA being cost-effective reached 90% at about 3000 pounds and remained at that level or above; at a cost-effectiveness threshold of 20,000 pounds the CBA group had an almost 100% probability of being considered cost-effective. User perspectives on the acceptability of group treatments were sought through semi-structured interviews. Most were familiar with key messages of AM; most who had attended any group sessions had retained key messages from the sessions and two-thirds talked about a reduction in fear avoidance and changes in their behaviour. Group sessions appeared to provide reassurance, lessen isolation and enable participants to learn strategies from each other.

CONCLUSIONS

Long-term effectiveness and cost-effectiveness of CBA in treating subacute and chronic LBP was shown, making this intervention attractive to patients, clinicians and purchasers. Short-term (3-month) clinical effects were similar to those found in high-quality studies of other therapies and benefits were maintained and increased over the long term (12 months). Cost per QALY was about half that of competing interventions for LBP and because the intervention can be delivered by existing NHS staff following brief training, the back skills training programme could be implemented within the NHS with relative ease.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN37807450.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Group treatments for sensitive health care problems: a randomised controlled trial of group versus individual physiotherapy sessions for female urinary incontinence

Background

The aim was to compare effectiveness of group versus individual sessions of physiotherapy in terms of symptoms, quality of life, and costs, and to investigate the effect of patient preference on uptake and outcome of treatment.

Methods

A pragmatic, multi-centre randomised controlled trial in five British National Health Service physiotherapy departments. 174 women with stress and/or urge incontinence were randomised to receive treatment from a physiotherapist delivered in a group or individual setting over three weekly sessions. Outcome were measured as Symptom Severity Index; Incontinence-related Quality of Life questionnaire; National Health Service costs, and out of pocket expenses.

Results

The majority of women expressed no preference (55%) or preference for individual treatment (36%). Treatment attendance was good, with similar attendance with both service delivery models. Overall, there were no statistically significant differences in symptom severity or quality of life outcomes between the models. Over 85% of women reported a subjective benefit of treatment, with a slightly higher rating in the individual compared with the group setting. When all health care costs were considered, average cost per patient was lower for group sessions (Mean cost difference £52.91 95%, confidence interval (£25.82 - £80.00)).

Conclusion

Indications are that whilst some women may have an initial preference for individual treatment, there are no substantial differences in the symptom, quality of life outcomes or non-attendance. Because of the significant difference in mean cost, group treatment is recommended.

Trial Registration

Trial Registration number: ISRCTN 16772662

A national facilitation project to improve primary palliative care: impact of the Gold Standards Framework on process and self-ratings of quality

BACKGROUND

Improving quality of end-of-life care is a key driver of UK policy. The Gold Standards Framework (GSF) for Palliative Care aims to strengthen primary palliative care through facilitating implementation of systematic clinical and organisational processes.

OBJECTIVES

To describe the general practices that participated in the GSF programme in 2003-5 and the changes in process and perception of quality that occurred in the year following entry into the programme, and to identify factors associated with the extent of change.

METHODS

Participating practices completed a questionnaire at baseline and another approximately 12 months later. Data were derived from categorical questions about the implementation of 35 organisational and clinical processes, and self-rated assessments of quality, associated with palliative care provision.

PARTICIPANTS

1305 practices (total registered population almost 10 million). Follow-up questionnaire completed by 955 (73.2%) practices (after mean (SD) 12.8 (2.8) months; median 13 months).

FINDINGS

Mean increase in total number of processes implemented (maximum = 35) was 9.6 (95% CI 9.0 to 10.2; p<0.001; baseline: 15.7 (SD 6.4), follow-up: 25.2 (SD 5.2)). Extent of change was largest for practices with low baseline scores. Aspects of process related to coordination and communication showed the greatest change. All dimensions of quality improved following GSF implementation; change was highest for the "quality of palliative care for cancer patients" and "confidence in assessing, recording and addressing the physical and psychosocial areas of patient care".

CONCLUSION

Implementation of the GSF seems to have resulted in substantial improvements in process and quality of palliative care. Further research is required of the extent to which this has enhanced care (physical, practical and psychological outcomes) for patients and carers.

