Gendered experiences of unemployment, suicide and self-harm: a population-level record linkage study.

BACKGROUND: Unemployment and being not in the labour force (NILF) are risk factors for suicide, but their association with self-harm is unclear, and there is continuing debate about the role of confounding by prior mental health conditions. We examine associations between employment status and self-harm and suicide in a prospective cohort, taking into account prior mental-health-related factors. METHODS: We used linked data from the New Zealand Integrated Data Infrastructure. The outcomes were chosen to be hospital presentation for self-harm and death by suicide. The exposure was employment status, defined as employed, unemployed, or NILF, measured at the 2013 Census. Confounders included demographic factors and mental health history (use of antidepressant medication, use of mental health services, and prior self-harm). Logistic regression was used to model effects. Analyses were stratified by gender. RESULTS: For males, unemployment was associated with an increased risk of suicide [odds ratio (OR): 1.48, 95% confidence interval (CI): 1.20-1.84] and self-harm (OR: 1.55, 95% CI: 1.45-1.68) after full adjustment for confounders. NILF was associated with an increased risk of self-harm (OR: 1.43, 95% CI: 1.32-1.55), but less of an association was seen with suicide (OR: 1.19, 95% CI: 0.94-1.49). For females, unemployment was associated with an increased risk of suicide (OR: 1.30, 95% CI: 0.93-1.80) and of self-harm (OR: 1.52, 95% CI: 1.43-1.62), and NILF was associated with a similar increase in risk for suicide (OR: 1.31, 95% CI: 0.98-1.75) and self-harm (OR: 1.32, 95% CI: 1.26-1.40). DISCUSSION: Exclusion from employment is associated with a considerably heightened risk of suicide and self-harm for both men and women, even among those without prior mental health problems.

A novel method of rapid appraisal of clinical practice guidelines for children with enuresis.

BACKGROUND: Enuresis (bedwetting) is a common but variably managed pediatric condition. Despite an abundance of published documents which provide recommendations for clinical evaluation and management of enuresis, no formal appraisal of their methodological quality has been undertaken. OBJECTIVE: The objective of the study is to evaluate the quality of current pediatric guidelines for enuresis (bedwetting) using a novel method of appraisal. STUDY DESIGN: A comprehensive gray literature search was undertaken to identify guideline documents that provided recommendations for management of enuresis in children and adolescents. The search strategy included guideline databases, targeted websites, Google search engines, and MEDLINE. Guideline documents included clinical practice guidelines, consensus documents, position statements, and other clinical review documents. Each document underwent basic appraisal by two independent assessors using the International Centre for Allied Health Evidence (iCAHE) Guideline Quality Checklist. Those documents which (1) had an iCAHE quality score of ≥10; (2) used a systematic search strategy; and (3) linked evidence to their recommendations underwent further detailed appraisal using the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument. RESULTS: Eighteen documents were shortlisted for basic appraisal. The iCAHE highlighted a lack of information regarding underlying evidence and dates (mean score 36% and 41%, respectively). Only three documents met basic quality criteria and progressed to detailed appraisal using the AGREE II. These included guidelines produced by the Paediatric Society of New Zealand and National Clinical Guideline Centre and a position statement from the Canadian Paediatric Society. All three guidelines presented clear and unambiguous recommendations (mean score 80%). However, information regarding stakeholder involvement was lacking (mean score 50%). CONCLUSIONS: Several guidelines exist for the evaluation and management of children with enuresis, but many lack appropriate methodological quality standards. The guideline produced by the National Clinical Guideline Centre achieved the highest quality rating and is recommended for future adaptation and implementation in relevant clinical settings.

Nurse specialist led flexible sigmoidoscopy in an outpatient setting.

