Patterns of remission from alcohol dependence in the United Kingdom: results from an online panel general population survey

BACKGROUND

Previous research has demonstrated that remissions from alcohol use disorders can occur without accessing treatment. The current study explored the prevalence of such untreated remissions in the UK and further, examined the extent to which people who resolved an alcohol use disorder regarded themselves as ever, or currently, being in recovery.

METHODS

Participants were recruited using the Prolific online platform. Participants who met criteria for lifetime alcohol dependence (ICD-10) were asked about their drinking at its heaviest, use of treatment services, whether they identified as being in recovery, and their current alcohol consumption (to identify those who were abstinent or drinking in a moderate fashion).

RESULTS

A total of 3,994 participants completed surveys to identify 166 participants with lifetime alcohol dependence who were currently abstinent (n = 67) or drinking in a moderate fashion (n = 99). Participants who were currently abstinent were more likely to have accessed treatment than those who were currently moderate drinkers (44.4% versus 16.0%; Fischer's exact test = 0.001). Further, those who were abstinent were heavier drinkers prior to remission [Mean (SD) drinks per week = 53.6 (31.7) versus 29.1 (21.7); t-test = 5.6, 118.7 df, p < .001] and were more likely to have ever identified themselves as 'in recovery' (51.5% versus 18.9%; Fischer's exact test = 0.001) than current moderate drinkers.

CONCLUSIONS

While participants with an abstinent remission were more likely than those currently drinking in a moderate fashion to have accessed treatment and to identify as being 'in recovery,' the majority of participants reduced their drinking without treatment (and did not regard themselves as in recovery).

What impacts the acceptability of wearable devices that detect opioid overdose in people who use opioids? A qualitative study

INTRODUCTION

Drug-related deaths involving an opioid are at all-time highs across the United Kingdom. Current overdose antidotes (naloxone) require events to be witnessed and recognised for reversal. Wearable technologies have potential for remote overdose detection or response but their acceptability among people who use opioids (PWUO) is not well understood. This study explored facilitators and barriers to wearable technology acceptability to PWUO.

METHODS

Twenty-four participants (79% male, average age 46 years) with current (n = 15) and past (n = 9) illicit heroin use and 54% (n = 13) who were engaged in opioid substitution therapy participated in semi-structured interviews (n = 7) and three focus groups (n = 17) in London and Nottingham from March to June 2022. Participants evaluated real devices, discussing characteristics, engagement factors, target populations, implementation strategies and preferences. Conversations were recorded, transcribed and thematically analysed.

RESULTS

Three themes emerged: device-, person- and environment-specific factors impacting acceptability. Facilitators included inconspicuousness under the device theme and targeting subpopulations of PWUO at the individual theme. Barriers included affordability of devices and limited technology access within the environment theme. Trust in device accuracy for high and overdose differentiation was a crucial facilitator, while trust between technology and PWUO was a significant environmental barrier.

DISCUSSION AND CONCLUSIONS

Determinants of acceptability can be categorised into device, person and environmental factors. PWUO, on the whole, require devices that are inconspicuous, comfortable, accessible, easy to use, controlled by trustworthy organisations and highly accurate. Device developers must consider how the type of end-user and their environment moderate acceptability of the device.

Frameless LINAC-Based Stereotactic Radiosurgery is Safe and Effective for Essential and Parkinsonian Tremor

PURPOSE/OBJECTIVE(S)

Stereotactic radiosurgery (SRS) to the thalamus is an ablative technique used for treatment of refractory tremor of essential or Parkinsonian origin. Because of the high dose, small target, and required precision, framed SRS on the Gamma Knife has been the historical platform of choice. We tested our recently developed technique to emulate GK dose distributions on a multi-leaf collimator (MLC)-equipped linear accelerator (LINAC) without cumbersome, inefficient cones in a prospective trial of safety and efficacy.

MATERIALS/METHODS

We quantified pre-treatment contralateral tremor according to FTM scoring system. We obtained MPRAGE, FGATIR, DTI, and RS-fMRI sequences. We identified the VIM via classical stereotactic reference location and connectomically, and then targeted it to 135 Gy dmax in a manner dosimetrically roughly equivalent to 4 mm GK shot. We adjusted each target such that the 25 Gy isodose line did not overlap the posterior limb of the capsule. We immobilized patients in a highly rigid thermoplastic mask and delivered treatment on an Edge™ LINAC with HDMLC. Intrafraction optical surface monitoring (OSMS) ensured patient immobility. We surveilled post-treatment imaging and recorded tremor scoring, QOL outcomes, and adverse events.

RESULTS

We accrued 42 patients (16 female, 26 males; median age 72.5) over 36 months. 38 had essential tremor, 4 had tremor-dominant Parkinson's; 2 withdrew prior to treatment. Ten patients were on therapeutic anti-coagulation, and were not required to discontinue. At time of submission 39 patients had follow-up ≥ 6 months. 35/39 (89.7%) exhibited clinically meaningful tremor reduction. Mean limb tremor reduction among responders was 43.5% (range: 9 - 100%). Time to patient-reported tremor improvement was 0.3 to 15 months. One patient experienced Gr 3, and 4 patients experienced Gr 1-2 toxicity.