Intraparenchymal pericatheter cyst following ventriculoperitoneal shunt insertion: does it always merit shunt revision?

Intraparenchymal pericatheter cyst is a rare complication of shunt surgery. It occurs as a consequence of increased CSF outflow resistance distal to a patent ventricular catheter. Treatment has traditionally consisted of shunt revision. We report on two such cases managed conservatively. The role of shunt revisions in cases with asymptomatic intraparenchymal pericatheter cyst is debatable.

Regulation of glycolysis in Lactococcus lactis: an unfinished systems biological case study

The unexpectedly long, and still unfinished, path towards a reliable mathematical model of glycolysis and its regulation in Lactococcus lactis is described. The model of this comparatively simple pathway was to be deduced from in vivo nuclear magnetic resonance time-series measurements of the key glycolytic metabolites. As to be expected from any nonlinear inverse problem, computational challenges were encountered in the numerical determination of parameter values of the model. Some of these were successfully solved, whereas others are still awaiting improved techniques of analysis. In addition, rethinking of the model formulation became necessary, because some generally accepted assumptions during model design are not necessarily valid for in vivo models. Examples include precursor-product relationships and the homogeneity of cells and their responses. Finally, it turned out to be useful to model only some of the metabolites, while using time courses of ubiquitous compounds such as adenosine triphosphate, inorganic phosphate, nicotinamide adenine dinucleotide (oxidised) and nicotinamide adenine dinucleotide (reduced) as unmodelled input functions. With respect to our specific application, the modelling process has come a long way, but it is not yet completed. Nonetheless, the model analysis has led to interesting insights into the design of the pathway and into the principles that govern its operation. Specifically, the widely observed feedforward activation of pyruvate kinase by fructose 1,6-bisphosphate is shown to provide a crucial mechanism for positioning the starving organism in a holding pattern that allows immediate uptake of glucose, as soon as it becomes available.

Design and analysis of trials with quality of life as an outcome: a practical guide

Health Related Quality of Life (HRQoL) measures are becoming more frequently used in clinical trials, as both primary and secondary endpoints. Investigators are now asking statisticians for advice on how to plan (e.g., sample size) and analyze studies using HRQoL measures. HRQoL measures such as the SF-36 are usually measured on an ordered categorical (ordinal) scale. In the designing stages and when analyzing, the scales are often scored and the scores treated as if they were continuous and normally distributed. However the ordinal scaling of HRQoL measures leads to problems in determining sample size, and conventional parametric methods of estimation and hypothesis testing may not be appropriate for such outcomes. We present practical guidelines for the design and analysis of trials with HRQoL measures as outcomes. We used conventional statistical methods (i.e., t-tests and multiple regression), various ordinal regression models (proportional odds, continuation ratio, polytomous and stereotype) and bootstrap methods to analyze an HRQoL dataset. To illustrate the various methods we used HRQoL data on the SF-36 Role Limitations Emotional dimension for two groups of patients with leg ulcers. The bootstrap, t-test, and multiple regression methods gave similar results. The various ordinal regression models also gave similar results. If the HRQoL measure has a large number of ordered categories, most of which are occupied, and the underlying scale really is continuous but measured imperfectly by an instrument with a limited number of discrete values, then an informal rule of thumb is that this discrete scale should be treated as continuous if it has seven or more categories and as ordinal otherwise.

A review of ordinal regression models applied on health-related quality of life assessments

There has been increasing emphasis in medical research on the design and analysis of quality of life scales. Many quality of life scales are ordinal and statistical methods such as ordinal regression models have been reviewed on a number of occasions. However, when such models are applied, the way the data have been generated is often overlooked. In this paper we illustrate the use of ordinal regression models, in particular the proportional odds model, the partial proportional odds model and the stereotype model in the MRC Cognitive Function and Ageing Study (MRC CFAS). The partial proportional odds and the stereotype models are often under-utilized, perhaps due to the lack of available software. However, in this paper, analysis based on these models has been carried out using the popular statistical software package SAS and macros devised in SAS. Furthermore, bootstrapping techniques have been applied to obtain valid estimates of the standard errors of the parameters in the stereotype model. Strikingly different results were obtained using the different ordinal regression models. We conclude that the way the data have been generated is particularly important for the analysis of quality of life assessments. Different methods of generating scores yield data with different properties. It is now possible to fit a variety of ordinal regression models and so select the appropriate one that correctly models the data.

