The changing incidence of childhood-onset type 1 diabetes in Wales: Effect of gender and season at diagnosis and birth.

AIMS: Determinants of the changing incidence of childhood-onset type 1 diabetes remain uncertain. We determined the recent time-trend of type 1 diabetes incidence in Wales and explored the role of vitamin D by evaluating the influence of season both at diagnosis and at birth. METHODS: Data from all Welsh paediatric units 1990-2019, and from primary care to determine ascertainment. RESULTS: Log-linear modelling indicated a non-linear secular trend in incidence with peak and subsequent decline. The peak occurred around June 2010: 31∙3 cases/year/100,000 children aged < 15y. It occurred earlier in children younger at diagnosis and earlier in boys. There were more cases in males aged <2y and >12y but more in females aged 9-10 y. More were diagnosed in winter. Also, children born in winter had less risk of future diabetes. CONCLUSIONS: The risk of developing type 1 diabetes before age 15y in Wales is no longer increasing. The data on season are consistent with a preventative role for vitamin D both during pregnancy and later childhood. Metereological Office data shows increasing hours of sunlight since 1980 likely to increase vitamin D levels with less diabetes. Additional dietary supplementation with vitamin D might further reduce the incidence of type 1 diabetes.

Testing the effects of checklists on team behaviour during emergencies on general wards: An observational study using high-fidelity simulation.

INTRODUCTION: Clinical teams struggle on general wards with acute management of deteriorating patients. We hypothesized that the Crisis Checklist App, a mobile application containing checklists tailored to crisis-management, can improve teamwork and acute care management. METHODS: A before-and-after study was undertaken in high-fidelity simulation centres in the Netherlands, Denmark and United Kingdom. Clinical teams completed three scenarios with a deteriorating patient without checklists followed by three scenarios using the Crisis Checklist App. Teamwork performance as the primary outcome was assessed by the Mayo High Performance Teamwork scale. The secondary outcomes were the time required to complete all predefined safety-critical steps, percentage of omitted safety-critical steps, effects on other non-technical skills, and users' self-assessments. Linear mixed models and a non-parametric survival test were conducted to assess these outcomes. RESULTS: 32 teams completed 188 scenarios. The Mayo High Performance Teamwork scale mean scores improved to 23.4 out of 32 (95% CI: 22.4-24.3) with the Crisis Checklist App compared to 21.4 (20.4-22.3) with local standard of care. The mean difference was 1.97 (1.34-2.6; p < 0.001). Teams that used the checklists were able to complete all safety-critical steps of a scenario in more simulations (40/95 vs 21/93 scenarios) and these steps were completed faster (stratified log-rank test χ2 = 8.0; p = 0.005). The self-assessments of the observers and users showed favourable effects after checklist usage for other non-technical skills including situational awareness, decision making, task management and communication. CONCLUSIONS: Implementation of a novel mobile crisis checklist application among clinical teams was associated in a simulated general ward setting with improved teamwork performance, and a higher and faster completion rate of predetermined safety-critical steps.

Optimising image quality and radiation dose for neonatal incubator imaging.

INTRODUCTION: Neonates often require imaging within incubators however limited evidence exists as to the optimal method and acquisition parameters to achieve these examinations. This study aims to standardise and optimise neonatal chest radiography within incubators. METHODS: A neonatal anthropomorphic phantom was imaged on two different incubators under controlled conditions using a DR system. Exposure factors, SID and placement of image receptor (direct v tray) were explored whilst keeping all other parameters consistent. Image quality was evaluated using absolute visual grading analysis (VGA) with contrast-to-noise ratio (CNR) also calculated for comparison. Effective dose was established using Monte Carlo simulation using entrance surface dose within its calculations. RESULTS: VGA and CNR reduced significantly (p < 0.05) whilst effective dose increased significantly (p < 0.05) for images acquired using the incubator tray. The optimal combinations of parameters for incubator imaging were: image receptor directly behind neonate, 0.5 mAs, 60 kV at 100 cm SID, however, if tray needs to be used then these need to be adapted to: 1 mAs at maximum achievable SID. Effective dose was highest for images acquired using both incubator tray and 100 cm SID owing to a decrease in focus to skin distance. There is significant increase (p < 0.01) in VGA between using 0.5 mAs and 1 mAs but an apparent lack of increase between 1 and 1.5 mAs. CONCLUSION: Using the incubator tray has an adverse effect on both image quality and radiation dose for incubator imaging. Direct exposure is optimal for this type of examination but if tray needs to be used, both mAs and SID need to be increased slightly to compensate. IMPLICATIONS FOR PRACTICE: This study can help inform practice in order to both standardise and optimise chest imaging for neonates in incubators.

