The effect of psychiatric decision unit services on inpatient admissions and mental health presentations in emergency departments: an interrupted time series analysis from two cities and one rural area in England.

AIMS: High-quality evidence is lacking for the impact on healthcare utilisation of short-stay alternatives to psychiatric inpatient services for people experiencing acute and/or complex mental health crises (known in England as psychiatric decision units [PDUs]). We assessed the extent to which changes in psychiatric hospital and emergency department (ED) activity were explained by implementation of PDUs in England using a quasi-experimental approach. METHODS: We conducted an interrupted time series (ITS) analysis of weekly aggregated data pre- and post-PDU implementation in one rural and two urban sites using segmented regression, adjusting for temporal and seasonal trends. Primary outcomes were changes in the number of voluntary inpatient admissions to (acute) adult psychiatric wards and number of ED adult mental health-related attendances in the 24 months post-PDU implementation compared to that in the 24 months pre-PDU implementation. RESULTS: The two PDUs (one urban and one rural) with longer (average) stays and high staff-to-patient ratios observed post-PDU decreases in the pattern of weekly voluntary psychiatric admissions relative to pre-PDU trend (Rural: -0.45%/week, 95% confidence interval [CI] = -0.78%, -0.12%; Urban: -0.49%/week, 95% CI = -0.73%, -0.25%); PDU implementation in each was associated with an estimated 35-38% reduction in total voluntary admissions in the post-PDU period. The (urban) PDU with the highest throughput, lowest staff-to-patient ratio and shortest average stay observed a 20% (-20.4%, CI = -29.7%, -10.0%) level reduction in mental health-related ED attendances post-PDU, although there was little impact on long-term trend. Pooled analyses across sites indicated a significant reduction in the number of voluntary admissions following PDU implementation (-16.6%, 95% CI = -23.9%, -8.5%) but no significant (long-term) trend change (-0.20%/week, 95% CI = -0.74%, 0.34%) and no short- (-2.8%, 95% CI = -19.3%, 17.0%) or long-term (0.08%/week, 95% CI = -0.13, 0.28%) effects on mental health-related ED attendances. Findings were largely unchanged in secondary (ITS) analyses that considered the introduction of other service initiatives in the study period. CONCLUSIONS: The introduction of PDUs was associated with an immediate reduction of voluntary psychiatric inpatient admissions. The extent to which PDUs change long-term trends of voluntary psychiatric admissions or impact on psychiatric presentations at ED may be linked to their configuration. PDUs with a large capacity, short length of stay and low staff-to-patient ratio can positively impact ED mental health presentations, while PDUs with longer length of stay and higher staff-to-patient ratios have potential to reduce voluntary psychiatric admissions over an extended period. Taken as a whole, our analyses suggest that when establishing a PDU, consideration of the primary crisis-care need that underlies the creation of the unit is key.

Loneliness prevention and the role of the Public Health system.

AIMS: To evaluate evidence on loneliness interventions that have been assessed and found effective, both for remediation and addressing fundamental causes of loneliness; to consider why population-level primary prevention strategies targeting fundamental causes are necessary, and determine areas for future research; and to outline an integrated approach to prevention considering roles for the Public Health system. METHOD: We conducted a review of systematic reviews to identify effective loneliness interventions and classified them in our Population-Prevention Matrix according to public health impact, amount of individual effort required, and level of prevention. We also highlighted emerging interventions that have yet to be formally evaluated. RESULTS: We identified a range of preventive or therapeutic approaches, and a dearth of population-level primary prevention interventions targeting fundamental causes of loneliness. Filling this gap will be essential in addressing the loneliness epidemic, and we provided emerging examples of population-level primary prevention interventions that may inform future efforts. CONCLUSION: Based on evidence to date, we suggest an integrated approach to prevention with significant roles for the US Public Health system, including its function as Chief Health Strategist to lead and guide multisystem approaches to loneliness prevention, with a particular focus on population-level primary prevention strategies.

Interactions Between syn- and anti-2,3-Hexanediol Lures on Trap Catches of Woodboring Beetles and Associates in Southeastern United States.