OBJECTIVE: There has been an increasing demand for diagnostic flexible sigmoidoscopy. In order to improve our diagnostic services, we established a nurse specialist led flexible sigmoidoscopy clinic in 1999. The aim of this study was to review the outcomes of this service between 1999 and 2004. METHOD: The following information was collected prospectively: source of referral, presenting symptoms, the result of the flexible sigmoidoscopy, depth of insertion, the follow-up plan and complications. RESULTS: A total of 3956 patients had a flexible sigmoidoscopy performed between 1999 and 2004. The presenting symptoms were as follows: rectal bleeding (RB) in 1915 patients, change of bowel habit (CBH) in 421 patients, RB+CBH in 814 patients. The depth of insertion of the sigmoidoscope was as follows: rectum in 85 patients, sigmoid colon in 595 patients, descending colon in 1969 patients, splenic flexure in 958 patients and transverse colon in 311 patients. The findings at sigmoidoscopy were as follows: normal in 1560 patients, cancer in 132 patients, inflammatory bowel disease in 276 patients, polyps in 415 patients, diverticular disease in 584 patients and haemorrhoids in 926 patients. Two patients sustained an iatrogenic rectal perforation. CONCLUSION: The nurse specialist led flexible sigmoidoscopy clinic offers an efficient and safe diagnostic service for patients presenting with colorectal symptoms.

A comparison of low-cost biosorbents and commercial sorbents for the removal of copper from aqueous media.

Three biosorbents, crab carapace, the macroalgae Fucus vesiculosus and peat were compared with two commercial materials, an activated-carbon and an ion-exchange resin for the removal of copper from aqueous media. Kinetic models of Lagergren first-order, pseudo-second order and intraparticular diffusion were used to model the data. The process for all materials is best represented by the pseudo-second order rate model. Langmuir and Freundlich isotherms were used to describe the sorption equilibrium data. Maximum uptake values were 79.4, 114.9 and 71.4 mg g(-1) for crab carapace, F. vesiculosus and ion-exchange resin, respectively. Langmuir and Freundlich isotherm models could not be fitted to the experimental data for peat and activated-carbon. Ion-exchange was calculated to contribute approximately 75%, 77% and 44% to the total biosorption by crab carapace, F. vesiculosus and peat, respectively. The removal efficiencies of crab carapace and F. vesiculosus were >95% and comparable with those achieved using ion-exchange resin. Results from this study suggest that both crab carapace and F. vesiculosus are efficient and effective biosorbent materials for the removal of copper from aqueous solutions and given that they are also low-cost, may be considered viable alternatives to activated-carbon and ion-exchange resin.

DNA methylase during Xenopus laevis development.

The DNA methylase activity present in embryos and cultured cells of Xenopus laevis resembles DNA methylase from mammalian tissues. Little or no activity is found in mature germinal vesicles, though nuclear activity rises rapidly after fertilization. This rise may result in part from a relocation of cytoplasmic enzyme.

Peritoneoscopy for the diagnosis of left lobe lesions of the liver.

Peritoneoscopy and direct-vision liver biopsy are simple, safe, and accurate methods for the documentation of focal lesions predominantly involving the left lobe of the liver or the left portion of the right lobe. Focal lesions of the left lobe of the liver constitute a major indication for peritoneoscopy and direct-vision biopsy of the liver when its use is not contraindicated and when blind percutaneous biopsy or biopsies and cytologic examination have failed to establish the diagnosis.

Barrett's esophagus. Prevalence and incidence of adenocarcinoma.

Between January 1973 and January 1989, 241 patients with Barrett's esophagus were treated at the Lahey Clinic Medical Center, Burlington, Mass. Of these patients, 65 presented with adenocarcinoma in Barrett's esophagus for a prevalence rate of 27%. Of 176 patients followed up for a total of 497 patient-years, adenocarcinoma developed in five patients for an incidence of one per 99 patient-years. The development of adenocarcinoma during endoscopic surveillance 1, 2, 2, 4, and 10 years after the initial diagnosis of Barrett's esophagus emphasizes the importance of long-term endoscopic and histologic surveillance. All five patients had severe dysplasia before adenocarcinoma developed. Yearly endoscopic follow-up examination is recommended for all patients with Barrett's esophagus unless mild dysplastic changes are found, in which case surveillance should be increased. Patients with severe dysplasia who are otherwise acceptable candidates for operation should be advised to have esophageal resection.

Studies on the concentration of pregnancy-associated plasma protein-A during normal and complicated pregnancy.