CONCLUSION

MLC-based SRS thalamotomy is safe and effective for refractory tremor treatment. Multidisciplinary management is key for proper patient selection, treatment, and monitoring. Our outcomes appear congruent to historical GK controls as well as more modern MRgFUS outcomes.

A scoping review of mHealth technologies for opioid overdose prevention, detection and response

ISSUES

Opioid overdose kills over 100,000 people each year globally. Mobile health (mHealth) technologies and devices, including wearables, with the capacity to prevent, detect or respond to opioid overdose exist in early form, or could be re-purposed or designed. These technologies may particularly help those who use alone. For technologies to be successful, they must be effective and acceptable to the at-risk population. The aim of this scoping review is to identify published studies on mHealth technologies that attempt to prevent, detect or respond to opioid overdose.

APPROACH

A systematic scoping review of literature was conducted up to October 2022. APA PsychInfo, Embase, Web of Science and Medline databases were searched.

INCLUSION CRITERIA

articles had to report on (i) mHealth technologies that deal with (ii) opioid (iii) overdose.

KEY FINDINGS

A total of 348 records were identified, with 14 studies eligible for this review across four domains: (i) technologies that require intervention/response from others (four); (ii) devices that use biometric data to detect overdose (five); (iii) devices that automatically respond to an overdose with administration of an antidote (three); (iv) acceptability/willingness to use overdose-related technologies/devices (five).

IMPLICATIONS

There are multiple routes in which these technologies may be deployed, but several factors impact acceptability (e.g., discretion or size) and accuracy of detection (e.g., sensitive parameter/threshold with low false positive rate).

CONCLUSION

mHealth technologies for opioid overdose may play a crucial role in responding to the ongoing global opioid crises. This scoping review identifies vital research that will determine the future success of these technologies.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

A proof-of-concept study of growth hormone in children with Phelan–McDermid syndrome

Background

Phelan–McDermid syndrome (PMS) is caused by 22q13 deletions including SHANK3 or pathogenic sequence variants in SHANK3 and is among the more common rare genetic findings in autism spectrum disorder (ASD). SHANK3 is critical for synaptic function, and preclinical and clinical studies suggest that insulin-like growth factor-1 (IGF-1) can reverse a range of deficits in PMS. IGF-1 release is stimulated by growth hormone secretion from the anterior pituitary gland, and this study sought to assess the feasibility of increasing IGF-1 levels through recombinant human growth hormone (rhGH) treatment, in addition to establishing safety and exploring efficacy of rhGH in children with PMS.

Methods

rhGH was administered once daily for 12 weeks to six children with PMS using an open-label design. IGF-1 levels, safety, and efficacy assessments were measured every 4 weeks throughout the study.

Results

rhGH administration increased levels of IGF-1 by at least 2 standard deviations and was well tolerated without serious adverse events. rhGH treatment was also associated with clinical improvement in social withdrawal, hyperactivity, and sensory symptoms.

Limitations

Results should be interpreted with caution given the small sample size and lack of a placebo control.

Conclusions

Overall, findings are promising and indicate the need for larger studies with rhGH in PMS.

Trial registration NCT04003207. Registered July 1, 2019, https://clinicaltrials.gov/ct2/show/NCT04003207.

471 C-Reactive Protein Accurately Predicts Severity of Acute Pancreatitis in Children

Introduction

Predicting severity of acute pancreatitis enables optimization of care, reducing morbidity and length of stay. Modified adult scoring systems have not yet been able to adequately predict severity in children. This study supports the use of CRP in children as a superior biomarker of acute pancreatitis severity compared with the modified Glasgow Pancreas score.

Method

This was a retrospective study of children presenting with a first episode of acute pancreatitis from 2002 - 2020 in a single tertiary paediatric surgical centre. Serum markers including CRP at 48 hours of admission were analysed. Statistical analysis included Receiver Operating Curve (ROC) analysis for promising biomarkers, and these were compared to the modified Glasgow Pancreas Score. A severe episode was defined by development of local complications and/or organ support. An Area Under Curve (AUC) &gt;0.90 was defined as an excellent predictor of severity.

Results

Data of 59 children were analysed, median age 13 years, 22 (37%) patients had a severe episode. ROC analysis demonstrated CRP as the best predictor of severity, giving an AUC of 0.92. Optimum cut off value for CRP was 107. 5mg/L (p &lt; 0.0001), producing 91% sensitivity and 84% specificity. This was significantly superior to the modified Glasgow Pancreas score, which gave an AUC of 0.66 (p &lt; 0.0424) producing 36% sensitivity and 100% specificity.

Conclusions

We have shown that a CRP &gt;107.5 within 48 hours of admission can be used to predict severity of acute pancreatitis in children with greater accuracy than current scoring systems.

