Impact of vaccination by priority group on UK deaths, hospital admissions and intensive care admissions from COVID-19.

National (and global) vaccination provides an opportunity to control the COVID-19 pandemic, which disease suppression by societal lockdown and individual behavioural changes will not. We modelled how vaccination through the UK's vaccine priority groups impacts deaths, hospital and ICU admissions from COVID-19. We used the UK COVID-19 vaccines delivery plan and publicly available data to estimate UK population by age group and vaccination priority group, including frontline health and social care workers and individuals deemed 'extreme clinical vulnerable' or 'high risk'. Using published data on numbers and distributions of COVID-19-related hospital and ICU admissions and deaths, we modelled the impact of vaccination by age group. We then modified the model to account for hospital and ICU admission, and death among health and social care workers and the population with extreme clinical vulnerability and high risk. Our model closely matches the government's estimates for mortality after vaccination of priority groups 1-4 and groups 1-9. The model shows vaccination will have a much slower impact on hospital and ICU admissions than on deaths. The early prioritisation of healthcare staff and clinically vulnerable patients increases the impact of vaccination on admissions and also protects the healthcare service. An inflection point, when 50% of the adult population has been vaccinated - with deaths reduced by 95% and hospital admissions by 80% - may be a useful point for re-evaluating vaccine prioritisation. Our model suggests substantial reductions in hospital and ICU admissions will not occur until late March and into April 2021.

Cyclic neutropenia and pyomyositis: a rare cause of overwhelming sepsis.

Primary pyomyositis is a pyogenic infection of skeletal muscle with abscess formation, which traditionally lacks an identifiable cause. We present a case of pyomyositis for which a cause was established. This was largely due to the fact that the patient was young and fit, enabling him to survive such overwhelming sepsis long enough for cycling of his neutrophil count to become apparent. Having had multiple abscesses drained, he was successfully treated with granulocyte colony stimulating factor and has remained well since.

Changing public attitudes towards corporal punishment: the effects of statutory reform in Sweden.

OBJECTIVE: One justification for a statutory ban on physical punishment is that passage of such legislation changes public attitudes towards the use of this form of parental discipline. The experience in Sweden is often cited as an example of legislation which changed public opinion. The aim of this brief article is to review the public opinion findings in Sweden in order to evaluate in greater detail the impact of changing the law. METHOD: A search was conducted to generate all published and publicly-available quantitative surveys of the public in Sweden and elsewhere. RESULTS: The results of time-series analysis of the data are clear. The 1979 legal reform in Sweden did not reduce the level of public support for parental use of corporal punishment as a means of disciplining children. Support for physical punishment began declining years before the reform was passed and the decline was in no way accelerated by the law reform. Changes in public opinion may have generated the legal reform, but the reverse is not true. Data from other jurisdictions also support the view that there is no relationship between the status of the law and the nature of public views with regard to corporal punishment. This result is consistent with analyses of the effects of legal reforms in other areas. CONCLUSIONS: The Swedish ban on corporal punishment did not affect public attitudes. Changing public views requires other initiatives.

Delay in presentation of symptomatic referrals to a breast clinic: patient and system factors.

We attempted to identify factors associated with delay in presentation and assessment of women with breast symptoms who attended a London breast clinic. A total of 692 consecutive symptomatic referrals, aged 40-75 years, were studied. Patient delay, assessed prior to diagnosis, was defined as time elapsing between symptom discovery and first presentation to a medical provider. This was studied in relation to: reasons for delaying, beliefs and attitudes, socio-demographic and clinical variables, psychiatric morbidity and subsequent diagnosis. Thirty-five per cent of the cohort delayed presentation 4 weeks or more (median 13 days). The most common reason given was that they thought their symptom was not serious (odds ratio (OR) = 5.32, 95% confidence interval (CI) 3.6-8.0). Others thought their symptom would go away (OR = 3.73, 95% CI 2.2-6.4) or delayed because they were scared (OR = 4.61, 95% CI 2.1-10.0). Delay was associated with psychiatric morbidity but not age. Patients who turned out to have cancer tended to delay less (median 7 days) but not significantly. Median system delay--time between first medical consultation and first clinic visit--was 18 days. Patients who thought they had cancer and those so diagnosed were seen more promptly (median 14 days). Most factors, including socio-economic status and ethnicity were non-contributory. Beliefs about breast symptoms and their attribution are the most important factors determining when women present. Health education messages should aim to convince symptomatic women that their condition requires urgent evaluation, without engendering fear in them.