Pregnancy-associated plasma protein-A was assayed in the blood of 347 women during pregnancy, using a new primary standard of PAPP-A as reference. The protein was assayed by antibody-antigen crossed electrophoresis with the lower limit of confident assay being 9.5 micrograms PAPP-A/ml (13 pmol/ml). PAPP-A was first detected at 14 weeks of gestation; by term it had risen to within the range 20 to 320 micrograms/ml. There was an indication that pregnancies involving a male baby had higher PAPP-A levels in blood than did those involving female babies. In 51 blood samples from 30 patients with gestational diabetes (taken between 28 weeks of pregnancy and term) there was no significant alteration in PAPP-A values compared with controls. In 35 blood samples from 15 patients with insulin-dependent diabetes, levels of PAPP-A were significantly lower than in controls or in gestational diabetes. In 43 blood samples from 35 patients with babies affected with intrauterine growth retardation (between 28 weeks and term), there was no significant difference in PAPP-A levels compared with controls. The effect of insulin on the blood levels of PAPP-A suggests that the concentration of PAPP-A is capable of altering significantly in response to certain physiological changes associated with the control of carbohydrate metabolism.

Esophageal reconstruction for complex benign esophageal disease.

We report the cases of 35 patients with complex benign esophageal disease who required radical surgical reconstruction. These patients had undergone 63 previous esophageal operations. Twenty-seven patients required esophagogastrectomy, four had esophageal exclusion before colon interposition, two had cardioplasty, and two without stricture did not require resection. Reconstruction was achieved by esophagogastrostomy in six patients, colon interposition in eight, and acid suppression and alkaline diversion in 21. One patient died of pneumonia 2 weeks after esophagogastrostomy. The overall rate of postoperative improvement was 70%, but the condition of 86% of patients was improved after the acid-suppression and alkaline-diversion procedure, which is the reconstructive procedure we prefer in properly selected patients with complex benign esophageal disease.

Reoperative achalasia surgery.

Forty-six patients with esophageal achalasia required reoperation between January 1970 and January 1986. Three of these patients required a second reoperative procedure, for a total of 49 reoperations. Indications for reoperation were inadequate myotomy, 17; gastroesophageal reflux, 14; concomitant antireflux operation, six; incorrect diagnosis, four; carcinoma of the esophagus, four; megaesophagus, three; and paraesophageal hernia, one. Various procedures were employed at the time of reoperation, including revision of the myotomy, takedown or revision of a previously performed wrap, fundoplication, and resection. Of the 48 patients available for follow-up study over an average postoperative period of 5 years, the condition of 38 (79%) was considered to have been improved by reoperation. The best results were obtained by revision or takedown of a previous wrap (an improvement rate of 88.9%) and radical resective procedures (89% to 100%). We conclude that for good results to be achieved after reoperative achalasia procedures, the preoperative diagnosis must be accurate, the operation should be performed early before the development of megaesophagus, and a short but complete esophagomyotomy must be performed, preferably without the addition of an antireflux procedure. Elimination or revision of a previously performed fundoplication can be expected to be followed by good results. The precise indications for radical resective procedures have yet to be defined clearly, but their wider application to carefully selected patients with postoperative achalasia seems justified.

Barrett's ulcer: a surgical disease?

Between 1973 and 1990, 285 patients with Barrett's esophagus were treated at the Lahey Clinic. Of these patients, 73 had adenocarcinoma in Barrett's esophagus either when first seen or while under surveillance. Of the remaining 212 patients with benign Barrett's esophagus, 30 had endoscopic evidence of a Barrett's ulcer, for a prevalence of 14%. Initial treatment consisted of aggressive medical therapy, including H2 antagonists and antacids as well as the usual dietary and antireflux measures. In 2 to 4 months, 27 patients underwent repeat endoscopy. Continued endoscopic evaluation in this group totaled 109 patient-years, with a range of 2 months to 13 years (median 2.3 years). Complete healing occurred in 23 of the 27 patients (85%) in 2 to 14 months (median 4 months). Recurrent ulcers developed in seven patients, and these ulcers healed with further medical therapy in five patients. Antireflux procedures were performed in four of six patients with nonhealing Barrett's ulcers, 1 to 1.5 cm in size, and all healed. Two patients refused to have an operation. In our experience, the majority of Barrett's ulcers heal with medical therapy. We reserve surgical intervention for otherwise suitable candidates for operation when no evidence of healing is found within 4 months of medical therapy or for the complications of Barrett's ulcer, namely, perforation, uncontrollable hemorrhage, or malignant degeneration, which were not encountered in this series.

Effect of antireflux operation on Barrett's mucosa.

