Relative risks of cardiovascular disease in people prescribed olanzapine, risperidone and quetiapine.

Antipsychotics may confer long term benefits and risks, including cardiovascular disease (CVD) risk. Several studies using routine clinical data have reported associations between antipsychotics and CVD but potential confounding factors and unclear classification of drug exposure limits their interpretation. METHOD: We used data from The Health Improvement Network, a large UK primary care database to determine relative risks of (CVD) comparing similar groups of people only prescribed olanzapine versus either risperidone or quetiapine. We included participants over 18 between 1995 and 2011. To assess confounding factors we created propensity scores for being prescribed each antipsychotic. We used propensity score matching and Poisson regression to calculate the CVD incidence rate ratios for olanzapine versus the other two drugs. RESULTS: We identified 18,319 people who received a single antipsychotic during follow-up (n=5090 risperidone, 7797 olanzapine and 4613 quetiapine). In unmatched analyses, the CVD incidence rate ratio (IRR) for olanzapine versus risperidone was 0.63 (0.51-0.77) but the propensity score matched IRR was 0.78 (0.61-1.02). In the unmatched olanzapine versus quetiapine analysis the IRR adjusted for age and sex for olanzapine was 1.52 (1.16-1.98) but the propensity score matched analysis gave an IRR of 1.08 (0.79-1.46). CONCLUSIONS: After propensity score matching, we found no statistical differences in CVD incidence between olanzapine and either risperidone or quetiapine. Analyses which did not account for confounding factors produced very different results. Researchers must address confounding factors when designing observational studies to assess adverse outcomes of drugs, including antipsychotics.

Evaluation of a point-of-care blood test for identification of Ebola virus disease at Ebola holding units, Western Area, Sierra Leone, January to February 2015.

Current Ebola virus disease (EVD) diagnosis relies on reverse transcription-PCR (RT-PCR) technology, requiring skilled laboratory personnel and technical infrastructure. Lack of laboratory diagnostic capacity has led to diagnostic delays in the current West African EVD outbreak of 2014 and 2015, compromising outbreak control. We evaluated the diagnostic accuracy of the EVD bedside rapid diagnostic antigen test (RDT) developed by the United Kingdom's Defence Science and Technology Laboratory, compared with Ebola virus RT-PCR, in an operational setting for EVD diagnosis of suspected cases admitted to Ebola holding units in the Western Area of Sierra Leone. From 22 January to 16 February 2015, 138 participants were enrolled. EVD prevalence was 11.5%. All EVD cases were identified by a positive RDT with a test line score of 6 or more, giving a sensitivity of 100% (95% confidence interval (CI): 78.2-100). The corresponding specificity was high (96.6%, 95% CI: 91.3-99.1). The positive and negative predictive values for the population prevalence were 79.0% (95% CI: 54.4-93.8) and 100% (95% CI: 96.7-100), respectively. These results, if confirmed in a larger study, suggest that this RDT could be used as a 'rule-out' screening test for EVD to improve rapid case identification and resource allocation.

An audit of consent practices and perceptions of lumbar puncture, Botswana inpatient setting experience

Introduction:The epidemic of HIV/AIDS in sub-Saharan Africa has led to significant increases in the burden of meningitis; especially cryptococcal meningitis. Morbidity and mortality resulting from meningitis occur partly due to delays in performing lumbar punctures both for diagnostic and therapeutic purposes. This study was conducted with the primary objective of exploring the attitudes and concerns that patients have with regard to lumbar puncture; and also to assess current consenting practices of doctors with regard to lumbar puncture. Methods : A descriptive cross-sectional study was conducted in medical wards of Princess Marina Hospital; a tertiary hospital in Gaborone; Botswana. Data were collected by means of a questionnaire-based survey involving patients or their next of kin; and doctors. Other relevant information was obtained from patient charts. Data collection involved 12 patients and 23 doctors. Results :Of the 12 patients interviewed; four stated that the reasons for doing lumbar puncture (LP) were explained to them. One respondent stated that LP risks were mentioned; while two stated that they were given the option to refuse LP. Most patients' possible reasons for refusal of LP was attributed to fear of pain. Five (42.7) patients/next of kin had never heard of LP before; and most of the interviewed patients associated the procedure with death and paralysis; while none associated with meningitis or HIV. Twenty-two (95.7) of 23 doctors stated that they routinely consent patients for LP; 11 (47.8) mentioned risks; and nine (39.1) stated that the patient has the option to decline the procedure. Only 26 of doctors routinely used local anaesthesia while 22 routinely asked for written consent. Conclusion: Contrasting responses between doctors and patients indicates a need for standard consenting practices among doctors. Also; patients' attitudes and receptiveness to lumbar punctures can be improved through education on lumbar puncture indications; benefits; and risks

