Evaluation of a point-of-care blood test for identification of Ebola virus disease at Ebola holding units, Western Area, Sierra Leone, January to February 2015.

Current Ebola virus disease (EVD) diagnosis relies on reverse transcription-PCR (RT-PCR) technology, requiring skilled laboratory personnel and technical infrastructure. Lack of laboratory diagnostic capacity has led to diagnostic delays in the current West African EVD outbreak of 2014 and 2015, compromising outbreak control. We evaluated the diagnostic accuracy of the EVD bedside rapid diagnostic antigen test (RDT) developed by the United Kingdom's Defence Science and Technology Laboratory, compared with Ebola virus RT-PCR, in an operational setting for EVD diagnosis of suspected cases admitted to Ebola holding units in the Western Area of Sierra Leone. From 22 January to 16 February 2015, 138 participants were enrolled. EVD prevalence was 11.5%. All EVD cases were identified by a positive RDT with a test line score of 6 or more, giving a sensitivity of 100% (95% confidence interval (CI): 78.2-100). The corresponding specificity was high (96.6%, 95% CI: 91.3-99.1). The positive and negative predictive values for the population prevalence were 79.0% (95% CI: 54.4-93.8) and 100% (95% CI: 96.7-100), respectively. These results, if confirmed in a larger study, suggest that this RDT could be used as a 'rule-out' screening test for EVD to improve rapid case identification and resource allocation.

Pulmonary artery thrombosis in a patient with right-sided heart failure.

Pulmonary thromboembolism occurring either abruptly or insidious poses a greater challenge in diagnosis. A high index of suspicion is required to proceed with proper investigations in patients with nonspecific cardiac or respiratory presentation to make the diagnosis of pulmonary embolism (PE). Early diagnosis of PE with prompt initiating of anticoagulation therapy has been proven to have a positive impact in mortality reduction associated with recurrent episodes of this condition. We present a case of a 76-year-old man, known to have cardiac failure on regular treatment who presented with predominant features of right-sided heart failure accompanied with dizziness. He was diagnosed to have pulmonary artery thrombosis by computerized tomography. Anticoagulation therapy was initiated with marked clinical improvement.

Body mass index and common mental disorders: exploring the shape of the association and its moderation by age, gender and education.

BACKGROUND: Obesity is known to be associated with increased prevalence of common mental disorders (for example, depression and anxiety), and there is evidence of age and gender differences in this relationship. However, categorisation of body mass index (BMI) and age has limited our ability to understand the nature of these differences. This study used continuous values of BMI and age to explore the shape of the association between common mental disorders and BMI and whether it varied with age, gender and education. METHOD: The analysis used cross-sectional data on 7043 adults from the English 2007 Adult Psychiatric Morbidity Survey. Common mental disorders were assessed using the revised Clinical Interview Schedule (CIS-R). Cubic splines allowed BMI and age to have non-linear effects in the logistic regression analysis. RESULTS: BMI was strongly associated with the presence of common mental disorders, and there was clear evidence that this association varied with gender and age. In young women the probability of having a disorder increased as BMI increased, whereas in young men the relationship was U-shaped-probabilities were higher for both underweight and obese men. These associations diminished in older age groups, particularly when potential confounders such as physical health were taken into account. There was no evidence that the relationship varied with education. CONCLUSIONS: Age and gender differences must be taken into account when investigating the link between BMI or obesity and common mental disorders. Furthermore, results of studies that categorise BMI may be highly sensitive to the width of the 'normal weight' reference category.

The association between personality disorder and an act of deliberate self harm in the older person.

BACKGROUND: Suicide rates are higher in the over 65s than in younger adults and there is a strong link between deliberate self harm (DSH) and suicide in older people. The association between personality disorder (PD) and DSH in older adults remains uncertain. Our objective was to describe this association. METHODS: A case control study was conducted in which participants were: (i) those who had undertaken an act of DSH and (ii) a hospital-based control group drawn from a geographical contiguous population. PD was assessed using the Standardised Assessment of Personality (SAP). RESULTS: Seventy-seven cases of DSH were identified; 61 (79.2%) of these participants were interviewed. There were 171 potential controls identified of whom 140 (81.9%) were included. An SAP was completed in 45/61 (73.8%) of cases and 100/140 (71.4%) of controls. The mean age was 79.8 years (SD = 9, range 65-103). The crude odds ratio for the association between PD and DSH was 5.91 [(95% CI 2.3, 14.9) p<0.0001]. There was a strong interaction with age stratified at 80 years. There was no association between PD and DSH after age 80. The adjusted odds ratio for PD in the group <80 years was 20.5 [(95% CI 3, 141) p = 0.002]. Borderline and impulsive PD traits tended to be associated with an episode of DSH more than other personality types. CONCLUSIONS: PD appears to be a strong and independent risk for an act of DSH in people aged between 65 and 80 years and should be looked for as part of any risk assessment in this population. Access to specialist services may be required to optimally manage this problem and reduce the subsequent risk of suicide.