In 2016, we conducted three experiments to clarify the effects of 2,3-hexanediols isomers on trap catches of Neoclytus acuminatus (F.) (Coleoptera: Cerambycidae). We also noted the effects of the isomers on trap catches of other cerambycids and associated species of predators and competitors. Catches of N. acuminatus in traps baited with ethanol + syn-2,3-hexanediol + racemic 3-hydroxyoctan-2-one were reduced with the addition of anti-2,3-hexanediol, an attractant for Curius dentatus Newman (Coleoptera: Cerambycidae). A fourth experiment conducted in 2017 verified that racemic 3-hydroxyoctan-2-one increases catches of N. acuminatus in traps baited with ethanol + syn-2,3-hexanediol. The addition of anti-2,3-hexanediol increased catches of Knulliana cincta (Drury) (Coleoptera: Cerambycidae) in traps baited with ethanol + racemic 3-hydroxyoctan-2-one, whereas attraction of Neoclytus scutellaris (Olivier) to traps baited with ethanol + racemic 3-hydroxyhexan-2-one was reduced by syn-2,3-hexanediol. Trap catches of the beetle predators Chariessa pilosa (Forster), Enoclerus ichneumonus (F.), and Madoniella dislocata (Say) (Coleoptera: Cleridae) were affected by 2,3-hexanediol isomers, whereas other common predators were unaffected by the isomers. Attraction of the bostrichid Xylobiops basilaris (Say) (Coleoptera: Bostrichidae) was increased by the 2,3-hexanediols; the relative effect of the two isomeric blends was dependent on trap co-baits of 3-hydroxy-2-ketones. The two enantiomeric blends of 2,3-hexanediol had minimal effects on catches of most species of ambrosia beetles, whereas the 3-hydroxy-2-ketones affected trap catches of some species.

Brainstem auditory evoked responses and bone conduction assessment in alpacas.

Auditory loss has been reported in camelids using brainstem auditory evoked responses (BAER). Differentiation between conductive versus sensorineural dysfunction has not been investigated. Therefore, the objective of the study was to investigate auditory function using BAER and bone conduction (BC). Twenty-four alpacas: 15 females, 9 intact males (2-16 years of age) were included in a randomized clinical trial. BAER and BC were recorded using two derivations (vertex to mastoid and vertex to cranial aspect of second cervical vertebra). All alpacas underwent complete physical examinations and were sedated with xylazine hydrochloride at 0.6 mg/kg IM. Peaks, when present, were identified and latencies, amplitudes, and amplitude ratios were determined. Eleven alpacas had normal responses and 13 had auditory loss based on BAER. The latter consisted of complete absence of peaks bilaterally (n = 3), absence of peaks unilaterally (n = 1), delayed latencies bilaterally (n = 4), and delayed latencies unilaterally (n = 5). Distinct peaks on BC supported conductive auditory loss in 6 alpacas, difficult to interpret due to stimulus artifact and additional undefined peaks in 4, and absent peaks in 3 alpacas. The cause of auditory loss was presumed to be due to otitis in 6, aging in 4 (10-16 years old), and congenital sensorineural (absent peaks on BAER and BC) in 3 alpacas with unpigmented fiber and irises. BAER and BC are useful and non-invasive to perform techniques for the investigation of auditory loss in alpacas, and further characterization as conductive or sensorineural.

Sulcatol: Enantiospecific Attractant for Monarthrum mali (Coleoptera: Curculionidae: Scolytinae), Leptostylus asperatus (Coleoptera: Cerambycidae) and Associated Predators.

In 2014-2019, we conducted six experiments in north-central Georgia in an attempt to verify the aggregation pheromone response of the ambrosia beetle Gnathotrichus materiarius (Fitch) (Coleoptera: Curculionidae: Scolytinae: Scolytini: Corthylina) to sulcatol known to be produced by male G. materiarius; we failed to catch any G. materiarius. However, we did find that another corthyline ambrosia beetle species Monarthrum mali (Fitch) was attracted to (R)-(-)-sulcatol, whereas the longhorn beetle Leptostylus asperatus (Haldeman) (Coleoptera: Cerambycidae: Lamiinae) was attracted to (S)-(+)-sulcatol. Attraction of both species was unaffected by the respective antipodes. Ethanol enhanced attraction of both species to traps baited with sulcatol. In at least one experiment, attraction to ethanol-baited traps was enhanced by sulcatol for Xylosandrus crassiusculus (Motschulsky), Xyleborus spp., and Hypothenemus spp. but reduced for Cnestus mutilatus (Blandford) (Coleoptera: Curculionidae: Scolytinae). Additionally, traps baited with ethanol and racemic sulcatol [50% (S)-(+): 50% (R)-(-)] caught the greatest numbers of four species of beetle predators: Coptodera aerata Dejean (Coleoptera: Carabidae), Colydium lineola Say (Coleoptera: Zopheridae), Madoniella dislocata (Say), and Pyticeroides laticornis (Say) (Coleoptera: Cleridae). Ethanol but not sulcatol attracted Temnoscheila virescens (F.) (Coleoptera: Trogossitidae). Information on interspecific relationships within forested communities may help us to better determine the roles of these species in maintaining stable and resilient forested ecosystems.