Performance of Parkinson's disease patients on the Visual Search and Attention Test: impairment in single-feature but not dual-feature visual search.

Nondemented patients with Parkinson's disease (PD) and a group of age and education matched controls were administered a modified version of the Visual Search and Attention Test (VSAT). This task measures subjects' speed at localizing letter or symbol targets based on either a single-feature or a dual-feature search. Three indices were derived from the VSAT: (a) the amount of time taken to complete each of the trials (completion time), (b) the number of target items not crossed out (omissions), and (c) the number of nontarget items crossed out (commissions). The results indicated that, in terms of completion time, the PD patients were impaired on the single-feature search conditions but not on the dual-feature search conditions, suggesting that PD patients are impaired in selective attention processes. It was also found that the number of target items omitted by the normal controls on the VSAT varied as a function of the nature of the target (letter or form) and the search requirements (single-feature or dual-feature search), whereas the number of targets omitted by the PD patients was not affected by these factors. Correlational analyses suggested that the three measures derived from the VSAT assessed different components of attentional performance in these patients. Overall, the results of this study suggest that the VSAT can be used to detect subtle attentional impairments in nondemented PD patients, and that the pattern of their impairment on this clinical test is similar to that found on experimental attentional measures.

Graded check lists to assist undergraduate students in self-directed learning and assessment in general and systematic anatomical pathology.

To guide undergraduate medical, dental and health science students undertaking self-directed learning and preparing for examinations in general and systematic pathology, comprehensive graded check lists of selected learning topics have been prepared. Each topic is allocated a grade of 0 (knowledge of the topic not required), 1 (awareness of existence of condition needed, but detailed information not required), 2 (moderately important) or 3 (very important, substantial knowledge required). As students advance through the undergraduate medical course they are provided with replacement lists in which the gradings of many topics have been increased to match requirements for increased knowledge. Over the five years that these check lists have been used, they have received a high level of approval, students finding them increasingly useful as self-directed learning progressively replaces didactic teaching methods. The introduction of the check lists has markedly reduced student inquiries regarding the levels of knowledge required for examinations, and has proved useful to teachers involved in the setting and marking of student assessments. As a result of student pressure, other departments have introduced graded topic lists.

Criminal justice processing of sexual assault cases. Highlights.

PIP: This article discusses the processing of criminal justice on sexual assault cases in Canada. To begin with, in 1983, Bill C-127 abolished the offense of rape and indecent assault and created three new crimes of sexual assault and three parallel offenses of assault. This legislation also introduced a number of important changes to the way crimes of sexual aggression are processed by the criminal justice system. In 1991, the Supreme Court struck down provisions of the sexual assault legislation preventing a defendant from introducing evidence regarding complainant's previous sexual conduct. As a result, Bill C-49 was introduced to provide a test to determine whether a complainant's sexual history could be admitted at trial. This bill also addresses the issue of consent and the defense of mistaken beliefs in consent. The focus of the Juristat is the criminal justice processing of the three levels of sexual assault, which are elaborated in this article. In order to distinguish between the different levels, body harm relates only to physical injury and does not include psychological harm. Drawing on the Uniform Crime Reporting Survey, the Sentence Study, the Adult Criminal Court Survey and the Youth Court Survey, the Juristat summarizes recent trends relating to the processing of sexual assault and assault by the police and the courts. Canada's Violence Against Women Survey provides a profile of sexual assault incidents among adult women in Canada.^ieng

Treatment of the axilla in patients with screen-detected breast cancer.

Management of the axillary lymph nodes in patients with screen-detected breast cancer is controversial. Optimal treatment should combine accurate determination of node status and avoidance of unnecessary morbidity. This study attempted to determine whether axillary node status could be accurately predicted using selected criteria in women with screen-detected breast cancer. Of 223 breast cancers excised in the Greater Manchester breast screening programme, 180 were invasive and 40 of these had associated lymph node metastases. The presence of involved nodes was associated with large tumour size, high tumour grade and the absence of mammographic microcalcification. Multiple logistic regression analysis revealed that each of these three factors was independently significant. Women with a screen-detected breast cancer < 1 cm in diameter or those with grade I tumours < 3 cm (35 per cent of the total) could be spared axillary surgery with an expected reduction in morbidity and operating time.

A randomized trial of one versus three doses of Augmentin as wound prophylaxis in at-risk abdominal surgery.