Pulmonary artery thrombosis in a patient with right-sided heart failure.

Pulmonary thromboembolism occurring either abruptly or insidious poses a greater challenge in diagnosis. A high index of suspicion is required to proceed with proper investigations in patients with nonspecific cardiac or respiratory presentation to make the diagnosis of pulmonary embolism (PE). Early diagnosis of PE with prompt initiating of anticoagulation therapy has been proven to have a positive impact in mortality reduction associated with recurrent episodes of this condition. We present a case of a 76-year-old man, known to have cardiac failure on regular treatment who presented with predominant features of right-sided heart failure accompanied with dizziness. He was diagnosed to have pulmonary artery thrombosis by computerized tomography. Anticoagulation therapy was initiated with marked clinical improvement.

Body mass index and common mental disorders: exploring the shape of the association and its moderation by age, gender and education.

BACKGROUND: Obesity is known to be associated with increased prevalence of common mental disorders (for example, depression and anxiety), and there is evidence of age and gender differences in this relationship. However, categorisation of body mass index (BMI) and age has limited our ability to understand the nature of these differences. This study used continuous values of BMI and age to explore the shape of the association between common mental disorders and BMI and whether it varied with age, gender and education. METHOD: The analysis used cross-sectional data on 7043 adults from the English 2007 Adult Psychiatric Morbidity Survey. Common mental disorders were assessed using the revised Clinical Interview Schedule (CIS-R). Cubic splines allowed BMI and age to have non-linear effects in the logistic regression analysis. RESULTS: BMI was strongly associated with the presence of common mental disorders, and there was clear evidence that this association varied with gender and age. In young women the probability of having a disorder increased as BMI increased, whereas in young men the relationship was U-shaped-probabilities were higher for both underweight and obese men. These associations diminished in older age groups, particularly when potential confounders such as physical health were taken into account. There was no evidence that the relationship varied with education. CONCLUSIONS: Age and gender differences must be taken into account when investigating the link between BMI or obesity and common mental disorders. Furthermore, results of studies that categorise BMI may be highly sensitive to the width of the 'normal weight' reference category.

The association between personality disorder and an act of deliberate self harm in the older person.

BACKGROUND: Suicide rates are higher in the over 65s than in younger adults and there is a strong link between deliberate self harm (DSH) and suicide in older people. The association between personality disorder (PD) and DSH in older adults remains uncertain. Our objective was to describe this association. METHODS: A case control study was conducted in which participants were: (i) those who had undertaken an act of DSH and (ii) a hospital-based control group drawn from a geographical contiguous population. PD was assessed using the Standardised Assessment of Personality (SAP). RESULTS: Seventy-seven cases of DSH were identified; 61 (79.2%) of these participants were interviewed. There were 171 potential controls identified of whom 140 (81.9%) were included. An SAP was completed in 45/61 (73.8%) of cases and 100/140 (71.4%) of controls. The mean age was 79.8 years (SD = 9, range 65-103). The crude odds ratio for the association between PD and DSH was 5.91 [(95% CI 2.3, 14.9) p<0.0001]. There was a strong interaction with age stratified at 80 years. There was no association between PD and DSH after age 80. The adjusted odds ratio for PD in the group <80 years was 20.5 [(95% CI 3, 141) p = 0.002]. Borderline and impulsive PD traits tended to be associated with an episode of DSH more than other personality types. CONCLUSIONS: PD appears to be a strong and independent risk for an act of DSH in people aged between 65 and 80 years and should be looked for as part of any risk assessment in this population. Access to specialist services may be required to optimally manage this problem and reduce the subsequent risk of suicide.