Point-of-Care Screening Echocardiograms and their Potential Utility in the Acute Inpatient Medical Setting

Demands on echocardiography services are increasing annually. This Quality Improvement Project aimed to see whether a point of care screening echocardiography (SE) service in the acute inpatient medical setting might help reduce demand on full trans-thoracic echocardiography services (FE). The indication and results of all FE requests on the admission ward were analysed over a three-month period. Following this, it was considered whether a theoretical SE occurring prior, would have changed the on-going utilisation of FE resources. Of the 67 requests analysed, 57 underwent FE. 25% revealed no abnormality. In 47%, a SE prior may have changed the future use of FE resources. This small retrospective review highlights the potential benefits of a SE service and further work is required.

Patients’ Understanding of Pre-operative Fasting

We aimed to assess elective day surgery patients’ understanding of the reason for pre-operative fasting. One hundred adult patients presenting to the peri-operative unit for day procedures requiring general anaesthesia were surveyed before discharge. All day-stay, adult patients able to complete a questionnaire in English were included. Only 22% (95%CI [14,31]) of patients correctly understood why fasting was necessary. Patients who did not understand were nearly five times more likely to underrate the importance of compliance (risk ratio 4.65, 95%CI [1.2,18]). Two per cent (95%CI [0.2,7]) of patients reported actual non-compliance, and 4% (95%CI [1,10]) stated they would consider misrepresenting their fasting status if it was inconvenient for them to have their surgery postponed. The results of this study suggest a need to better inform day surgery patients about the reason for pre-operative fasting. A better understanding of the need for pre-operative fasting may lead to improved compliance and patient safety.

Significant OH production under surface cleaning and air cleaning conditions: Impact on indoor air quality

We report measurements of hydroxyl (OH) and hydroperoxy (HO₂ ) radicals made by laser-induced fluorescence spectroscopy in a computer classroom (i) in the absence of indoor activities (ii) during desk cleaning with a limonene-containing cleaner (iii) during operation of a commercially available "air cleaning" device. In the unmanipulated environment, the one-minute averaged OH concentration remained close to or below the limit of detection (6.5×10⁵  molecule cm^-3 ), whilst that of HO₂ was 1.3×10⁷  molecule cm^-3 . These concentrations increased to ~4×10⁶ and 4×10⁸  molecule cm^-3 , respectively during desk cleaning. During operation of the air cleaning device, OH and HO₂ concentrations reached ~2×10⁷ and ~6×10⁸  molecule cm^-3 respectively. The potential of these OH concentrations to initiate chemical processing is explored using a detailed chemical model for indoor air (the INDCM). The model can reproduce the measured OH and HO₂ concentrations to within 50% and often within a few % and demonstrates that the resulting secondary chemistry varies with the cleaning activity. Whilst terpene reaction products dominate the product composition following surface cleaning, those from aromatics and other VOCs are much more important during the use of the air cleaning device.

Using whole genome sequencing to identify resistance determinants and predict antimicrobial resistance phenotypes for year 2015 invasive pneumococcal disease isolates recovered in the United States

Our whole genome sequence (WGS) pipeline was assessed for accurate prediction of antimicrobial phenotypes. For 2316 invasive pneumococcal isolates recovered during 2015 we compared WGS pipeline data to broth dilution testing (BDT) for 18 antimicrobials. For 11 antimicrobials categorical discrepancies were assigned when WGS-predicted MICs and BDT MICs predicted different categorizations for susceptibility, intermediate resistance or resistance, ranging from 0.9% (tetracycline) to 2.9% (amoxicillin). For β-lactam antibiotics, the occurrence of at least four-fold differences in MIC ranged from 0.2% (meropenem) to 1.0% (penicillin), although phenotypic retesting resolved 25%-78% of these discrepancies. Non-susceptibility to penicillin, predicted by penicillin-binding protein types, was 2.7% (non-meningitis criteria) and 23.8% (meningitis criteria). Other common resistance determinants included mef (475 isolates), ermB (191 isolates), ermB + mef (48 isolates), tetM (261 isolates) and cat (51 isolates). Additional accessory resistance genes (tetS, tet32, aphA-3, sat4) were rarely detected (one to three isolates). Rare core genome mutations conferring erythromycin-resistance included a two-codon rplD insertion (rplD69-KG-70) and the 23S rRNA A2061G substitution (six isolates). Intermediate cotrimoxazole-resistance was associated with one or two codon insertions within folP (238 isolates) or the folA I100L substitution (38 isolates), whereas full cotrimoxazole-resistance was attributed to alterations in both genes (172 isolates). The two levofloxacin-resistant isolates contained parC and/or gyrA mutations. Of 11 remaining isolates with moderately elevated MICs to both ciprofloxacin and levofloxacin, seven contained parC or gyrA mutations. The two rifampin-resistant isolates contained rpoB mutations. WGS-based antimicrobial phenotype prediction was an informative alternative to BDT for invasive pneumococci.