Mentoring experiences among Navy midshipmen

Previous research suggests that mentor relationships are facilitative of career success, career satisfaction, and retention in organizations. Yet, little research has been done to explore the prevalence or function of mentor relationships in military populations. In this study, preliminary data were collected regarding the prevalence of mentor relationship experiences among 576 third year midshipmen at the U.S. Naval Academy. Only 40% of respondents had ever experienced a mentor relationship. Most mentors were senior military personnel, and 87% were male. Most relationships were mutually initiated, and they tended to last for several years. Although both career and psychosocial mentor functions were present in these relationships, psychosocial functions were most notable and most highly correlated with positive appraisals of mentor relationships. Midshipmen viewed mentoring as extremely important and rated their own mentor relationships as extremely positive. Implications for further research on mentoring are discussed.

Evaluation of the ICT whole blood antigen card test to detect infection due to nocturnally periodic Wuchereria bancrofti in South India

The commercially available ICT Card Test for bancroftian filariasis was evaluated for its sensitivity and specificity in detecting microfilaria carriers among 189 individuals each in filariasis-endemic and nonendemic areas in South India, and compared to both conventional night blood finger prick thick blood smear examination and venous blood membrane filtration. Though the specificity of the test was 100% in comparison to both, the sensitivity was 98.5% against the finger prick thick blood smear and 71.9 compared to the membrane filtration technique. Similarly, the positive predictive value was 100% against both techniques, but the negative predictive values were 99.5% against the finger prick thick blood smear and 88.3% compared to the membrane filtration technique. The test's lower sensitivity compared to the filtration technique requires further investigation.

Development of rapid assessment procedures for the delimitation of lymphatic filariasis-endemic areas

Lymphatic filariasis caused by Wuchereria bancrofti is a major public health problem in 73 tropical and subtropical countries including India. Delimitation of endemic areas is essential to plan control operations. The current method of night blood survey (NBS) for delimitation is cumbersome, time-consuming and expensive. Therefore, there is a need to develop assessment procedures which can rapidly delimit endemic areas. For this purpose we evaluated three procedures: direct interviewing of key informants using structured questionnaires, an indirect method of a self-administered questionnaires to key informants and physical examination by health workers for the presence of chronic filarial disease. Thirty rural communities in a filariasis-endemic region in Cuddalore district in Tamil Nadu State in southern India constituted the study population. The determination of filariasis endemicity in the village communities assessed by the above procedures was compared in terms of rapidity, specificity, sensitivity and cost with the microfilaria rate and disease rate obtained by night blood sample survey and clinical examination by physicians. Prevalence score, control preference score and weighted mean number of cases with filarial disease per village were calculated using the key informant questionnaire techniques. While the prevalence and control preference score showed low sensitivity and moderate specificity, weighted mean number of cases showed high sensitivity and moderate specificity in identifying endemic villages. The prevalence of disease as determined by the physical examination of a sample population by health workers was highly sensitive in identifying communities endemic for filariasis. The degree of association between the disease rates estimated by physician and trained health workers was significant (r = 0.56; P < 0.05). These observations suggest that the weighted mean number of cases per village obtained through key informant techniques may be considered at a primary level to crudely identify endemic areas, followed by physical examination by health workers for filariasis, since it is relatively cheap and rapid.

Personality characteristics of future military leaders

Relatively little is known about the personality characteristics of military personnel, particularly those who are most successful in military careers. This study evaluated the personality characteristics of 530 third-year midshipmen at the U.S. Naval Academy. Participants completed the Hogan Personality Inventory and a demographic questionnaire. Class ranking data were also obtained as an indicator of success at the Naval Academy. The results indicated that compared with national norms, midshipmen scored somewhat higher on scales of ambition, sociability, intellectance, and school success and lower on scales of adjustment, likability, and prudence. Ambition, prudence, intellectance, and school success were each significantly positively correlated with class standing. The implications of these findings for understanding personality correlates of success in military leadership are discussed.