Factors associated with anxiety in patients attending a sexually transmitted infection clinic: qualitative survey.

We used qualitative methods to explore factors, which might explain increased anxiety in patients attending a sexually transmitted infection (STI) clinic. Twenty patients, who scored significantly for anxiety on the Hospital Anxiety and Depression Scale (HADS) attended a 20-minute interview. This explored factors contributing to their current psychological symptoms. Transcripts revealed three main themes. First were factors related to possible STIs and the clinic visit. These included health anxieties about HIV or fertility and clinic factors, including staff attitudes and clinic location. Second were factors unrelated to the clinic, including previous emotional difficulties or substance misuse. Third were issues concerning stigma, embarrassment and shame. The origins of anxiety in STI patients are multifactorial and difficult to identify during brief appointments. Despite modern clinics and attitudes, stigma and embarrassment remain prominent. Interventions to address these factors could improve psychological health in this patient group.

Supplemental vitamin D3 concentration and biological type of steers. II. Tenderness, quality, and residues of beef.

Vitamin D3 was orally supplemented to determine the supplemental dose that improved beef tenderness in different cattle breed types. Feedlot steers (n = 142) were arranged in a 4 x 3 factorial arrangement consisting of four levels of supplemental vitamin D3 (0, 0.5, 1, and 5 million IU/steer daily) administered for eight consecutive days antemortem using three biological types (Bos indicus, Bos Taurus-Continental, and Bos Taurus-English). Warner-Bratzler shear force (WBSF) was measured at 3, 7, 10, 14, and 21 d postmortem, and trained sensory analysis was conducted at 7 d postmortem on LM, semimembranosus, gluteus medius, and supraspinatus steaks. Concentrations of vitamin D3 and the metabolites 25-hydroxyvitamin D3, and 1,25-dihydroxyvitamin D3 were determined in the LM, liver, kidney, and plasma. Biological type of cattle did not interact (P > 0.10) with vitamin D3 supplementation for sensory or tenderness traits, suggesting that feeding vitamin D3 for 8 d before slaughter affected the different biological types of cattle similarly. Supplementing steers with 0.5, 1, or 5 million IU/(steer(d) decreased (P < 0.05) LM WBSF at 7, 10, 14, and 21 d postmortem compared with controls, and vitamin D3 treatments of 0.5, 1, and 5 million IU decreased (P < 0.05) semimembranosus WBSF at 3, 7, and 14 d postmortem. In general, vitamin D3-induced improvements in WBSF were most consistent and intense in LM steaks. Sensory panel tenderness was improved (P < 0.05) by all vitamin D3 treatments in LM steaks. Sensory traits ofjuiciness, flavor, connective tissue, and off-flavor were not (P > 0.05) affected by vitamin D3 treatments. All vitamin D3 treatments decreased micro-calpain activity and increased muscle Ca concentrations (P < 0.05). Vitamin D3 concentrations were increased (P < 0.05) by supplementation in all tissues tested (liver, kidney, LM, and plasma); however, cooking steaks to 71 degrees C decreased (P < 0.05) treatment residue effects. The vitamin D metabolite 1,25-dihydroxyvitamin D3 was increased (P < 0.05) only in plasma samples as a result of the vitamin D3 treatments. These results indicate that supplementation with vitamin D3 at 0.5 million IU/steer daily for eight consecutive days before slaughter improved tenderness in steaks from different subprimal cuts by affecting muscle Ca concentrations, micro-calpain activities, and muscle proteolysis, with only a small effect on tissue residues of vitamin D3.