Onset of Drug Use among Rural Black Youth

A sample of 362 Black students (grades 7 to 12) who reside in a rural county in Alabama was surveyed by teacher-administered questionnaire to examine the age of onset and periods of risk for drug use, and patterns of multiple drug use. A questionnaire was used also to obtain demographic parameters of drug use as well as information about the use of six categories of drugs. Results suggest that aggregately rural Black youth began drinking alcohol, smoking cigarettes and marijuana, and using smokeless tobacco and solvents by age 10 years, whereas initiation into cocaine use began by age 1 years. The period of risk for initiation of drug use was between ages 10 and 14 years. Approximately 65% of ever-users were single drug users, whereas 35% were multiple drug users at the period of initial experimentation.

Strain features and distributions in pneumococci from children with invasive disease before and after 13-valent conjugate vaccine implementation in the USA

The effect of second-generation pneumococcal conjugate vaccines on invasive pneumococcal disease (IPD) strain distributions have not yet been well described. We analysed IPD isolates recovered from children aged <5 years through Active Bacterial Core surveillance before (2008–2009; n = 828) and after (2011–2013; n = 600) 13-valent pneumococcal conjugate vaccine (PCV13) implementation. We employed conventional testing, PCR/electrospray ionization mass spectrometry and whole genome sequence (WGS) analysis to identify serotypes, resistance features, genotypes, and pilus types. PCV13, licensed in February 2010, effectively targeted all major 19A and 7F genotypes, and decreased antimicrobial resistance, primarily owing to removal of the 19A/ST320 complex. The strain complex contributing most to the remaining β-lactam resistance during 2011–2013 was 35B/ST558. Significant emergence of non-vaccine clonal complexes was not evident. Because of the removal of vaccine serotype strains, positivity for one or both pilus types (PI-1 and PI-2) decreased in the post-PCV13 years 2011–2013 relative to 2008–2009 (decreases of 32–55% for PI-1, and >95% for PI-2 and combined PI-1 + PI-2). β-Lactam susceptibility phenotypes correlated consistently with transpeptidase region sequence combinations of the three major penicillin-binding proteins (PBPs) determined through WGS analysis. Other major resistance features were predictable by DNA signatures from WGS analysis. Multilocus sequence data combined with PBP combinations identified progeny, serotype donors and recipient strains in serotype switch events. PCV13 decreased the frequency of all PCV13 serotype clones and concurrently decreased the frequency of strain subsets with resistance and/or adherence features conducive to successful carriage. Our results serve as a reference describing key features of current paediatric IPD strains in the USA after PCV13 implementation.

(237)Np Mössbauer effect study on NpFeAsO

We report (237)Np Mössbauer measurements on NpFeAsO. The Np atoms were found to occupy only one crystallographic site. The value of the isomer shift (δ ∼ 9.1 mm s(-1) versus NpAl2) indicates a 5f(4) electronic configuration (Np(3+) ions). The magnetic ordering of the Np sublattice below 60 K is established and the saturated ordered magnetic moment is determined to be 1.73μB at 3.6 K. The unique set of hyperfine parameters exclude a modulated magnetic structure or spin waves on the Np site. The neptunium magnetic moments μNp are found to lie along the tetragonal c-axis.

Improving outcomes for psychoses through the use of psycho-education; preliminary findings

A psycho-education programme is provided for patients suffering from psychosis in Scotland's only high secure hospital. An 18-month pilot study was carried out with consecutive case sample (treatment group) and 'treatment as usual' comparison group (control group). Pre, post and 6-month follow-up assessments were carried out. A range of outcome measures were used, including two measures of knowledge: a self-report assessment tool - Forensic Assessment of Knowledge Tool and the Understanding Medication Questionnaire. Other measures were used to establish level of insight, Schedule for the Assessment of Insight and assess mental state [Positive and Negative Syndrome Scale (PANSS)]. Results from (n = 48) participants indicate no statistical difference between the treatment and control group scores on any assessment prior to commencement of the intervention, indicating a well-matched sample group. However, all four assessments showed statistically significant changes post group. Treatment group showed an ability to improve knowledge and retain information about psychosis, which may account for their improved mental state and level of insight. Despite methodological limitations and a small sample group, this project has given an early indication of the positive value of this psycho-education programme in a forensic setting.

The book, the stories, the people: an ongoing dialogic narrative inquiry study combining a practice development project. Part 2: the practice development context

This paper is the second part of a two-article practice development report. It builds on the first part by introducing and discussing a Writing for Recovery practice development project, conducted at two UK sites. The paper begins by briefly describing the project within the context of helping mental health users, carers and survivors develop skills in creative writing in order to engage in the process of narrative re-storying in line with preferred identity. A selective overview of broad and focal background literature relevant to the project is then provided in order to position it within a values-based mental health nursing practice. Following this, the specific plan for running the project is briefly summarized, covering actual and anticipated ethical issues. The paper ends with a discussion of dissemination aims.