In a randomized prospective trial of prophylactic antibiotics in at-risk abdominal surgery, one dose of intravenous Augmentin (amoxycillin 250 mg and clavulanic acid 125 mg) on induction has been compared with three 8 hourly doses in 900 patients. Wound infection rates which included minor and delayed infections were very similar in those given one dose: 48/449 (10.7%) compared with those given three doses: 49/451 (10.9%) 95% confidence limits - 4.25% + 3.9%. There were more septic and sepsis-related deaths in those patients given one dose (14 deaths) than in those given three doses (7 deaths) P > 0.1 95% CL - 0.4% + 3.0%. However, there were more very elderly patients in the one dose group: 64% of the deaths were aged over 80 and all but one had an emergency operation. There was no difference in the other outcome measures studied which included non-fatal deep sepsis, length of postoperative hospital stay, duration of postoperative fever or the use of antibiotics for postoperative infection. One dose of a suitable intravenous antibiotic gives prophylaxis against wound infection in at-risk abdominal surgery which is at least as effective as multiple doses. However, there may be a risk of overwhelming systemic sepsis in very elderly patients having emergency surgery.

The use of the Body Mass Index in studies of abdominal wound infection.

Abdominal wound infection rates were significantly related to obesity, as measured by Body Mass Index, in two large clinical trials of prophylactic antibiotics in at-risk abdominal surgery. Obesity is a risk factor that should be taken into account in any study in which wound infection is an outcome measure.

Mechanisms of sex-steroid accumulation in the aetiology of human breast carcinoma: the role of intracellular sex hormone binding globulin.

In malignant breast tissue cytosols (n = 14), significantly high levels of oestradiol (E2), testosterone and 5a-dihydrotestosterone (DHT) and sex hormone binding globulin (SHBG) were found as compared to breast tissue cytosols from normal women (n = 12) (p less than 0.001 for all parameters measured). In serum from the same patients and normal control groups no differences in these hormones or SHBG were detected, nor was relationship between serological and cytosolic levels observed. In the cytosol of the malignant group there was a significant correlation between testosterone and DHT, r = 0.98, p less than 0.001. This was also the case in the cytosol of normal breast tissue, r = 0.97, p less than 0.001. No such correlation between the two androgens was observed in the sera of either group. We hypothesise that the malignant breast is able to regulate its own hormonal milieu and that the nearly 8 times higher levels of intracellular SHBG compared to those in normal breast cytosol may be one the factors responsible for this accumulation of sex-steroids. In addition, SHBG due to its higher affinity for androgens than for E2 may shift the balance in favour of free oestrogens in malignant breast tissue.

Simplifying infusion chemotherapy: preliminary communication.

A low-intervention policy for Hickman catheter maintenance has been evaluated and found to be safe and cost effective. A simple, lightweight, disposable device has been used for 24-hour ambulatory home infusion. Implementation of this policy as part of a prospective randomized trial of single-agent chemotherapy in advanced breast cancer has demonstrated that slow intravenous infusion reduces the acute toxicity of epirubicin when compared with bolus injection.

Sex-steroid receptors in human breast cancer. Incidence and interrelationships.

Over-expression of oestrogen and progesterone receptor (ER and PR respectively) has been reported in malignant breast disease but the techniques employed have been relatively insensitive and prone to underestimations. Using a highly sensitive microassay method, we have estimated ER (n = 39), PR (n = 32) and androgen receptor (AR) (n = 37) in cytosolic and nucleosolic fractions obtained from the same tissue samples. Induction of PR by oestrogen is a widely recognized phenomenon, and a relationship between PR and ER is to be expected. There is evidence that sex-steroids and their receptors act in concert and it is therefore surprising that AR has been poorly studied in malignant breast disease, despite indications that its presence increases hormone responsiveness. Our hypothesis is that, unlike the normal breast, in malignancy a possible deregulation of transcriptional control may lead to an over expression of all three classes of sex-steroid receptor. Using the microassay, we have tested this hypothesis and found not only a greater incidence of ER, AR and PR than previously reported in malignant breast disease, but considerably higher levels of these receptors. In addition, our findings demonstrate that these receptors tend to be expressed simultaneously rather than discretely, supporting the view that a deregulation of transcriptional control may account for the clinical and biological heterogeneity of the disease.

Aspiration and instillation of tetracycline in the treatment of testicular hydrocele.

Testicular hydroceles recurred within 6 months in 7 of 15 patients (46.7%) treated by aspiration and instillation of tetracycline. There was objective reduction in the size of the hydrocele in three patients (20%) but only five (33.3%) were cured. Severe pain was a complication in seven cases. This form of treatment is not recommended.