Aspirin prescribing for cardiovascular disease in middle-aged and older adults in Ireland: Findings from The Irish Longitudinal Study on Ageing.

Aspirin use for cardiovascular indications is widespread despite evidence not supporting use in patients without cardiovascular disease (CVD). This study characterises aspirin prescribing among people aged ≥50 years in Ireland for primary and secondary prevention, and factors associated with prescription. This cross-sectional study includes participants from wave 3 (2014-2015) of The Irish Longitudinal Study on Ageing. We identified participants reporting use of prescribed aspirin, other antiplatelets/anticoagulants, and doctor-diagnosed CVD (MI, angina, stroke, TIA) and other cardiovascular conditions. We examined factors associated with aspirin use for primary and secondary prevention in multivariate regression. For a subset, we also examined 10-year cardiovascular risk (using the Framingham general risk score) as a predictor of aspirin use. Among 6618 participants, the mean age was 66.9 years (SD 9.4) and 55.6% (3679) were female. Prescribed aspirin was reported by 1432 participants (21.6%), and 77.6% of aspirin users had no previous CVD. Among participants with previous CVD, 16.5% were not prescribed aspirin/another antithrombotic. This equates to 201,000 older adults nationally using aspirin for primary prevention, and 16,000 with previous CVD not prescribed an antithrombotic. Among those without CVD, older age, male sex, free health care, and more GP visits were associated with aspirin prescribing. Cardiovascular risk was significantly associated with aspirin use (adjusted relative risk 1.15, 95%CI 1.08-1.23, per 1% increase in cardiovascular risk). Almost four-fifths of people aged ≥50 years on aspirin have no previous CVD, equivalent to 201,000 adults nationally, however prescribing appears to target higher cardiovascular risk patients.

Metallomics Study in Plants Exposed to Arsenic, Mercury, Selenium and Sulphur.

This chapter is focussing on the interaction of arsenic, mercury and selenium with plans. Aspects of biotransformations are discussed, before the analytical methodologies are listed and critically appraised in the second part. A holistic view is given, starting from the soil environment and continuing to the plant roots and the translocations into the upper part of the plants. Under different soil conditions, different kinds of elemental species are identified, which have an impact on how the elemental species are taken up by the plant. The uptake mechanisms of these elemental species are explained and compared before the biotransformation reactions of all elemental species in the plant root; their transport into the vacuoles and translocation to the leaves and grains are discussed. Here in particular the interaction with sulphur-rich phytochelatins is described for all three elemental species. Since the sulphur chemistry is so important for the uptake, bioaccumulation and translocation of the metals and metalloids, a subchapter about sulphur chemistry in plants has been added. All aspects of biotransformation dealt with in this chapter is finally rounded up by a thorough description of the analytical methodology given with a focus on the use of HPLC-ICPMS/ESI-MS for both quantitative and molecular analysis.

A survey of the practice of electroconvulsive therapy in Asia.

OBJECTIVE: To describe a comprehensive survey of the practice of electroconvulsive therapy (ECT) in Asia. METHOD: Between 2001 and 2003, a 29-item questionnaire was sent to 977 psychiatric facilities in 45 Asian countries. RESULTS: Completed questionnaires were returned by 334 (34.2%) institutions in 29 (64.4%) countries. Electroconvulsive therapy was available in 257 institutions in 23 countries. During the year before the survey, 39,875 patients (62% men) received a mean of 7.1 ECT treatments. Most patients (73.1%) were 18 to 44 years old; few were younger than 18 years (6.0%) or older than 64 years (4.4%). Indications for ECT were schizophrenia (41.8%), major depression (32.4%), mania (14.0%), catatonia (6.9%), drug abuse (1.8%), dysthymia (1.6%), and others. Brief-pulse ECT devices were used in only 115 (58.4%) of 197 institutions. Routine electroencephalographic monitoring was conducted in only 59 (23.0%) institutions. Bilateral electrode placement was invariable in 202 (78.6%) institutions. Unmodified ECT was administered to 22,194 (55.7%) patients at 141 (54.9%) institutions in 14 countries. Continuation ECT was available in only 115 (44.7%) institutions in 17 countries. No institution had a formal ECT training program. CONCLUSIONS: The practice of ECT in Asia may seem suboptimal: schizophrenia, not depression, is the most common indication; most institutions offer sine-wave ECT; unmodified ECT is commonly administered; bilateral electrode placement is invariable in most institutions; electroencephalographic monitoring is uncommon; continuation ECT is infrequent; and no formal training in ECT is available. We speculate that the suboptimal practices reflect felt needs and ground realities in standards of medical care in developing countries rather than a misuse of ECT.