The book, the stories, the people: an ongoing dialogic narrative inquiry study combining a practice development project. Part 1: the research context

This paper, part one of a two paper report, describes key aspects of the research context of an ongoing practice development project, conducted on two UK sites. The paper begins with a discussion of the project's origins within a community of people working in the recovery paradigm, including the contributory strand of the first author's recovery and survivor writing. The discussion then turns to three inter-related areas within which the research component sits and which provide it with philosophical, theoretical and conceptual coherence. Each area will be unpacked and its significance explained. This will provide a platform for discussing the focus, methodology and methods of the research, and related assumptions governing both data collection and analysis. The paper concludes with a research commitment to a mental health nursing practice allied to recovery as narrative healing. Links are made to the second paper which describes the context and specifics of a Writing for Recovery project for users, survivors and carers. This shares with, and builds on, the overall project's research context and its assumptions.

Prevalence and some clinical characteristics of equine cheek teeth diastemata in 471 horses examined in a UK first-opinion equine practice (2008 to 2009)

Cheek teeth (CT) diastemata are now recognised as a clinically significant equine disorder, but their prevalence in the general equine population is unknown. There is also limited information on the signalment of affected horses; the more commonly affected Triadan sites; and the shape and clinical characteristics of CT diastemata. During the 12-month study period (2008 to 2009), standardised records were obtained during routine dental examinations performed by five veterinarians in a first-opinion equine practice. Cheek teeth diastemata were identified in 49.9 per cent of all horses (n=471) of mean age 11 years (range one to 30 years), with 83.5 per cent of all diastemata affecting mandibular CT and 16.5 per cent affecting maxillary CT. The mean number of diastemata per case was 1.7 (range one to 20) and the mandibular 07 to 08 position was most commonly affected. Valve diastemata were more common (72.1 per cent prevalence) than open diastemata (27.9 per cent). Food trapping was present in 91.4 per cent of diastemata, with gingivitis and periodontal pockets adjacent to 34.2 per cent and 43.7 per cent, respectively. Halitosis was present in 45.5 per cent of affected horses. There was an age-related increase in both the prevalence of diastemata, and in the numbers of diastemata per affected horse, and horses over 15 years old had a significantly increased proportion of open diastemata.

Initiation of antiretroviral therapy in patients with a CD4 count of less than 350 cells: a retrospective audit against key indicators from the CQUIN payment framework

A proportion of funding for the South Yorkshire HIV Network is dependant on meeting the targets of the Commissioning for Quality and Innovation (CQUIN) payment framework. This states that 85% of patients with a CD4 count below 350 should be on antiretroviral therapy (ART). We also audited how many patients we started on treatment within six weeks. We found 88% of the 243 patients were on ART at the end of the audit, but significantly less had been started on treatment within six weeks of their CD4 count falling below 350. Although the target was achieved, there were patients who should be excluded as shown by other clinical guidelines, for example patients on treatment for tuberculosis. If these patients were excluded and the threshold level increased, it would help emphasize the at-risk patient group and lead to a fairer allocation of funding.

'New to Forensic'; implementing a problem-based introductory educational programme for forensic practitioners in Scotland

The New to Forensic educational programme has been developed for use across all forensic services in Scotland. It is designed to meet the needs of all staff who are both new to and already working within forensic mental health services. Its objectives are targeted to both clinical and non-clinical staff. The programme follows the patient's journey through the mental health and criminal justice systems. It covers mental disorder, legislation, psychiatric defences, assessment and treatment, risk of harm to others, services, attitudes and boundaries, multidisciplinary working, users and carers, community, learning disability, and prison services. It is self-directed and practice based, and uses a problem-based approach. Over a 3-year period, trainers and mentors have been trained to deliver the programme by members of the School of Forensic Mental Health http://www.forensicnetwork.scot.nhs.uk/ and all services have adopted the programme as a core educational initiative. Initial findings from the programme evaluation indicate a significant improvement in learning following engagement in the initiative.

Metabolism of 3-chloro-4-fluoroaniline in rat using [14C]-radiolabelling,19F-NMR spectroscopy, HPLC-MS/MS, HPLC-ICPMS and HPLC-NMR

The metabolic fate of 3-chloro-4-fluoroaniline was investigated in rat following intraperitoneal (i.p.) administration at 5 and 50 mg kg(-1) using a combination of HPLC-MS, HPLC-MS/MS, (19)F-NMR spectroscopy, HPLC-NMR spectroscopy and high-pressure liquid chromatography-inductively coupled plasma mass spectrometry (HPLC-ICPMS) with (35)Cl and (34)S detection. The metabolism of 3-chloro-4-fluoroaniline at both doses was rapid and extensive, to a large number of metabolites, with little unchanged compound excreted via the urine. Dosing at 5 mg kg(-1) with [(14)C]-labelled compound enabled the comparison of standard radioassay analysis methods with (19)F-NMR spectroscopy. (19)F-NMR resonances were only readily detectable in the 0-12 h post-dose samples. Dosing at 50 mg kg(-1) allowed the facile and specific detection and quantification of metabolites by (19)F-NMR spectroscopy. Metabolite profiling was also possible at this dose level using HPLC-ICPMS with (35)Cl-specific detection. The principal metabolites of 3-chloro-4-fluoroaniline were identified as 2-amino-4-chloro-5-fluorophenyl sulfate and 2-acetamido-4-chloro-5-fluorophenyl glucuronide. N-acetylation and hydroxylation followed by O-sulfation were the major metabolic transformations observed.