The role of objective personality inventories in suicide risk assessment: an evaluation and proposal

Objective personality assessment instruments offer a comparatively underutilized source of clinical data in attempts to evaluate and predict risk for suicide. In contrast to focal suicide risk measures, global personality inventories may be useful in identification of long-standing styles that predispose persons to eventual suicidal behavior. This article reviews the empirical literature regarding the efficacy of established personality inventories in predicting suicidality. The authors offer several recommendations for future research with these measures and conclude that such objective personality instruments offer only marginal utility as sources of clinical information in comprehensive suicide risk evaluations. Personality inventories may offer greatest utility in long-term assessment of suicide risk.

Pilot study of suicide risk factors among personnel in the United States Marine Corps (Pacific Forces)

Risk factors for suicide among active-duty members of the United States Marine Corps were investigated. Three groups were suicide attempters (n = 172), completers (n = 22), and a nonpsychiatric comparison group (n = 384). A series of multiple regression and discriminant analyses were conducted to assess whether any of 137 selected risk-factors differentiated the suicidal group from the comparison group. The following factors differentiated suicide attempters and completers from the comparison group and were associated with increased suicide risk: History of Abuse, Neglect, or Rejection, Lower Performance Evaluation, Symptoms of Depression, No History of Gambling Behavior, Younger Age, History of Alcohol Abuse, and Hopelessness. A discriminant analysis using these seven variables resulted in a 77% accuracy rate. When evaluating variables that could be obtained by a review of military records alone, three variables differentiated the attempters and completers from the comparison group, Lower Performance Evaluation, Younger Age, and a History of Military or Legal Problems. These variables correctly classified 73% of the sample. Implications for suicide-risk assessment for individuals in the Marine Corps are provided.

Hematuria-loin pain syndrome: its existence as a discrete clinicopathological entity cannot be supported

OBJECTIVE

To (a) review existing literature and current concepts on Hematuria-Loin Pain Syndrome (HLPS) and (b) to describe seven cases of this syndrome.

PATIENTS AND SETTING

Seven HLPS patients seen over a period of 8 years by the pain and nephrology services of the Toronto Hospital, Toronto, Ontario, Canada.

METHODS AND RESULTS

Retrospective analysis was performed. All patients were remarkable for the variability of clinical presentation, pain characteristics, and dissociation of pain and hematuria occurrence. Routine renal investigations revealed different benign kidney pathologies in 5 of 7 patients. All patients, however, displayed variable combinations of personality factors, drug seeking behaviour, psychopathology, and presence of significant psychosocial stressors. Four cases were managed conservatively with antidepressants, anxiolytics, and supportive counseling and did very well despite persistent hematuria in two.

CONCLUSIONS

HLPS does not constitute a distinct clinicopathological entity. In a minority of cases only underlying kidney pathology is related to pain, and in many cases psychosocial stressors and underlying psychopathology may play a significant role in the reported disabling pain. A concerted medical/psychological approach is advocated.

Randomised controlled double blind study of role of recombinant erythropoietin in the prevention of chronic lung disease

AIM

To evaluate the role of recombinant human erythropoietin (R-HuEpo) in reducing iron infusion, which may exacerbate free radical damage, leading to chronic lung disease.

METHODS

A multicentre, randomised, placebo controlled, double blind study was carried out in four neonatal intensive care units in Yorkshire. Infants were randomly allocated and received either R-HuEpo (480 U/kg/wk) or placebo by twice weekly subcutaneous injection. The primary outcome measure was the number of days on respiratory support and a secondary outcome the number of blood transfusions required.

RESULTS

Forty two very low birthweight (VLBW) infants were randomly allocated. There was little difference in the need for respiratory support one month after randomisation, but subsequently there was a trend towards a reduction in the proportion requiring respiratory support in the R-HuEpo group (difference at three months -0.50, 95% confidence interval -1.00, 0.17). During stay in hospital, the median number of blood transfusions was lower for infants in the R-HuEpo group (difference in medians -2, 95% CI -4, 0). The study was stopped early because of failure to recruit babies at the expected rate.