Regression of Barrett's epithelium after antireflux operations remains a controversial topic. We evaluated the effect of antireflux procedures in patients with Barrett's esophagus on the regression of columnar epithelium and dysplasia and its potential protective effect on the subsequent development of carcinoma. Of the 241 patients with Barrett's esophagus treated at the Lahey Clinic from 1973 to 1989, 37 patients underwent an antireflux operation. Regression was defined as histological evidence of regenerating squamous mucosa that completely or partially replaced the columnar epithelium. Improvement in lower esophageal sphincter pressure to 12 mm Hg or greater occurred in 19 of 26 patients (73%) who had perioperative manometry. Symptomatic relief of esophagitis occurred in 34 of 37 patients (92%). Four patients had partial regression with regenerating squamous mucosa juxtaposed with areas of columnar epithelium. Carcinoma developed in 3 of 37 patients (8.1%). One patient had recurrence of severe symptoms of reflux esophagitis before development of carcinoma. Patients with Barrett's esophagus who have undergone a successful antireflux operation with symptomatic relief and evidence of improvement in lower esophageal sphincter pressures rarely show regression of Barrett's mucosa and may still be at risk for development of carcinoma. Therefore, the indications for antireflux operation in Barrett's esophagus should remain the same as for other patients with gastroesophageal reflux, but yearly endoscopic and histological surveillance should be continued postoperatively.

Achalasia and squamous cell carcinoma of the esophagus: analysis of 241 patients.

Achalasia of the esophagus is presumed by many to be a premalignant lesion leading to an increased risk of squamous cell carcinoma. There is disagreement, however, as to the precise risk of malignant degeneration and there is no consensus as to either the need for close surveillance of achalasia patients or the surveillance technique that should be employed. A review of the available literature on the subject has disclosed a wide range of reported cancer risks in achalasia patients, from zero to 33 times that of the normal population. Cancers, when discovered, are often unresectable and the median survival when they are resectable is low. A personal experience with 241 achalasia patients treated during the past quarter of a century disclosed that 9 had carcinoma, for a prevalence of 3.7%. Carcinoma developed in 3 of these 9 while they were under our observation. This translates into one cancer per 1,138 patient-years of follow-up, an incidence of 88 per 100,000 population, and a risk 14.5 times that of the age-adjusted and sex-adjusted general population. Because of the low postresection survival rate if treatment is delayed until carcinoma of the esophagus becomes symptomatic, closer surveillance of achalasia patients is recommended than has been the case. Because it seems unlikely that close endoscopic surveillance will prove to be cost-effective, periodic (every 2 to 3 years) blind brush biopsy warrants further study as a means of surveillance.

Use of fiberoptic endoscopy in diagnosis and therapy of upper gastrointestinal disorders.

The future role of therapeutic endoscopy appears bright and depends on the possibilities of technology and the ingenuity of those performing the procedures. New techniques are being devised, and the therapeutic applications are being evaluated continually. Such issues as appropriate indications, efficacy, and cost-effectiveness remain important considerations for the practitioner dealing with gastrointestinal disorders.

Reoperation after esophagomyotomy for achalasia of the esophagus.

Eleven patients who required reoperation for persistent or recurrent symptoms after esophagomyotomy are reported on. Failure of the original operation was attributed to inadequate myotomy in three, healed myotomy in four, and reflux esophagitis in four. The myotomy was extended or a new myotomy created in the first two categories of patients. Three of the four patients with reflux esophagitis were treated by antrectomy and Roux-en-Y esophagojejunostomy; one of these also required concomitant exision of the esophagogastric junction because of stricture. The fourth patient with esophagitis ultimately required colonic interposition for relief of symptoms. Ten of the eleven patients were improved after reoperation, but results were less good than those achieved by a properly performed primary esophagomyotomy. This -re-emphasizes the need for attention to the technical details of esophagomyotomy if good results are to be achieved.

Postgastrectomy syndromes.