Computer-based education for patients with psychosis

AIM

To evaluate the use of a computer-delivered psycho-education programme which tries to improve patients' knowledge and understanding of psychosis.

METHOD

The study used a qualitative approach to gather opinions from participants (n=10) using semi-structured interviews.

FINDINGS

The results indicated that patients in forensic psychiatry were able to use the CD-ROM with relative ease. They found it acceptable and enjoyable to use and had little difficulty working through the programme and developing their own relapse prevention plan.

CONCLUSION

The study suggests that patients with psychosis are willing to try new ways to learn about their illness and enjoy learning about a complex and sensitive subject. CD-ROM is a useful way to deliver information on psychosis, which may appeal to the younger patient population, who are more familiar with computer technology.

Nicotine improves memory for delayed intentions

RATIONALE

The present paper asked first whether the cholinergic agonist nicotine improves memory for delayed intentions (prospective memory, ProM) and second whether pharmacological dissociation would support the psychological distinction that is made between strategic (effortful) and automatic (non-effortful) intention activation in prospective memory.

OBJECTIVES

To use nicotine as a pharmacological tool with which to examine the neurochemical bases of prospective memory and to dissociate strategic from automatic components of ProM retrieval.

METHODS

In three experiments, minimally deprived (2 h) smokers either smoked or abstained prior to completing a standard prospective memory study. This involved participants in the simultaneous processing of a ProM task and a cover task (ongoing between the setting and the recall of the intention). Here, the ongoing task involved lexical decision (LDT), while the ProM task required a response to pre-specified target items occurring within the LDT stimuli. Variations in task instructions were used to manipulate the processing requirements of the ProM task, the attention allocated to the ProM task and the balance of importance assigned to the ongoing and ProM tasks.

RESULTS

In experiment 1, where the ProM processing was automatic, nicotine did not improve ProM accuracy. In experiment 2, where the ProM task involved strategic processing, positive effects of nicotine were observed. In experiment 3, we covaried ProM task instructions, assigned task importance and nicotine conditions. We observed a main effect of nicotine on ProM accuracy, a main effect of task on ProM accuracy and a main effect of assigned task importance on ProM accuracy. There were no interactions between the factors.

CONCLUSIONS

Employing both direct and indirect manipulations of strategic engagement, we demonstrated nicotine-induced enhancement of performance on the ProM task. The results are consistent with the view that relatively small changes in instruction and in task variables engage strategic processing in a ProM task and that when these conditions stretch cognitive resources, nicotine may significantly improve performance.

Associations between BMI, social strata and the estimated energy content of foods

OBJECTIVE

Many studies have shown that the prevalence of obesity is greater in lower social classes. The reasons for this effect however are unclear. Since there is also a link between education and social class, and an association between education and prevalence of obesity, one hypothesis is that lack of education about energy contents of foods may contribute to the effects of social class on obesity.

SUBJECTS

We tested the hypothesis that knowledge of food energy contents is associated with differences in body mass index (BMI) in a sample of 346 people of both genders, aged between 18 and 45 y, of variable body mass index and drawn from different social strata.

RESULTS

Estimates of food energy contents were on average well correlated with the actual energy contents, but individual estimates were very poor in all subpopulations of this sample. We found that subjects of different BMIs did not differentially estimate the energy contents of foods high in carbohydrate, but low in fat and protein (fruit and bread). However, foods that contained high fat contents, independent of the other macronutrients present, were generally perceived to have significantly lower energy contents by obese people than nonobese subjects (although this was not observed for all high-fat foods). Overall, this difference interacted with social class, such that the difference between the BMI groups was exaggerated in the lower social stratum but abolished in the higher social class. Binary logistic regressions revealed that the probability of being obese (BMI>30 kg/m2) in the lower social class group was significantly negatively associated with the estimated food energy content of most high-fat foods. Such an association was not found in the higher social class group. In the lower social class group, overall food knowledge appeared superior in the leaner subject group (BMI<30 kg/m2), but obese subjects were actually better at estimating the energy contents of snacks and alcoholic beverages. The leaner group significantly overestimated the energy contents of these items.

CONCLUSION

Differences between individuals in estimates of food energy contents may contribute to the development of obesity in lower social strata. Whether this is driven by a protective effect in lean subjects of overestimating the energy contents of certain foods (snacks and alcoholic beverages) or a susceptibility in the obese because they underestimate the energy contents of other foods is not certain. Knowing which of these alternatives is true is important and may help design public health education programmes directed at these people to help alleviate the obesity epidemic.

Effect of contraction frequency on energy expenditure and substrate utilisation during upper and lower body exercise

OBJECTIVE

To examine the effect of contraction frequency on energy expenditure and substrate utilisation during upper (UE) and lower (LE) body exercise.