An updated and more efficient search strategy to identify primary care-relevant clinical prediction rules.

OBJECTIVES: The aim of the study was to develop an improved search strategy for clinical prediction rules. STUDY DESIGN AND SETTING: We first refined a list of 30 primary care-relevant journals and improved the efficiency of the Haynes Narrow Filter/Teljour/Murphy Inclusion Filter with 26 items by removing one term (Modified Haynes 26 filter). We then developed the "Royal College of Surgeons in Ireland (RCSI) filter" and compared it with the modified HNF/TMIF26 for its ability to detect prediction rules in the primary care literature. All abstracts and, if necessary, full text were reviewed independently in parallel by primary care physicians. The key outcomes were the percentage of prediction rules identified out of the total identified by both search strategies (sensitivity) and the number of articles that had to be reviewed to identify them (efficiency). RESULTS: The Modified Haynes 26 filter returned 1,701 abstracts vs. 1,062 for the RCSI filter. The RCSI filter identified 105 of 111 of all prediction rules identified by either filter, compared with 107 of 111 by the Modified Haynes 26 filter (94.6% vs. 96.4%; P = 0.52). In addition, 9.9% of abstracts found using the RCSI filter were prediction rules, compared with only 6.3% using the Modified Haynes 25 filter (P = 0.001). CONCLUSION: We have developed a novel "RCSI filter" that more efficiently identifies prediction rules in the medical literature.

Quality, scope and reporting standards of randomised controlled trials in Irish Health Research: an observational study.

BACKGROUND: Despite efforts to improve the accuracy and transparency of the design, conduct, and reporting of randomised controlled trials (RCTs), deficiencies remain. Such deficiencies contribute to significant, avoidable waste of health research investment and impede reproducibility. This study aimed to synthesise and critically analyse changes over time in the conduct and reporting of internationally published evidence on patient and/or population health-oriented RCTs conducted in one country. METHODS: This observational study drew on systematic review methods. We searched six databases for published RCTs (database inception to December 2018) where ≥ 80% of participants were recruited in the Republic of Ireland. RCTs of interventions targeted at patients, providers and/or policy makers intended to improve health, healthcare or health research were included. For each study, screening, data extraction and methodological quality appraisal were conducted by one member of the author team. RESULTS: From 17,560 titles and abstracts, 752 unique RCTs were published in 745 papers between 1968 and 2018, with a steady year-on-year increase since 1968. The number of participants was in the range of 2-8628. The majority were parallel design (86%) and classified as treatment evaluation. Of the 418 RCTs published since the introduction of mandatory clinical trial registration by the International Committee of Medical Journal Editors in 2005, 32% (n = 134) provided a trial registration number. This increased to 47% when taking studies published between 2013 and 2018 (n = 232). Since the 1996 publication of the CONSORT statement, 16% of included RCTs made specific reference to a standardised reporting guideline and this increased to 31% for more recent studies published between 2013 and 2018. Overall, 7% (n = 53) of studies referred to a published study protocol, increasing to 20% for studies published between 2013 and 2018. CONCLUSION: Evidence from this single-country study of RCTs published in the international literature suggests that both the number overall, the number registered and the number referencing reporting guidelines have increased steadily over time. Despite widespread endorsement of reporting standards, reporting of RCTs remains suboptimal in domains such as compliance with the CONSORT statement and prospective trial registration. Researchers, funders and journal editors, nationally and internationally, should continue to focus on improving reporting and examining avoidable waste of health research investment.

A statistical evaluation of the safety factor and species sensitivity distribution approaches to deriving environmental quality guidelines.