Postgastrectomy syndromes requiring further operation are fortunately uncommon, as the symptoms are disabling and the results of corrective surgery are, at times, disappointing. Our sixty-six patients underwent a total of seventy-six procedures with forty-one successful results and thirty-five failures. Among the secessful group, only fourteen results were graded as excellent. (Table V.) Our experience, like that of others, demonstrates the necessity of accurate evaluation of the patient and of accurate syndrome classification. This not only allows the appropriate operation to be chosen but also helps to indicate those in whom operation should be avoided. Where more than one surgically remediable syndrome exists, simultaneous correction should be undertaken. Treatment of the mechanical problems of obstructed afferent loop by jejunojejunostomy and of stomal obstruction by complete stomal reconstruction provides satisfactory results. Roux-en-Y anastomosis is effective in patients with alkaline gastritis, but we caution against the use of this procedure in patients with vague symptoms and minimal endoscopic changes. Antiperistaltic jejunal reversal is the procedure of choice in managing severe postvagotomy diarrhea. Although most patients with dumping can be managed conservatively, a small number with severe symptoms and nutritional problems cannot and require further operation. Our experience with conversion from Billroth II to Billroth I and with isoperistaltic interposition, although minimal, has been reasonably satisfactory. Four groups of patients remain with symptoms of chronic vomiting, late postvagotomy atonic stomach, dumping "plus," and miscellaneous symptoms. These patients have complaints that are difficult to define and usually have poor results with further operations. We believe that surgery should be avoided in these patients and that conservative measures be continued.

Ten to 20-year clinical results after short esophagomyotomy without an antireflux procedure (modified Heller operation) for esophageal achalasia.

To determine the long-term clinical results after modified esophagomyotomy without an antireflux procedure for esophageal achalasia, the status of all patients undergoing this operation with a minimum follow-up time of 10 years was reviewed; 81 such patients were operated on between January 1970 and January 1981. Thirteen patients were lost to follow-up review permitting clinical evaluation during the past year of 68 patients (84%) observed for a median of 13.6 years. Fifty-nine patients (87%) were improved by operation; 90% of the patients who underwent a primary procedure were improved, whereas only 73% of patients undergoing reoperation benefited. Kaplan-Meier analysis of the results of all 81 patients disclosed an improvement rate of 98.5% at 5 years, 95.6% at 10 years, 85.8% at 15 years, and 67.3% at 20 years. When the level of improvement or lack thereof was analyzed, the percentage of excellent results decreased from 54% to 32% (P = 0.02). The percentage of good results remained the same, whereas fair or poor results together increased from 20% to 37% (P = 0.05). Neither age, sex, esophageal caliber, duration of symptoms, or previous therapy appeared to influence these results. We conclude that limited esophagomyotomy without an antireflux procedure results in persistent long-term improvement for the patient with esophageal achalasia. The level of improvement, however, decreases with the passage of time, presumably because of persistent disease in the body of the esophagus leading to impaired esophageal emptying in some patients and late reflux esophagitis in other patients owing to poor esophageal clearance.

Current status of cricopharyngeal myotomy for cervical esophageal dysphagia.

OBJECTIVE: We have reviewed our experience with cricopharyngeal myotomy for a variety of conditions causing cervical esophageal dysphagia to clarify its indications and results as well as to determine what, if any, ancillary procedures are indicated. METHODS: Eighty-three patients underwent cricopharyngeal myotomy between January 1970 and January 1995, 54 of whom had a pharyngoesophageal diverticulum. The remainder suffered from a variety of motor disorders of the upper esophageal sphincter. Clinical follow-up evaluation was obtained in 71 of the 83 patients (86%). RESULTS: Good or excellent results were obtained in 87% of the patients with pharyngoesophageal diverticula, 100% after myotomy plus diverticulectomy, 87% after myotomy plus diverticulopexy and 67% after myotomy alone. Of patients with hypertensive upper esophageal sphincter, 100% had good or excellent results, whereas only 60% with nonspecific esophageal motor disorders were so evaluated. None of the patients with bulbar palsy or miscellaneous conditions had good or excellent results. CONCLUSIONS: We recommend cricopharyngeal myotomy for all patients with a pharyngoesophageal diverticulum coupled with diverticulopexy for the majority, reserving diverticulectomy for those with recurrent pouches or extremely large pouches (6-8 cm in diameter). Good or excellent results can be expected after myotomy in patients with a hypertensive upper esophageal sphincter. Myotomy is rarely indicated for patients with dysphagia secondary to bulbar palsy. The role of cricopharyngeal myotomy for patients with non-specific esophageal motor disorders remains controversial.