METHODS

Twenty four college students were recruited: 12 were tested on an arm ergometer, and the other 12 were tested on a leg ergometer. Each subject underwent three experimental trials on three separate days, and the three trials were presented in a randomised order. Each trial consisted of 10 minutes of arm cranking or leg cycling at 40, 60, or 80 rev/min, with power output being kept constant at 50 W. Steady state oxygen uptake (VO(2)) and respiratory exchange ratio (RER) were measured during each exercise. Energy expenditure was calculated from the steady state VO(2) adjusted for substrate metabolism using RER. Carbohydrate and fat oxidation were calculated from VO(2) and RER based on the assumption that protein breakdown contributes little to energy metabolism during exercise.

RESULTS

Energy expenditure was greater (p<0.05) at 80 rev/min than at 40 rev/min. No difference was found between 40 and 60 rev/min and between 60 and 80 rev/min during both UE and LE. During LE, carbohydrate oxidation was also higher at 80 rev/min than at 40 rev/min, whereas no difference in fat oxidation was found among all three pedal rates. During UE, no speed related differences in either carbohydrate or fat utilisation were observed.

CONCLUSIONS

Pedalling at a greater frequency helped to maximise energy expenditure during exercise using UE or LE despite an unchanging power output. Whereas contraction frequency affects energy expenditure similarly during both UE and LE, its impact on carbohydrate utilisation appears to be influenced by exercise modality or relative exercise intensity.

The appropriate rate of breast conserving surgery: an evidence-based estimate

PURPOSE

The objective of the present study was to estimate the proportion of incident cases of breast cancer that should receive breast conserving surgery (BCS), using an evidence-based approach.

METHODS

An extensive search of the literature was undertaken to identify eligibility criteria for BCS. The eligibility criteria for BCS were combined with the information about case mix and patient preference to estimate the need for BCS. An epidemiological approach was then used to estimate the incidence of each eligibility criterion for BCS in a typical North American population of breast cancer patients. The effect of sampling error on the estimated appropriate rate of BCS was calculated, and the effect of systematic error using alternative sources of information, was estimated by sensitivity analysis.

RESULTS

The analysis showed that 69.6% of breast cancer cases are eligible for BCS, and that 48.0 +/- 6.0% of breast cancer patients are both eligible for BCS and prefer it to mastectomy. Based on sensitivity analysis, the plausible range of the appropriate rate was 42.1% to 49.43%. The proportion of breast cancer cases in which BCS was appropriate was stage dependent; 63.0 +/- 11.5% in ductal carcinoma in-situ; 57.0 +/- 9.9% in stage I; 52.2 +/- 9.4% in stage II, and 27.2 +/- 5.2% in stage III.

CONCLUSIONS

This model suggests that BCS is appropriate in 48% of all breast cancer patients. This information may be useful in auditing surgical practice, and may serve as a basis for planning of ancillary services, including radiotherapy.

The presence of a FLT3 internal tandem duplication in patients with acute myeloid leukemia (AML) adds important prognostic information to cytogenetic risk group and response to the first cycle of chemotherapy: analysis of 854 patients from the United Kingdom Medical Research Council AML 10 and 12 trials

In acute myeloid leukemia (AML), further prognostic determinants are required in addition to cytogenetics to predict patients at increased risk of relapse. Recent studies have indicated that an internal tandem duplication (ITD) in the FLT3 gene may adversely affect clinical outcome. This study evaluated the impact of a FLT3/ITD mutation on outcome in 854 patients, mostly 60 years of age or younger, treated in the United Kingdom Medical Research Council (MRC) AML trials. An FLT3/ITD mutation was present in 27% of the patients and was associated with leukocytosis and a high percentage of bone marrow blast cells (P <.001 for both). It had a borderline association with a lower complete remission rate (P =.05) and a higher induction death rate (P =.04), and was associated with increased relapse risk (RR), adverse disease-free survival (DFS), event-free survival (EFS), and overall survival (OS) (P <.001 for all). In multivariate analysis, presence of a mutation was the most significant prognostic factor predicting RR and DFS (P <.0001) and was still significant for OS (P =.009) and EFS (P =.002). There was no evidence that the relative effect of a FLT3/ITD differed between the cytogenetic risk groups. More than one mutation was detected in 23% of FLT3/ITD(+) patients and was associated with worse OS (P =.04) and EFS (P =.07). Biallelic disease or partial/complete loss of wild-type alleles was present in 10% of FLT3/ITD(+) patients. The suggestion is made that detection of a FLT3/ITD should be included as a routine test at diagnosis and evaluated for therapeutic management.