Global, Regional, and National Levels and Trends in Burden of Oral Conditions from 1990 to 2017: A Systematic Analysis for the Global Burden of Disease 2017 Study.

Government and nongovernmental organizations need national and global estimates on the descriptive epidemiology of common oral conditions for policy planning and evaluation. The aim of this component of the Global Burden of Disease study was to produce estimates on prevalence, incidence, and years lived with disability for oral conditions from 1990 to 2017 by sex, age, and countries. In addition, this study reports the global socioeconomic pattern in burden of oral conditions by the standard World Bank classification of economies as well as the Global Burden of Disease Socio-demographic Index. The findings show that oral conditions remain a substantial population health challenge. Globally, there were 3.5 billion cases (95% uncertainty interval [95% UI], 3.2 to 3.7 billion) of oral conditions, of which 2.3 billion (95% UI, 2.1 to 2.5 billion) had untreated caries in permanent teeth, 796 million (95% UI, 671 to 930 million) had severe periodontitis, 532 million (95% UI, 443 to 622 million) had untreated caries in deciduous teeth, 267 million (95% UI, 235 to 300 million) had total tooth loss, and 139 million (95% UI, 133 to 146 million) had other oral conditions in 2017. Several patterns emerged when the World Bank's classification of economies and the Socio-demographic Index were used as indicators of economic development. In general, more economically developed countries have the lowest burden of untreated dental caries and severe periodontitis and the highest burden of total tooth loss. The findings offer an opportunity for policy makers to identify successful oral health strategies and strengthen them; introduce and monitor different approaches where oral diseases are increasing; plan integration of oral health in the agenda for prevention of noncommunicable diseases; and estimate the cost of providing universal coverage for dental care.

Trap Height Affects Catches of Bark and Woodboring Beetles (Coleoptera: Curculionidae, Cerambycidae) in Baited Multiple-Funnel Traps in Southeastern United States.

In north-central Georgia, trap height affected catches of some species of bark and woodboring beetles (Coleoptera) in traps baited with lures used in surveillance programs to detect non-native forest insects. Traps were placed within the canopy and understory of mature oak trees (Quercus spp.) with collection cups placed 18-23 m above ground level (AGL), and 0.3-0.5 m AGL, respectively. Traps were baited with ethanol to target ambrosia beetles (Curculionidae: Scolytinae) in one experiment, ethanol + syn-2,3-hexanediol + racemic 3-hydroxyhexan-2-one + racemic 3-hydroxyoctan-2-one to target hardwood woodborers (Cerambycidae) in a second experiment, and α-pinene + racemic ipsenol + racemic ipsdienol to target pine bark beetles (Curculionidae) and woodborers (Cerambycidae) in a third experiment. Canopy traps were more effective than understory traps for detecting Cnestus mutilatus (Blandford) (Curculionidae), Neoclytus scutellaris (Olivier), and Monochamus titillator (F.) (Cerambycidae). The reverse was true for Xylosandrus crassiusculus (Motschulsky), Dendroctonus terebrans (Olivier) (Curculionidae), and Neoclytus acuminatus (F.) (Cerambycidae). Catches of a third group which included Hylobius pales (Herbst), Ips grandicollis (Eichhoff) (Curculionidae), Neoclytus mucronatus (F.), and Anelaphus pumilus (Newman) (Cerambycidae) were largely unaffected by trap height. Similar patterns were noted for species of Cleridae, Scarabaeidae, Trogossitidae, and Zopheridae but not Histeridae or Tenebrionidae (Coleoptera). Catches of the bee assassin Apiomerus crassipes (F.) (Hemiptera: Reduviidae) in traps baited with the hardwood borer blend were greater in canopy traps than in understory traps.