The species sensitivity distribution (SSD) distribution approach to estimating water quality guidelines (WQGs) is the preferred method in all jurisdictions reviewed (Australia, Canada, New Zealand, Organisation for Economic Co-operation and Development [OECD] members, South Africa, United States) and is one of the recommended methods for European Commission members for 33 priority and priority hazardous substances. In the event that jurisdiction-specific criteria for data quality, quantity, and taxonomic representation are not met, all of these jurisdictions endorse the use of additional safety factors (SFs) applied to either the SSD-based WQG or, the lowest suitable toxicity test endpoint. In Canada, the British Columbia Ministry of Environment endorses this latter approach as the preferred approach in the belief that so-derived WQGs are more protective than SSD-based WQGs. The level of protection afforded by the latter SF approach was evaluated by statistically sampling minima from random samples of the following distributions: normal, Gumbel, logistic, and Weibull, using a range of coefficients of variation (cVs) and applying the SFs of 2 or 10 used in British Columbia. The simulations indicate that the potentially affected fraction of species (PAF) can be as high as 20%, or, approach 0%. The PAF varies with sample size and CV. Because CVs can vary systematically with mode of toxic action, the PAF using SF-based WQGs can also vary systematically with analyte class. The varying levels of protection afforded by SF-based WQGs are generally inconsistent with the common water quality management goal that allows for a small degree of change under long-term exposure. The findings suggest that further efforts be made to develop high-quality WQGs that support informed decision making and are consistent with the environmental management goal instead of using SFs in the hope of achieving an acceptable but unknown, degree of environmental protection.

Acute and maintenance ECT with flupenthixol in refractory schizophrenia: sustained improvements in psychopathology, quality of life, and social outcomes.

OBJECTIVE: To determine the effects of ECT combined with antipsychotic medication therapy on psychopathology, quality of life, and social functioning in patients with refractory schizophrenia. METHOD: An open acute (Phase I) and maintenance (Phase II) study of the combination of ECT and flupenthixol in the treatment of 46 schizophrenic patients who were nonresponsive to antipsychotic medication from at least two different classes. Scales used: the Brief Psychiatric Rating Scale (BPRS), the Quality of Life Scale (QLS), Social and Occupational Functioning Assessment Scale (SOFAS), Global Assessment of Functioning (GAF), and Mini-Mental State Exam (MMSE). The duration of Phase II was 1 year. RESULTS: In Phase I, there were marked reductions in the BPRS scores, and substantial increases in the QLS, SOFAS, GAF, and MMSE scores. During Phase II, the BPRS negative symptoms worsened but remained improved from baseline. Changes in other outcome measures were negligible. CONCLUSION: ECT and MECT combined with flupenthixol were effective in improving psychopathology in patients refractory to antipsychotic medication alone. Ratings of psychopathology, quality of life, and social functioning all improved in Phase I and were generally sustained during Phase II in patients who had remitted.

A qualitative study of day release in Irish general practice training programmes.

This research, conducted by postal questionnaires and focus groups, gathered the opinions of both current and former GP trainees on Irish General Practice Training Programmes about the educational value of day release. Six focus groups, comprising 34 general practice trainees, were conducted. Results demonstrated that both current and former GP trainees recognised the educational value of day release in their general practice training. Suggested improvements that would enhance learning at day release included more practice management; more external speakers; sessions resourced by trainees focusing on scenarios encountered in real-life general practice; and a greater degree structure and organisation at day release. Small group learning was widely seen as a beneficial format for adult learning at day release.

NCCN task force: clinical utility of PET in a variety of tumor types.

Use of PET is widespread and increasing in the United States, mainly for oncologic applications. In November 2006, the National Comprehensive Cancer Network (NCCN) gathered a panel of experts to review the literature and develop clinical recommendations for using PET scans in lymphoma and non-small cell lung, breast, and colorectal cancers. However, because its use is not restricted to these diseases, and evidence is accumulating for its application in other types of cancers, NCCN convened a second meeting in December 2008 to expand on the initial report. A multidisciplinary panel met to discuss the current data on PET application for various tumor types, including genitourinary, gynecologic, pancreatic, hepatobiliary, thyroid, brain, small cell lung, gastric, and esophageal cancers, and sarcoma and myeloma. This report summarizes the proceedings of this meeting, including discussions of the background of PET, the role of PET in oncology, principles of PET use, emerging applications, and possible future developments.

Use of the Neuro-Wrap system for severe post-electroconvulsive therapy headaches.