Psychiatric health in a sexually transmitted infections clinic: effect on reattendance.

BACKGROUND AND OBJECTIVES: Sexually transmitted infections (STIs) remain a public health priority, but associated psychological morbidity has recently been ignored. One aspect of STI control is test of cure and further treatment at follow-up clinic appointments. We chose reattendance rates as a measure of compliance and assessed whether reattendance was related to psychological morbidity. METHODS: 938 STI clinic patients were offered the Hospital Anxiety and Depression Scale (HAD) and staff rated each patient's psychological health. Predictors of attendance, caseness and staff recognition were assessed by logistic regression. RESULTS: 401/774 [51.9%; 95% confidence interval (CI): 48.3-55.4%] patients, who completed the HAD, scored above threshold. Staff rated 151/743 (20.4%) patients as having "psychological problems." HAD caseness was not associated with attending arranged follow-up [adjusted odds ratio (adj. OR): 0.83 (0.49-2.05)]. Patients rated with psychological problems by staff were more likely to attend [adj. OR: 1.91 (1.02-3.60)]. CONCLUSIONS: Half of our sample had significant anxiety and staff should be more aware of this suffering. Our work suggests that such awareness might improve subsequent attendance.

Sexual molestation of men: interviews with 224 men attending a genitourinary medicine service.

Prevalence studies of sexual molestation in men attending genitourinary medicine (GUM) clinics have concentrated on experiences in adulthood or as a child, or on men who report male sexual partners only. Use of questionnaires in such studies can lead to under-reporting of 'sensitive' events. Our aim is to identify the lifetime prevalence of sexual molestation in men attending a GUM clinic using a self-administered, computerized interview via a cross-sectional survey. Eighteen per cent of respondents reported sexual molestation as an adult and 12% reported child sexual abuse (CSA). Sexual molestation in adulthood was more common in men who reported male sexual partners and in men reporting child sexual abuse. Fourteen per cent of victims reported being infected with a sexually transmitted infection (STI) after adult sexual molestation. In conclusion, a significant proportion of men attending GUM services report sexual molestation. Further research is required into effective ways of addressing this unmet need.

Attrition in an exercise intervention: a comparison of early and later dropouts.

OBJECTIVE: To identify reasons for dropout and factors that may predict dropout from an exercise intervention aimed at improving physical function in frail older persons. DESIGN/SETTING: An 18-month randomized controlled intervention in a community setting. The intervention comprised 2 groups: class-based and self-paced exercise. PARTICIPANTS: 155 community-dwelling older persons, mean age 77.4, with mildly to moderately compromised mobility. MEASUREMENTS: The primary outcome measure was dropout. Dropouts were grouped as: D0, dropout between baseline and 3-month assessment, and D3, dropout after 3-month assessment. MEASUREMENTS: Measurements of demographics, health, and physical performance included self-rated health, SF-36, disease burden, adverse events, PPT-8, MacArthur battery, 6-minute walk, and gait velocity. RESULTS: There were 56 dropouts (36%), 31 in first 3 months. Compared with retained subjects (R), the D0 group had greater disease burden (P = .011), worse self-perceived physical health (P = .014), slower usual gait speed (P = .001), and walked a shorter distance over 6 minutes (P<.001). No differences were found between R and D3. Multinomial logistic regression showed 6-minute walk (P<.001) and usual gait velocity (P<.001) were the strongest independent predictors of dropout. Controlling for all other variables, adverse events after randomization and 6-minute walk distance were the strongest independent predictors of dropout, and self-paced exercise assignment increased the risk of dropout. CONCLUSIONS: We observed baseline differences between early dropouts and retained subjects in disease burden, physical function, and endurance, suggesting that these factors at baseline may predict dropout. Improved understanding of factors that lead to and predict dropout could allow researchers to identify subjects at risk of dropout before randomization. Assigning targeted retention techniques in accordance with these factors could result in decreased attrition in future studies. Therefore, the results of selective attrition of frailer subjects, such as decreased heterogeneity, restricted generalizability of study findings, and limited understanding of exercise effects in this population, would be avoided.