Presumed Neuroglycopenia Caused by Severe Hypoglycemia in Horses.

BACKGROUND: Neuroglycopenia refers to a shortage of glucose in the brain resulting in neuronal dysfunction and death if left untreated. Presumed neuroglycopenia has not been described in horses. OBJECTIVE: To report neurological signs in horses with presumed neuroglycopenia as the result of severe hypoglycemia. ANIMALS: Ninety horses (hours to 28 years of age) diagnosed with hypoglycemia (blood glucose concentration < 75 mg/dL [< 4.2 mmol/L]). METHODS: Retrospective study. Electronic medical records were searched. Signalment, history, complaint, clinical signs, laboratory findings including CSF analysis, electroencephalogram, clinical or definitive diagnosis, and outcome were recorded. Kruskal-Wallis analysis of variance and logistic regression were used to investigate association between blood glucose concentration and data extracted. Statistical significance was set at P < 0.05. RESULTS: Thirty-eight and 52 horses had mild (50-74 mg/dL [2.8-4.1 mmol/L]), and severe hypoglycemia (< 50 mg/dL [< 2.8 mmol/L]), respectively. Most common causes of hypoglycemia included liver and gastrointestinal (40%) disease, sepsis (33%), neoplasia (7%), and insulin-induced (4%). Most common neurologic deficits included obtundation (100%), seizures (42%), and disorientation (22%). CSF-glucose was severely low (mean 2.5 mg/dL [0.1 mmol/L], median 0 mg/dL). Paroxysmal discharges in support of seizures were identified in the occipital (visual) and parietal (closest to temporal-auditory) cortical regions upon EEG examination (8/8 horses). CONCLUSIONS AND CLINICAL IMPORTANCE: Neuroglycopenia is presumed to occur in horses as the result of severe hypoglycemia. Subclinical seizures, and intermittent blindness and deafness of cortical origin can occur. Severe altered state of consciousness and seizures can be observed at a blood glucose cut-off value of < 42 mg/dL (< 2.3 mmol/L).

Interactions between Ethanol, syn-2,3-Hexanediol, 3-Hydroxyhexan-2-one, and 3-Hydroxyoctan-2-one Lures on Trap Catches of Hardwood Longhorn Beetles in Southeastern United States.

The effectiveness of a four-component "super lure" consisting of ethanol (E) and the cerambycid pheromones syn-2,3-hexanediol (D6), racemic 3-hydroxyhexan-2-one (K6), and racemic 3-hydroxyoctan-2-one (K8) on trap catches of Cerambycidae (Coleoptera) was determined in southeast United States with seven trapping experiments in 2011-2013. We captured 74 species of longhorn beetles in our three-year study. Ethanol significantly increased the mean catches of seven species and increased the number of cerambycid species detected. Traps with the "super lure" were effective for 8 of 13 species of Cerambycidae previously shown to be attracted to binary combinations of ethanol plus one of the three pheromones. However, the "super lure" was less effective for the remaining five species with catch reductions of 40-90% compared with combinations of ethanol and one or two of the pheromones. For example, K6 + K8 lures reduced catches of Anelaphus villosus (F.) in traps with E + D6 by 90%. Similarly, catches of Anelaphus pumilus (Newman) in traps with E + K6 + D6 were reduced by 50% with the addition of K8. Catches of Knulliana cincta (Drury) in traps with K6 + K8 lures were interrupted by D6, an effect negated by the addition of ethanol. Given the interruptive effects on trap catches of some species when lures are combined in a single trap, developing optimal lure blends to maximize detection efficacy will be a challenge for managers of detection programs for non-native invasive species of longhorn beetles.

Audit of compliance with the British Committee for Standards in Haematology (BCSH) revised guidelines for the diagnosis and assessment of treatment response of hairy cell leukemia in University Hospital Galway.

INTRODUCTION: Hairy cell leukemia (HCL) is an uncommon B cell lymphoproliferative disorder. The object of the present audit was to assess whether the investigation and management of HCL in University College Hospital Galway (UCHG) complies with the British Committee for Standards in Haematology (BCSH) guidelines. METHODS: Following a review of the records in our Haematology Department, 18 cases of HCL were identified between January 2006 and October 2014. RESULTS: Blood film examination had been performed in all cases. Flow cytometry of liquid material had been undertaken in 89 % (n = 16) of cases, of which only 31 % (n = 5) included all four hairy cell panel markers (CD11c, CD25, CD103, CD123). Although all initial trephine biopsies included CD20, none analyzed DBA44. Only 65 % (n = 11) of treated patients had a post-treatment bone marrow biopsy preformed. CONCLUSION: This audit highlights areas of improvement in the diagnosis and management of HCL in UCHG, which do not currently adhere to the BCSH recommendations.