Health related quality of life for young people receiving dialectical behaviour therapy (DBT): a routine outcome-monitoring pilot.

PURPOSE: Adults presenting with borderline personality disorder (BPD) score poorly on measures of health related quality of life (HRQoL). Little is known about HRQoL in adolescents with BPD type presentations and how treatment impacts quality of life. Our primary aim was to use routinely collected quality-of-life outcome measures pre and post-treatment in dialectical behaviour therapy (DBT) for adolescents to address this gap. Secondary aims were to benchmark these data against EuroQol 5 dimensions (EQ-5D™) outcomes for clients treated in clinical trials and to assess the potential of the EQ-5D™ as a benchmarking tool. METHOD: Four adolescent DBT teams, routinely collecting outcome data using a pseudonymised secure web-based system, supplied data from consecutive discharges. RESULTS: Young people in the DBT programmes (n = 43) had severely impaired HRQoL scores that were lower at programme admission than those reported in published studies using the EQ-5D™ in adults with a BPD diagnosis and in one study of adolescents treated for depression. 40 % of adolescents treated achieved Reliable Clinical Change. HRQoL improved between admission and discharge with a large effect size. These results were not statistically significant when clustering in programme outcomes was accounted for. CONCLUSION: Young people treated in NHS DBT programmes for BPD type presentations had poorer HRQoL than adults with a BPD diagnosis and adolescents with depression treated in published clinical trials. The EQ-5D™ detected reliable change in this group of adolescents. Programme outcome clustering suggests that both the measure and the web-based monitoring system provide a mechanism for benchmarking clinical programmes.

Empirical examination of the interpersonal maintenance model of anorexia nervosa.

OBJECTIVE: A cognitive interpersonal maintenance model of anorexia nervosa (AN) was first proposed in 2006 and updated in 2013 (Schmidt and Treasure, J Br J Clin Psychol, 45, 343-366, 2006; Treasure and Schmidt, J Eat Disorders, in press.). The aim of this study was to test the interpersonal component of this model in people with AN requiring intensive hospital treatment (inpatient/day patient). METHOD: On admission to hospital women with AN or eating disorder not otherwise specified (AN subtype; n = 152; P) and their primary carers (n = 152; C) completed questionnaires on eating symptoms (P), depression and anxiety (P, C), accommodation and enabling (C), and psychological control (C). Structural equation modeling was used to examine relationships among these components. RESULTS: Carers' expressed emotion and level of psychological control were significantly related to carers' distress, which in turn, was related to patients' distress. This pathway significantly predicted eating symptoms in patients. DISCUSSION: The cognitive interpersonal maintenance model of eating disorders (EDs) was confirmed in part and suggests that interventions targeting interpersonal maintaining factors such as carer distress might impact on patient outcomes.

The simple clinical score: a tool for benchmarking of emergency admissions in acute internal medicine.

Quality of care in intensive care and surgery has benefited from establishing comparative standards. At present there is no accepted tool to compare outcomes for emergency admissions in internal medicine. The Simple Clinical Score (SCS) was used in 1098 consecutive medical emergency admissions to adjust mortality for severity of illness. Hospital mortality adjusted for severity of illness and length of stay in the cohort was in keeping with mortality in the Irish derivation study with a trend towards lower mortality in the very high-risk group. Three parameters with poor reproducibility were identified. The SCS has several potential applications: identification of patients with low risk of death suitable for early hospital discharge; early identification of patients with a high risk of death, who will require care in critical care areas (or specialist palliative care); and benchmarking of acute medical departments internationally in a similar way to how APACHE II scoring has been used in critical care units worldwide.

Shared decision making observed in clinical practice: visual displays of communication sequence and patterns.

UNLABELLED: The aim of the study was to examine the communication strategies of general practitioners attempting to involve patients in treatment or management decisions. This empirical data was then compared with theoretical 'competences' derived for 'shared decision making'. The subjects were four general practitioners, who taped conducted consultations with the specific intent of involving patients in the decision-making process. The consultations were transcribed, coded into skill categorizations and presented as visual display using a specifically devised sequential banding METHOD: The empirical data from these purposively selected consultation from clinicians who are experienced in shared decision making did not match suggested theoretical frameworks. The views of patients about treatment possibilities and their preferred role in decision making were not explored. The interactions were initiated by a problem-defining phase, statements of 'equipoise' consistently appeared and the portrayal of option information was often intermingled with opportunities to allow patients to question and reflect. A decision-making stage occurred consistently after approximately 80% of the total consultation duration and arrangements were consistently made for follow-up and review. Eight of the 10 consultations took more than 11 min - these specific consultations were characterized by significant proportions of time provided for information exchange and patient interaction. The results demonstrate that some theoretical competences are not distinguishable in practice and other stages, not previously described, such as the 'portrayal of equipoise', are observed. The suggested ideal of a shared decision-making interaction will either require more time than currently allocated, or alternative strategies to enable information exchange outside the consultation.