The economics of employing a counsellor in general practice: analysis of data from a randomised controlled trial.

BACKGROUND: Counselling is currently adopted in many general practices, despite limited evidence of clinical and cost effectiveness. AIM: To compare direct and indirect costs of counsellors and general practitioners (GPs) in providing care to people with emotional problems. METHOD: We carried out a prospective, randomized controlled trial of non-directive counselling and routine general practice care in 14 general practices in north London. Counsellors adhered to a Rogerian model of counselling. The counselling sessions ranged from one to 12 sessions over 12 weeks. As reported elsewhere, there were no differences in clinical outcomes between the two groups. Therefore, we conducted a cost minimisation analysis. We present only the economic outcomes in this paper. Main outcome measures were cost data (service utilisation, travel, and work absence) at baseline, three months, and nine months. RESULTS: One hundred and thirty-six patients with emotional problems, mainly depression, took part. Seventy patients were randomised to the counsellors and 66 to the GPs. The average direct and indirect costs for the counsellor was 162.09 Pounds more per patient after three months compared with costs for the GP group; however, over the following six months the counsellor group was 87.00 Pounds less per patient than the GP group. Over the total nine-month period, the counsellor group remained more expensive per patient. CONCLUSIONS: Referral to counselling is no more clinically effective or expensive than GP care over a nine-month period in terms of direct plus indirect costs. However, further research is needed to establish indirect costs of introducing a counsellor into general practice.

Reliability and responsiveness of two physical performance measures examined in the context of a functional training intervention.

BACKGROUND AND PURPOSE: The reliability and responsiveness of 2 physical performance measures were assessed in this nonrandomized, controlled pilot exercise intervention. SUBJECTS: Forty-five older individuals with mobility impairment (mean age=77.9 years, SD=5.9, range=70-92) were sequentially assigned to participate in an exercise program (intervention group) or to a control group. METHODS: The intervention group performed exercise 3 times a week for 12 weeks that targeted muscle force, endurance, balance, and flexibility. Outcome measures were the 8-item Physical Performance Test (PPT-8) and the 6-minute walk test. Test-retest reliability and responsiveness indexes were determined for both tests; interrater reliability was measured for the PPT-8. RESULTS: The intraclass correlation coefficient for interrater reliability for the PPT-8 was. 96. Intraclass correlation coefficients for test-retest reliability were.88 for the PPT-8 and.93 for the 6-minute walk test. The intervention group improved 2.4 points and the control group improved 0.7 point on the PPT-8, as compared with baseline measurements. There was no change in 6-minute walk test distance in the intervention group when compared with the control group. The responsiveness index was.8 for the PPT-8 and.6 for the 6-minute walk test. CONCLUSION AND DISCUSSION: Measurements for both the PPT-8 and the 6-minute walk test appeared to be highly reliable. The PPT-8 was more responsive than the 6-minute walk test to change in performance expected with this functional training intervention.

Development of an instrument to measure terminal restlessness.

Terminal restlessness is a clinical phenomenon that is frequently observed but poorly defined. Its management is important in providing good quality palliative care. We present the development of an objective observer-rated instrument to measure terminal restlessness.

Randomised controlled assessment of non-directive psychotherapy versus routine general-practitioner care.