Pine Sawyers (Coleoptera: Cerambycidae) Attracted to α-Pinene, Monochamol, and Ipsenol in North America.

Detection tools are needed for Monochamus species (Coleoptera: Cerambycidae) because they are known to introduce pine wilt disease by vectoring nematodes in Asia, Europe, and North America. In 2012-2014, we examined the effects of the semiochemicals monochamol and ipsenol on the flight responses of the sawyer beetles Monochamus carolinensis (Olivier), Monochamus clamator (LeConte), Monochamus mutator LeConte, Monochamus notatus (Drury), Monochamus obtusus Casey, Monochamus scutellatus (Say), and Monochamus titillator (F.) complex (Coleoptera: Cerambycidae) to traps baited with α-pinene. Experiments were set in pine forests in New Brunswick and Ontario (Canada), and Arizona, Georgia, Michigan, Montana, Oregon, South Carolina, Utah, and Washington (United States). In brief, 40 traps were placed in 10 blocks of 4 traps per block per location. Traps were baited with: 1) α-pinene; 2) α-pinene + monochamol; 3) α-pinene + ipsenol; and 4) α-pinene + monochamol + ipsenol. Monochamol increased catches of six species and one species complex of Monochamus with an additive effect of ipsenol for five species and one species complex. There was no evidence of synergy between monochamol and ipsenol on beetle catches. Monochamol had no effect on catches of other Cerambycidae or on any associated species of bark beetles, weevils, or bark beetle predators. We present a robust data set suggesting that the combination of α-pinene, ipsenol, and monochamol may be a useful lure for detecting Monochamus species.

Responses of Cerambycidae and Other Insects to Traps Baited With Ethanol, 2,3-Hexanediol, and 3,2-Hydroxyketone Lures in North-Central Georgia.

In north-central Georgia, 13 species of woodboring beetles (Coleoptera: Cerambycidae: Cerambycinae) were attracted to multiple-funnel traps baited with ethanol and one of the following pheromones: (1) racemic 3-hydroxyhexan-2-one; (2) racemic 3-hydroxyoctan-2-one; and (3) syn-2,3-hexanediol. The following species were attracted to traps baited with ethanol and 3-hydroxyhexan-2-one: Anelaphus pumilus (Newman), Eburia quadrigeminata (Say), Euderces pini (Olivier), Knulliana cincta (Drury), Neoclytus mucronatus (F.), Neoclytus scutellaris (Olivier), and Xylotrechus colonus (F.). Clytus marginicollis Castelnau & Gory, and Anelaphus parallelus (Newman) were attracted to traps baited with ethanol and 3-hydroxyoctan-2-one, whereas traps baited with ethanol and syn-2,3-hexanediol were attractive to Anelaphus villosus (F.), A. parallelus, Neoclytus acuminatus (F.), Neoclytus jouteli jouteli Davis, and Megacyllene caryae (Gahan). Ethanol enhanced catches of seven cerambycid species in traps baited with syn-2,3-hexanediol and 3,2-hydroxyketones. Catches of bark and ambrosia beetles (Curculionidae: Scolytinae) in ethanol-baited traps were largely unaffected by the addition of syn-2,3-hexanediol and 3,2-hydroxyketone lures, except for two species. The mean catches of Hypothenemus rotundicollis Wood & Bright and Dryoxylon onoharaensum (Murayama) in ethanol-baited traps increased and decreased, respectively, with the addition of racemic 3-hydroxyoctan-2-one. Traps baited with ethanol and syn-2,3-hexanediol were attractive to Xylobiops basilaris (Say) (Bostrichidae) and Chariessa pilosa (Forster) (Cleridae), whereas Temnoscheila virescens (F.) (Trogossitidae) were attracted to traps baited with ethanol and 3-hydroxyhexan-2-one. The assassin bug, Apiomerus crassipes (F.) (Hemiptera: Reduviidae), was attracted to traps baited with ethanol and 3,2-hydroxyketones.