U.S. military overseas medical research laboratories.

Many infectious disease threats to U.S. military operations are uncommon in the United States. The advanced development and testing of countermeasures, such as vaccines, drugs, or insect repellents, requires the capability to study militarily important infectious diseases where they occur. With formal agreements between the U.S. and each host country, the U.S. military operates seven overseas medical research laboratories (labs). Six labs conduct infectious disease research and are distributed over three continents: Africa (labs in Egypt and Kenya), Asia (labs in Indonesia and Thailand), and South America (labs in Brazil and Peru). One other lab is located in Germany and conducts psychosocial research related to military personnel and their families. In addition to product development, these labs play vital roles supporting overseas deployments, providing technical training, and promoting international relations. Also, these labs are well positioned to become part of a developing global surveillance and response system to help address the threat posed by emerging infectious diseases. This article will present an overview of this unique medical research capability, describe the history and some of the activities of each lab, and discuss the importance of maintaining these labs in the 21st century.

Experience with the use of an investigational F(ab')2 heptavalent botulism immune globulin of equine origin during an outbreak of type E botulism in Egypt.

During an outbreak of type E foodborne botulism in Cairo in 1991, an investigational equine F(ab')2 "despeciated" heptavalent botulism immune globulin (dBIG) was provided to the Egyptian Ministry of Health by the U.S. Army. Of 54 patients known to have been treated with antitoxins, 4 received commercially available trivalent antitoxins, 45 received dBIG, and 5 received both commercial antitoxin and dBIG. Physicians recorded side effects in 10 (22%) of 45 patients who received dBIG; in nine cases, reactions were considered "mild," and in one case they were believed to be serum sickness. In contrast, possible serum sickness during hospitalization was recorded for two of four patients who were receiving commercial antitoxins. No complications of therapy were noted for any patient who was receiving both antitoxin types. In a separate study, 31 patients were contacted about their reactions to the antitoxin by telephone after discharge from the hospital. Seven (54%) of 13 patients attributed symptoms that they experienced while they were hospitalized to receipt of dBIG, while four (44%) of nine patients who indicated that they had received commercial antitoxins and one (20%) of five who received both commercial antitoxin and dBIG reported side effects before discharge. Data on the efficacy of the antitoxins were not obtained. In our experience, equine dBIG was at least as safe as commercially available antitoxins in treating type E foodborne botulism.

A high risk of hepatitis C infection among Egyptian blood donors: the role of parenteral drug abuse.

To determine the prevalence and risk factors of hepatitis C virus (HCV) infection among Egyptian blood donors, 188 consecutive adult blood donors from four hospitals and one temporary donor center located in Cairo, Egypt were evaluated. Sera were tested for HCV antibodies (anti-HCV) using second-generation enzyme-linked immunosorbent assay (ELISA) test kits. Sera that were repeatedly reactive by ELISA were further verified by a second-generation recombinant immunoblot assay (RIBA). Antibodies to HCV were detected by RIBA in 26.6% of the blood donors, which is higher than the 10-19% prevalence of antibody found in other studies of Egyptian blood donors. A history of selling blood (odds ratio [OR] = 12.1) and the use of illicit parenteral drugs (OR = 2.5) were significantly associated with anti-HCV seropositivity after controlling for age and gender. These data indicate that the use of illicit drugs may be one reason for high levels of reported HCV infection among Egyptian blood donors. These findings also indicate that Egyptian blood donors should be screened for anti-HCV and individuals who have a history of drug abuse should be deferred from donating blood.

Coxiella burnetii antibody prevalences among human populations in north-east Africa determined by enzyme immunoassay.

Retrospective serosurveys were conducted to determine the prevalence of antibody to phase-I Coxiella burnetii among humans in various locations of north-east Africa. Sera were tested by the enzyme immunoassay (EIA). Initially the EIA was compared with the standard indirect fluorescent antibody (IFA) method for the detection of antibody to C. burnetii. Results indicated that the EIA was slightly less sensitive (88%), but highly specific (94%) and less subjective than the IFA technique. EIA was subsequently adopted for estimating prevalences in the studied human populations. Data obtained by EIA indicated that the prevalence of C. burnetii antibody among adult Egyptian blood donors was 20% (n = 358) in the Suez Canal area, 16% (n = 501) in the Nile Valley and 10% (n = 427) in the Nile Delta. Among adult patients with acute, undifferentiated fever in Egypt, the prevalence was 28% (n = 50) of acute sera, with seroconversion in 12% of convalescent sera. Antibody to C. burnetii was detected by EIA in the sera of 25% (n = 71) of cattle workers in Egypt, 10% (n = 100) of housewives in Sudan, and 37% (n = 104) of adults in north-west Somalia. Following a fever outbreak affecting all ages in northern Sudan, IgG antibody to C. burnetii was present in 54% of the febrile persons (n = 185) and in 53% of afebrile persons (n = 186). IgM antibody to C. burnetii was demonstrated in 29% of the febrile persons and 15% of the afebrile persons. These results implicate C. burnetii as a possibly important and under-reported cause of human disease and undiagnosed fevers in north-east Africa.