The predictive value of hierarchical cytogenetic classification in older adults with acute myeloid leukemia (AML): analysis of 1065 patients entered into the United Kingdom Medical Research Council AML11 trial

Acute myeloid leukemia (AML) in older adults carries a poor prognosis, and the optimum treatment remains to be determined. In younger patients, treatment stratification is frequently based upon diagnostic karyotype, which was the most important prognostic factor in the UK Medical Research Council (MRC) AML10 trial. Considered here is whether karyotype is also predictive in older adults; this is done by studying 1065 cases from MRC AML11 (median age, 66 years). Three prognostic groups were distinguished on the basis of response to induction therapy and overall survival (OS). Those with t(15;17), t(8;21), or inv(16) composed the favorable risk group. Overall, these abnormalities predicted a superior complete remission (CR) rate (72%), reflecting relatively low levels of resistant disease (RD) (8%), and lower relapse risk (RR) (56%) associated with superior OS (34% at 5 years). Normal karyotype (CR, 63%; RD, 17%; RR, 78%; OS, 15%) and other noncomplex abnormalities (CR, 53%; RD, 32%; RR, 85%; OS, 10%) composed the intermediate group; while complex karyotype predicted an extremely poor prognosis (CR, 26%; RD, 56%; RR, 91%; OS, 2%). Combining MRC AML10 and AML11 (n = 2677) revealed that the most favorable changes were rarer in older patients (younger than 55 years, 24%; 55 years or older, 7%), while complex abnormalities were more common (6% vs 13%). This study suggests that hierarchical cytogenetic classification identifies biologically distinct subsets of AML that are represented in all age groups. Furthermore, it highlights the importance of karyotype as a critical independent determinant of outcome in older patients with AML, providing a potential framework for stratified treatment approaches.

Effect of flue gas desulfurization (FGD) by-product on water quality at an underground coal mine

In this paper, a field study was carried out to examine the effect of flue gas desulfurization (FGD) by-product on water quality at an underground coal mine in central-eastern Ohio. Flue gas desulfurizalion by-product was injected into the down-dip portions of the Robert-Dawson mine in an attempt to seal major seeps exiting the mine and to coat exposed pyritic surfaces. Immediately following grout injection, significant increases in acidity, iron, aluminum, sulfur, and calcium were observed at most surface and ground water locations near where grouting was carried out. Following this initial flush of elements, concentrations of most constituents have decreased to near pre-grouting levels. Data from the site and geochemical modeling suggest that an increase in water level or rerouting of drainage flow resulted in the dissolution of iron and aluminum sulfate salts and ferrihydrite. Dissolution of the FGD grout material resulted in increases in calcium and sulfate concentrations in the drainage waters. Water within the mine voids was saturated with respect to calcium sulfate and gypsum immediately following grout injection. Based on an analysis of core samples obtained from the site, acid mine drainage (AMD) was in contact with at least some portions of the grout and this resulted in grout weathering. Subsequent transport of calcium and sulfate to the underclay, perhaps by fracture flow, has resulted in the deposition of gypsum and calcium sulfate solids.

Estimating the need for radiotherapy for lung cancer: an evidence-based, epidemiologic approach

BACKGROUND AND OBJECTIVES

Current estimates of the proportion of cancer patients who will require radiotherapy (RT) are based almost entirely on expert opinion. The objective of this study was to use an evidence-based approach to estimate the proportion of incident cases of lung cancer that will require RT at any point in the evolution of the illness.

METHODS

A systematic review of the literature was undertaken to identify indications for RT for lung cancer, and to ascertain the level of evidence that supported each indication. An epidemiologic approach was then used to estimate the incidence of each indication for RT in a typical North American population of lung cancer patients. The effect of sampling error on the estimated appropriate rate of RT was calculated mathematically, and the effect of systematic error, was estimated by sensitivity analysis.

RESULTS

It was shown that 53.6% +/- 3.3% of small-cell lung cancer (SCLC) cases develop one or more indications for RT at some point in the course of the illness, 45.4% +/- 4.3% in their initial treatment, and 8.2% +/- 1.5% later for recurrence of progression. Overall, 64.3% +/- 4.7% of non-small-cell lung cancer (NSCLC) cases require RT, 45.9% +/- 4.3% in their initial treatment, and 18.3% +/- 1.8% later in the course of the illness. The proportion of NSCLC cases that ever require RT is stage dependent; 41.0% +/- 5.5% in Stage I; 54.5% +/- 6.5% in Stage II; 83.5% +/- 10.6% in Stage III; and 65.7% +/- 7.6% in Stage IV. In total, 61.0% +/- 3.9% of all patients with lung cancer will develop one or more indications for RT at some point in the illness, 44.6% +/- 3.6% in their initial treatment, and 16.5% +/- 1.5% later for recurrence or progression.

CONCLUSION

This method provides a rational starting point for the long-term planning of radiation services, and for the audit of access to RT at the population level. We now plan to extend this study to the other major cancer sites to enable us to estimate the appropriate RT treatment rate for the cancer population as a whole.

EVI1 expression in acute myeloid leukaemia

Acute myeloid leukaemia (AML) with 3q26 cytogenetic abnormalities is associated with overexpression of EVI1, dysmegakaryopoiesis and poor prognosis. Screening for EVI1 transcripts was performed in 336 cases of AML, including 139 patients with acute promyelocytic leukaemia (APL). Expression was detected in 7 out of 10 cases with and 23 out of 326 without 3q26 abnormalities including one APL case. Among cases lacking 3q abnormalities, detection of EVI1 transcripts was neither associated with characteristic dysmegakaryopoietic features, nor predictive of a poor outcome, indicating that screening will probably not assist in treatment stratification. This study nevertheless demonstrates that deregulation of EVI1, although rare in APL, is a relatively frequent event in AML.