Ipsenol, Ipsdienol, Ethanol, and α-Pinene: Trap Lure Blend for Cerambycidae and Buprestidae (Coleoptera) in Pine Forests of Eastern North America.

In 2007-2008, we examined the flight responses of wood-boring beetles (Coleoptera: Cerambycidae and Buprestidae) to multiple-funnel traps baited with the pine volatiles, ethanol, and α-pinene [85% (-)], and the bark beetle pheromones, racemic ipsenol and racemic ipsdienol. Experiments were conducted in mature pine stands in Canada (Ontario and New Brunswick) and the United States (Arkansas, Florida, Michigan, New Hampshire, North Carolina, Ohio, Tennessee, and Wisconsin). At each location, traps were deployed in 10 replicate blocks of four traps per block. The trap treatments were: 1) blank control; 2) ipsenol and ipsdienol; 3) ethanol and α-pinene; and 4) a quaternary blend of ipsenol, ipsdienol, ethanol, and α-pinene. Traps baited with the quaternary blend caught the greatest numbers of Acanthocinus nodosus (F.), Acanthocinus obsoletus (Olivier), Acmaeops proteus (Kirby), Astylopsis sexguttata (Say), Rhagium inquisitor (L.) (Cerambycidae), and Buprestis lineata (F.) (Buprestidae). Traps baited with ethanol and α-pinene caught the greatest numbers of Arhopalus rusticus (LeConte), Asemum striatum (L.), Tetropium spp., Xylotrechus sagittatus (Germar) (Cerambycidae), and Buprestis maculipennis Gory (Buprestidae) with minimal interruption by ipsenol and ipsdienol. Our results suggest that multiple-funnel traps baited with the quaternary lure blend of ipsenol, ipsdienol, ethanol, and α-pinene are effective for trapping various species of wood-boring beetles in pine forests of eastern North America, and may have utility in detection programs for adventive species in North America and overseas.

Investigation of an association between onset of narcolepsy and vaccination with pandemic influenza vaccine, Ireland April 2009-December 2010.

In 2011, the Irish Medicines Board received reports of onset of narcolepsy following vaccination against influenza A(H1N1)pdm09 with Pandemrix. A national steering committee was convened to examine the association between narcolepsy and pandemic vaccination. We conducted a retrospective population-based cohort study. Narcolepsy cases with onset from 1 April 2009 to 31 December 2010 were identified through active case finding. Narcolepsy history was gathered from medical records. Pandemic vaccination status was obtained from vaccination databases. Two independent experts classified cases using the Brighton case definition. Date of onset was defined as date of first healthcare contact for narcolepsy symptoms. Incidence of narcolepsy in vaccinated and non-vaccinated individuals was compared. Of 32 narcolepsy cases identified, 28 occurred in children/adolescents and for 24 first healthcare contact was between April 2009 and December 2010. Narcolepsy incidence was 5.7 (95% confidence interval (CI): 3.4­8.9) per 100,000 children/adolescents vaccinated with Pandemrix and 0.4 (95% CI: 0.1­1.0) per 100,000 unvaccinated children/adolescents (relative risk: 13.9; absolute attributable risk: 5.3 cases per 100,000 vaccinated children/adolescents). This study confirms the crude association between Pandemrix vaccination and narcolepsy as observed in Finland and Sweden. The vaccine is no longer in use in Ireland. Further studies are needed to explore the immunogenetic mechanism of narcolepsy.

Tissue engineering in flexor tendon surgery: current state and future advances.

Tissue engineering of flexor tendons addresses a challenge often faced by hand surgeons: the restoration of function and improvement of healing with a limited supply of donor tendons. Creating an engineered tendon construct is dependent upon understanding the normal healing mechanisms of the tendon and tendon sheath. The production of a tendon construct includes: creating a three-dimensional scaffold; seeding cells within the scaffold; encouraging cellular growth within the scaffold while maintaining a gliding surface; and finally ensuring mechanical strength. An effective construct incorporates these factors in its design, with the ultimate goal of creating tendon substitutes that are readily available to the reconstructive hand surgeon.

ATLANTIC DIP: simplifying the follow-up of women with previous gestational diabetes.