CONCLUSIONS

R-HuEpo seems to reduce the number of days in oxygen for ill VLBW infants. These data could be used to construct a larger multicentre study to evaluate this effect further.

Contraceptive knowledge, contraceptive use, and self-esteem among Navy personnel

This study evaluated the sexual knowledge (including contraceptive and reproductive knowledge), contraceptive use, and self-esteem among a sample of 158 male and female United States Navy sailors assigned to Navy ships. In spite of the fact that men and women viewed themselves as relatively knowledgeable with respect to contraception, results showed substantial knowledge deficits. Women demonstrated significantly greater sexual knowledge than men, and contraceptive/ reproductive knowledge was highly correlated with self-reported use of contraceptives. Finally, self-esteem was highly correlated with sexual knowledge and certain contraceptive use behaviors.

Salient personality characteristics among Navy divers

This study evaluated the personality characteristics of U.S. Navy divers. Seventy-two active duty Navy divers completed the Million Index of Personality Styles. The sample strongly showed the traits of Enhancing. Modifying, Individuating, Thinking, and Controlling. The results are discussed in terms of adaptation to the environmental demands of military diving. Suggestions for further research are offered.

Effects of locus of control, occupational stress, and psychological distress on job satisfaction among nurses

This study evaluated the effects of locus of control, occupational stress, and psychological symptom distress on reported job satisfaction in a sample of 34 practicing nurses. As predicted, greater work-related stress and higher psychological symptom distress were significantly negatively correlated with job satisfaction. External locus of control was also negatively associated with job satisfaction.

Nurses' personality types based on the Myers-Briggs Type Indicator

One personality type was common for 15 of 34 nurses administered the Myers, Briggs Type Indicator.

Personality characteristics of successful Navy submarine personnel

This study evaluated the personality characteristics of senior enlisted and occupationally successful Navy submarine personnel. One hundred subjects completed the Schedule for Nonadaptive and Adaptive Personality (SNAP). Results indicated that the traits of detachment, propriety, and workaholism were most descriptive of the sample. Thirty-seven percent met SNAP criteria for a personality disorder, typically antisocial, obsessive-compulsive, or avoidant. The results are discussed in terms of adaptation to environmental demands aboard submarines. Suggestions for further research are offered.

Dengue haemorrhagic fever and the dengue shock syndrome in India

The clinical spectrum of dengue fever ranges from asymptomatic infection through severe haemorrhage and sudden fatal shock. Increased capillary permeability is the diagnostic feature of dengue haemorrhagic fever (DHF). The pathophysiology of DHF/dengue shock syndrome (DSS) is related to sequential infection with different serotypes of the virus, variations in virus virulence, interaction of the virus with environmental or host factors and a combination of various risk factors. Infection due to low virulence strains is assumed to be the reason for the infrequent incidence of serious dengue disease in India. Since all four serotypes of the dengue virus have been implicated in various outbreaks in this country and several outbreaks of DHF/DSS have been recorded since the first report in 1963, further epidemics of the disease are likely. The situation is aggravated by the recent emergence of DHF/DSS in Sri Lanka. In view of the potential of this disease to spread, effective preventive and control measures should be a priority.

When does a choice of coping strategies help? The interaction of choice and locus of control

Undergraduate student volunteers either were given a choice of coping strategies or were assigned to a coping strategy which was used to help them tolerate the cold pressor. Subjects who were given a choice of coping strategies reported their strategy to be more credible and perceived a greater sense of control than subjects who were not given a choice. Improved pain tolerance, however, did not result directly from being given a choice. Increases in pain tolerance depended on locus of control. Subjects who had a high internal health locus of control reported a greater strength of self-efficacy and demonstrated increased pain tolerance following a choice of strategies. In comparison, subjects who reported a more external health locus of control did not benefit from receiving a choice. This study has implications for our understanding of the role of choice in therapy and for improving the effectiveness of our interventions with individuals.