Evaluation of a twice-a-week application of 1% niclosamide lotion in preventing Schistosoma haematobium reinfection.

A randomized double-blind trial was conducted to assess the efficacy of a twice-a-week application of 1% niclosamide lotion for prevention of Schistosoma haematobium reinfection. Six hundred farmers in Fayoum, Egypt, 18-40 years of age, were treated to cure their S. haematobium infection, then randomly assigned to self-apply niclosamide or placebo lotion to their limbs, neck, and torso. Subjects were exposed to schistosomal-infested water during routine irrigation activities from April to October 1992. Three hundred fifty subjects met the inclusion criteria and completed the trial, 169 (48.3%) in the niclosamide group and 181 (51.7%) in the placebo group. The subjects assigned to the niclosamide-treated group were comparable with those in the placebo group in age (27.2 versus 27.8 years), total water contact (101.9 versus 109.0 hr), lotion application compliance (93.5% versus 90.6%), and avoidance of whole body water contact (94.7% versus 96.7%). The reinfection rate with S. haematobium was 30.8% in the niclosamide-treated group and 28.2% in the placebo group. Niclosamide lotion applied to the limbs and trunk twice a week failed to prevent S. haematobium reinfection.

Short-course norfloxacin and trimethoprim-sulfamethoxazole treatment of shigellosis and salmonellosis in Egypt.

In a double-blind clinical study, 109 adult Egyptian patients infected with Shigella spp. and 45 infected with Salmonella spp. were randomly assigned to three treatment groups: 1) norfloxacin in a single 800-mg dose, 2) norfloxacin, 400 mg twice a day for three days, and 3) trimethoprim (160 mg)-sulfamethoxazole (800 mg) (TMP-SMX), twice a day for three days. Among Shigella-infected patients, diarrheal symptoms had resolved in 86-97% and bacteriologic failure (repeat positive stool culture) occurred in only two patients five days after the start of the three treatment regimens. Among Salmonella-infected patients, diarrheal symptoms had resolved in 76-82% of patients and bacteriologic failure was common (18-36%) five days after the start of therapy. These data indicate that short-course therapy with either norfloxacin or TMP-SMX can be effectively used to treat shigellosis in adults in developing countries. However, for uncomplicated Salmonella spp. infection, short-course therapy with norfloxacin and TMP-SMX may not lead to a rapid resolution of symptoms or consistently eliminate this enteropathogen.

Abdominal tuberculosis in Cairo, Egypt.

Twenty-two abdominal tuberculosis patients seen at Abbassia Fever Hospital in Cairo, Egypt from January 1990 to August 1992 are described; their mean age was 21.5 years, range 9-54 years; 17 were female. Common symptoms were fever, malaise, abdominal pain (64%) and weight loss (82%). Chest X-rays were normal in 14 patients (64%), but ultrasonography/computerized tomography of the abdomen was abnormal in 20 patients (91%), with adenopathy the usual finding. Anaemia and a raised erythrocyte sedimentation rate were present in all patients, and purified protein derivative skin test (5 Tu) was positive in 82%. Predominant abnormal physical findings were abdominal (86%), including hepatomegaly/splenomegaly and abdominal mass. Diagnosis was made from biopsy material (caseating granulomas) in 6 patients by laparotomy, 1 by laparoscopy, and 3 by cervical or supraclavicular node biopsy; and from laboratory examination of excretions in only 4 patients (acid-fast bacilli in stools of 2, mycobacteria in urine and menstrual fluid). Eight patients required presumptive diagnosis after response to specific isoniazid (+ethambutol) antituberculous therapy.

Recurrence of Rift Valley fever in Egypt.

Rift Valley fever (RVF) has been recorded in man and in domestic animals in Egypt after a 12-year absence. Human infections were first noted in the Aswan Governorate in late May, 1993. Only cases of ocular disease, an infrequent and late manifestation, were reported. Of 41 cases, 35 were tested serologically and 27 (77%) had RVF virus-specific IgM antibodies. An estimated 600-1500 infections occurred in the region. Abortions in cattle and buffalo were seen concurrently and antibodies to RVFV were present in 39% of domestic livestock, presumably unvaccinated. RVFV was isolated from an aborted water buffalo fetus.