OBJECTIVE: To determine, in a nonblinded trial, if the Neuro-Wrap system is effective in reducing the severity of pain in patients with severe post-electroconvulsive therapy (ECT) headaches not adequately responsive to routine analgesic treatment. BACKGROUND: A very troubling side effect of ECT is severe post-ECT headaches. Although these headaches usually respond to routine analgesic medication, some patients continue to experience severe headache despite treatment. This very unpleasant sensation, repeated with each ECT, may cause patients to prematurely stop ECT and experience a relapse in their psychiatric symptoms. "Cold therapy" has been used for a long time as an adjunct to treat headache and pain. The Neuro-Wrap system is a method to provide temperature-controlled cooling to the head without the need to frequently reapply ice packs or physically hold the ice packs in position. It has been used successfully for patients with migraine headaches. This is the first report of its use with patients experiencing severe post-ECT headaches. METHODS: The study comprised a total of 14 patients receiving ECT who experienced a severe headache for 2 successive ECT treatments or 2 of their last 4 treatments and who had only partial or no response to usual analgesic treatment for their headache. After completion of the ECT, the Neuro-Wrap was placed on the head of the patient for a maximum of 40 minutes. Patients continued to receive analgesic medication as needed for relief of headache pain. Patients were their own control group. RESULTS: A total of 85 Neuro-Wrap treatments were given to 14 patients ranging in age from 23 to 71 years old. Nine patients reported clearly positive results on 67 different occasions. Three reported mild alleviation of headaches on 15 occasions. The remaining 2 patients had a total of 3 treatments with no benefit. After the initial treatment, 12 of 14 patients wanted to use the machine after all their subsequent ECT sessions. CONCLUSIONS: Cold therapy with Neuro-Wrap is an effective alternative treatment for refractory headaches caused by ECT.

ECT practice in Japan.

OBJECTIVES: We sought to determine the characteristics of electroconvulsive therapy (ECT) practice in Japan. Only by knowing practice patterns can standards of care be successfully developed and implemented. METHODS: From September 1, 2001, to August 31, 2003, a questionnaire was sent to 248 institutions. RESULTS: A total of 100 institutions (40.3%) completed the questionnaire. ECT was available in 83 institutions. A total of 1,210 patients received 11,146 ECTs from 895 psychiatrists. Brief-pulse device was used in 21 institutions. EEG monitoring was used routinely in 15 institutions. Bilateral ECT was always used. Patients who received ECT were diagnosed schizophrenia (48.9%), major depression (37.4%), catatonia (6.8%), mania (4.4%), and dysthymia (0.8%). The majority of patients who received ECT were in the age group 45-64 years (40.4%) and 65 years and older (39.3%). A total of 670 patients received a total of 6364 unmodified ECT at 60 institutions. There were no ECT-related deaths during the survey. CONCLUSION: ECT use in Japan is low. More than half of ECTs instituted were unmodified. The majority of patients who received ECT were diagnosed with schizophrenia and major depression.

Survey of the practice of electroconvulsive therapy in teaching hospitals in India.

OBJECTIVES: We sought to obtain an overview of electroconvulsive therapy (ECT) practice in teaching hospitals in India. METHOD: From September 1, 2001, to August 31, 2002, a 29-item questionnaire enquiring about ECT practice during the past year was sent to 188 teaching institutions and psychiatric hospitals. RESULTS: Seventy-four institutions (39.4%) completed the questionnaire. ECT was available in 66 institutions. A total of 19,632 patients received 114,111 instances of ECT from 316 psychiatrists, of which 13,891 patients (70.8%) received 89,475 treatments (78.4%) from 128 psychiatrists in the psychiatric hospitals. The male-to-female ratio was 1.56 to 1. Brief-pulse device was used in 39 institutions. EEG monitoring was used routinely in only 8 institutions. Bilateral ECT was used in almost all institutions. Patients with schizophrenia received ECT most frequently (36.5%), followed by patients with major depression (33.5%), mania (17.9%), catatonia (6.2%), and dysthymia (2.8%). Patients who received ECT were in age group of 45-64 years (43.9%), followed by 25-44 years (34.5%), 65 years and older (14.7%), 18-24 years (5.6%), and younger than 18 years (1.4%). A total of 10,234 patients (52%) received unmodified ECT 52,450 treatments (46%) at 33 institutions. There was one case of ECT-related death during a survey. Continuation ECT was performed in 29 institutions and maintenance ECT in 17. CONCLUSIONS: More than 70% of ECT administrations in India were performed in the psychiatric hospitals. Approximately half of ECT use was unmodified ECT. The majority of patients who received ECT were diagnosed with schizophrenia and major depression. ECT training programs for psychiatry residents were acceptable.

Anticholinergics and ECT.