OBJECTIVE: Previous gestational diabetes (GDM) is associated with a significant lifetime risk of type 2 diabetes. In this study, we assessed the performance of HbA1c and fasting plasma glucose (FPG) measurements against that of 75 g oral glucose tolerance testing (OGTT) for the follow-up screening of women with previous GDM. METHODS: Two hundred and sixty-six women with previous GDM underwent the follow-up testing (mean of 2.6 years (s.d. 1.0) post-index pregnancy) using HbA1c (100%), and 75 g OGTT (89%) or FPG (11%). American Diabetes Association (ADA) criteria for abnormal glucose tolerance were used. DESIGN, COHORT STUDY, AND RESULTS: The ADA HbA1c high-risk cut-off of 39 mmol/mol yielded sensitivity of 45% (95% CI 32, 59), specificity of 84% (95% CI 78, 88), negative predictive value (NPV) of 87% (95% CI 82, 91) and positive predictive value (PPV) of 39% (95% CI 27, 52) for detecting abnormal glucose tolerance. ADA high-risk criterion for FPG of 5.6 mmol/l showed sensitivity of 80% (95% CI 66, 89), specificity of 100% (95% CI 98, 100), NPV of 96% (95% CI 92, 98) and PPV of 100% (95% CI 91, 100). Combining HbA1c ≥39 mmol/mol with FPG ≥5.6 mmol/l yielded sensitivity of 90% (95% CI 78, 96), specificity of 84% (95% CI 78, 88), NPV of 97% (95% CI 94, 99) and PPV of 56% (95% CI 45, 66). CONCLUSIONS: Combining test cut-offs of 5.6 mmol/l and HbA1c 39 mmol/mol identifies 90% of women with abnormal glucose tolerance post-GDM (mean 2.6 years (s.d.1.0) post-index pregnancy). Applying this follow-up strategy will reduce the number of OGTT tests required by 70%, will be more convenient for women and their practitioners, and is likely to lead to increased uptake of long-term retesting by these women whose risk for type 2 diabetes is substantially increased.

Development of a cardiologist delivered service leads to improved outcomes following admission with acute coronary syndromes in a large district general hospital.

BACKGROUND: East Lancashire Hospitals NHS Trust reorganized its services in October 2007 with acute admissions sent to one site which allowed the development of a 24/7 Consultant delivered cardiology service. METHODS: A retrospective analysis of all patients admitted with an acute coronary syndrome between two periods: Group 1: October 2006 to September 2007 and Group 2: October 2007 and September 2008. We looked at the following end points-length of stay, in-hospital and 30 day all cause mortality. RESULTS: 633 patients in group 1 and 748 patients in group 2. There was significant reduction in length of stay from a median (IQ range) 7 (5-11) days to 5 (3-9) days; P<0.0001. The in-hospital mortality reduced from 15.8% (n=100) to 7.6% (n=56); P<0.0001. The mortality at 30 days reduced from 15.2% (n=96) to 8.3% (n=62); P<0.0001. These reductions remained significant after adjustment for demographic and risk factor variables. CONCLUSION: A 24/7 Consultant Cardiologist delivered cardiac care is associated with marked reductions in all cause mortality following admission with acute coronary syndromes. This improvement occurred with a significant reduction in hospital length of stay.

British Association for Psychopharmacology consensus statement on evidence-based treatment of insomnia, parasomnias and circadian rhythm disorders.

Sleep disorders are common in the general population and even more so in clinical practice, yet are relatively poorly understood by doctors and other health care practitioners. These British Association for Psychopharmacology guidelines are designed to address this problem by providing an accessible up-to-date and evidence-based outline of the major issues, especially those relating to reliable diagnosis and appropriate treatment. A consensus meeting was held in London in May 2009. Those invited to attend included BAP members, representative clinicians with a strong interest in sleep disorders and recognized experts and advocates in the field, including a representative from mainland Europe and the USA. Presenters were asked to provide a review of the literature and identification of the standard of evidence in their area, with an emphasis on meta-analyses, systematic reviews and randomized controlled trials where available, plus updates on current clinical practice. Each presentation was followed by discussion, aimed to reach consensus where the evidence and/or clinical experience was considered adequate or otherwise to flag the area as a direction for future research. A draft of the proceedings was then circulated to all participants for comment. Key subsequent publications were added by the writer and speakers at draft stage. All comments were incorporated as far as possible in the final document, which represents the views of all participants although the authors take final responsibility for the document.