BACKGROUND: We compared the efficacy of and patients' satisfaction with general-practice-based psychotherapists with those of general practitioners in providing treatment to people with emotional difficulties. METHODS: We carried out a prospective, randomised, controlled trial of brief, non-directive psychotherapy and routine general-practice care. Therapists adhered to a non-directive Rogerian model of psychotherapy. Between one and 12 sessions of psychotherapy were given over 12 weeks in 14 general practices in north London, UK. Of 136 patients with emotional difficulties, mainly depression, 70 patients were randomly assigned to the therapist and 66 to the general practitioner. Depression, anxiety, other mental-disorder symptoms, and social adjustment were measured by self-report at baseline, 3 months, and 9 months. Patients' satisfaction was also measured by self-report at 3 and 9 months. FINDINGS: All patients improved significantly over time. There were no significant differences between the groups receiving brief psychotherapy and routine general-practitioner care. Patients assigned brief psychotherapy were more satisfied with the help they received than those assigned to the general practitioner at both 3 and 9 months' follow-up (mean scores on satisfaction scale 50.9 [SD 7.9] vs 44.4 [9.8] and 45.6 [9.4] vs 37.1 [11.2], respectively). INTERPRETATION: General-practitioner care is as effective as brief psychotherapy for patients usually referred by doctors to practice-based psychotherapists. Patients with emotional difficulties prefer brief psychotherapy from a counsellor to care from their general practitioner.

Phylogenetic characterization of bacteria in the subsurface microbial culture collection.

The Subsurface Microbial Culture Collection (SMCC) was established by the U.S. Dept. of Energy (DOE) and contains nearly 10,000 strains of microorganisms (mostly bacteria) isolated from terrestrial subsurface environments. Selected groups of bacterial isolates from three sample sites situated above geochemically and hydrologically different subsurface environments have been characterized by phylogenetic analysis of 16S ribosomal RNA (rRNA) gene nucleotide sequences. Among these isolates were members of six major phylogenetic groups of bacteria: the high-G+C and low-G+C Gram-positive bacteria; the alpha-, beta-, and gamma-subdivisions of the Proteobacteria; and the Flexibacter/Cytophaga/Bacteroides group. A small number of the SMCC strains may be members of new bacterial genera, but most of them could be placed with reasonable confidence into more than 35 previously described genera. The majority of the Gram-positive isolates were species of Arthrobacter, Bacillus, or Streptococcus, whereas Acinetobacter, Comamonas, Pseudomonas, Sphingomonas, and Variovorax were among the most frequently encountered Gram-negative genera. A high proportion of the strains were placed in fewer than 10 genera, implying that there is substantial duplication within the SMCC at the genus level. When groups of isolates assigned to Acinetobacter, Arthrobacter, or Sphingomonas were analyzed in more detail, however, it was found that each group consisted of subgroups of strains that probably differed at the species level. Restriction endonuclease analysis (applied to the strains from one sample site) indicated that additional diversity was present at the strain level. Most of the SMCC isolates assigned to some genera (e.g., Acinetobacter) were very closely related to previously described species in those genera, but most of the isolates assigned to other genera (e.g., Arthrobacter and Sphingomonas) appeared (or were shown) to be new species, thereby indicating that a reasonable amount of novelty is present within the SMCC at the species level.

The Hampstead Schizophrenia Survey 1991. I: Prevalence and service use comparisons in an inner London health authority, 1986-1991.

BACKGROUND: A point prevalence study of schizophrenia was carried out in 1986 in the former Hampstead Health District using a key informant method to identify cases. The point prevalence of broadly defined schizophrenia was 4.7 per 1000. METHOD: A repeat census of people with schizophrenia, using the same method, was carried out in 1991 and the point prevalence calculated. The accuracy of the census method was estimated. Contact with services, social and occupational activity, and medication usage in the 1986 and 1991 samples were compared. RESULTS: The point prevalence rate of broadly defined schizophrenia in 1991 was 5.1 per 1000. The results of both censuses showed we underestimated the number of individuals with DSM-III-R positive schizophrenia by about 14%. The level of contact with specialist services was greater in 1991 than 1986. Patients in 1991 were discharged on higher doses of medication, and their most recent admission was more likely to be due to non-compliance, than the 1986 group. CONCLUSION: The point prevalence confirmed the high rate reported in 1986. The accuracy of the census was within acceptable limits for service planning. Contact with specialist services increased between 1986 and 1991.