Anticholinergic medication is commonly used prior to anesthetizing patients for electroconvulsive therapy (ECT). Its routine use is the subject of ongoing controversy. This article reviews how anticholinergics came to be used with ECT and the work supporting or refuting their routine use. The route of administration and their use with beta blockers are reviewed. Atropine, glycopyrrolate, and scopolamine are compared. While acknowledging the pau-city of carefully controlled trials with large numbers of patients, the routine use of intravenous atropine prior to administering ECT is recommended unless specifically contraindicated.

Practice Patterns of Electroconvulsive Therapy: A California Perspective (1984).

The sixty-five California hospitals administering electroconvulsive therapy (ECT) during 1984 were surveyed regarding ECT practices to develop data on the community standard of care. Usable data were obtained from 58 hospitals. In each facility two psychiatrists usually administered ECT, including one psychiatrist who received credentials in or after 1977. Thirty-four brief-pulse and 43 sine-wave machines were in use. Treatment was performed on the psychiatric unit in 41.4% of the hospitals, in the operating room or the recovery room in 50% of the hospitals, and in other locations in 8.6% of the hospitals. The psychiatrist administered the anesthesia in 12 (21%) of the hospitals. Unilateral electrode placement was used in 42% of patients. The use of anesthetic agents, ancillary equipment, and staffing patterns is reviewed.

Maintenance ECT: A Survey of Practice (1986).

A questionnaire on the use of maintenance or continuation ECT was mailed to 173 practitioners of ECT. Of 86 respondents, 51 reported they used maintenance therapy, and 35 did not. Users came from 24 states, with five states accounting for more than half. Of practitioners giving maintenance ECT, each treated a median of three patients annually between 1981 through 1984, with a range from zero to "thousands." Frequency of treatments is determined empirically, with most treatments given monthly. Memory impairment is the most commonly cited risk. Depression is the diagnosis in 90% of the patients, with schizoaffective, schizophrenic, and manic patients equally comprising the remainder of the patients. The longest series reported for any one patient is 2,400 treatments.

Maintenance Electroconvulsive Therapy in Clinical Practice.

Five cases of maintenance electroconvulsive therapy (ECT) are reviewed to illustrate the indications for this treatment. The patients' conditions described are consistent with the recommendations of the 1990 American Psychiatric Association Task Force on ECT. Guidelines and examples for selecting patients for maintenance ECT are presented, but when to preferentially treat with continuation pharmacotherapy versus ECT requires further study. Optimal dosing, interval between treatments, and duration of treatment remain questions. The logistics of the treatment are briefly presented and should be easily incorporated into most ECT programs.

Atypical Cholinesterase and Prolonged Apnea During Electroconvulsive Therapy.

A 62-year-old man developed prolonged apnea during ECT with succinylcholine. He was found to have atypical cholinesterase. Subsequent ECTs were given using atracurium as the muscle relaxant. A review of the finding of atypical cholinesterase is presented along with a discussion of the use of atracurium.

Electroconvulsive therapy practice in Thailand.

OBJECTIVES: To obtain an overview of electroconvulsive therapy (ECT) practice in Thailand. METHODS: Questionnaires were sent to all institutions providing psychiatric care; data were collected from September 1, 2001, to August 31, 2002. RESULTS: Fifty-three responses were received from 67 institutions (79.1%). ECT is available in 26 hospitals. Approximately 6,914 patients received 51,565 ECT treatments, of which, 6,469 patients (93.56%) received 48,240 treatments (93.55%) in the psychiatric hospitals. The ECT utilization rate was 11.15 patients treated per 100,000. Twelve institutions used MECTA (Spectrum or SR1) or Thymatron DGx. Bilateral ECT was used exclusively in all institutions. In 2 medical schools, all patients received double ECT throughout their treatment courses. Unmodified ECT was always used in nine psychiatric hospitals and five general hospitals, and occasionally used in 2 university hospitals comprising 94.2% of all ECT usage. Patients with schizophrenia most frequently received ECT (74%), followed by mania (8%) and major depression (7%). The nurse alone administered ECT in four psychiatric hospitals. Although the death rate was estimated at 0.08%, there was no ECT-related death during the survey period. Continuation ECT was performed in 11 and maintenance ECT in 6 institutions. Five institutions had acceptable training programs for psychiatry residents but none had training syllabus, 2 institutions had teaching schedule for medical students. CONCLUSIONS: ECT use in Thailand is high. Nearly all ECTs (93.6%) were performed in the psychiatric hospital and 94.2% of all treatments were unmodified ECT. Lacking of proper training in ECT is evident.