Lateral hypothalamic control of killing: evidence for a cholinoceptive mechanism.

In rats that would not ordinarily kill mice, lateral hypothalamic injection of crystalline carbachol, a cholinomimetic, elicited killing. Norepinephrine, amphetamine, serotonin, and sodium salts were ineffective at the same site. Carbachol was ineffective when injected into the medial, dorsal, or ventral hypothalamus. As additional evidence for a cholinoceptive mechanism, neostigmine elicited killing, and, in spontaneous killers, methyl atropine blocked it. The results indicate that the lateral hypothalamus contains a cholinoceptive component of an innate system that activates killing, and anticholinergic treatment can be used as a means of suppressing killing.

Relative risks of cardiovascular disease in people prescribed olanzapine, risperidone and quetiapine.

Antipsychotics may confer long term benefits and risks, including cardiovascular disease (CVD) risk. Several studies using routine clinical data have reported associations between antipsychotics and CVD but potential confounding factors and unclear classification of drug exposure limits their interpretation. METHOD: We used data from The Health Improvement Network, a large UK primary care database to determine relative risks of (CVD) comparing similar groups of people only prescribed olanzapine versus either risperidone or quetiapine. We included participants over 18 between 1995 and 2011. To assess confounding factors we created propensity scores for being prescribed each antipsychotic. We used propensity score matching and Poisson regression to calculate the CVD incidence rate ratios for olanzapine versus the other two drugs. RESULTS: We identified 18,319 people who received a single antipsychotic during follow-up (n=5090 risperidone, 7797 olanzapine and 4613 quetiapine). In unmatched analyses, the CVD incidence rate ratio (IRR) for olanzapine versus risperidone was 0.63 (0.51-0.77) but the propensity score matched IRR was 0.78 (0.61-1.02). In the unmatched olanzapine versus quetiapine analysis the IRR adjusted for age and sex for olanzapine was 1.52 (1.16-1.98) but the propensity score matched analysis gave an IRR of 1.08 (0.79-1.46). CONCLUSIONS: After propensity score matching, we found no statistical differences in CVD incidence between olanzapine and either risperidone or quetiapine. Analyses which did not account for confounding factors produced very different results. Researchers must address confounding factors when designing observational studies to assess adverse outcomes of drugs, including antipsychotics.

Factors associated with anxiety in patients attending a sexually transmitted infection clinic: qualitative survey.

We used qualitative methods to explore factors, which might explain increased anxiety in patients attending a sexually transmitted infection (STI) clinic. Twenty patients, who scored significantly for anxiety on the Hospital Anxiety and Depression Scale (HADS) attended a 20-minute interview. This explored factors contributing to their current psychological symptoms. Transcripts revealed three main themes. First were factors related to possible STIs and the clinic visit. These included health anxieties about HIV or fertility and clinic factors, including staff attitudes and clinic location. Second were factors unrelated to the clinic, including previous emotional difficulties or substance misuse. Third were issues concerning stigma, embarrassment and shame. The origins of anxiety in STI patients are multifactorial and difficult to identify during brief appointments. Despite modern clinics and attitudes, stigma and embarrassment remain prominent. Interventions to address these factors could improve psychological health in this patient group.

Phylogenetic characterization of bacteria in the subsurface microbial culture collection.

The Subsurface Microbial Culture Collection (SMCC) was established by the U.S. Dept. of Energy (DOE) and contains nearly 10,000 strains of microorganisms (mostly bacteria) isolated from terrestrial subsurface environments. Selected groups of bacterial isolates from three sample sites situated above geochemically and hydrologically different subsurface environments have been characterized by phylogenetic analysis of 16S ribosomal RNA (rRNA) gene nucleotide sequences. Among these isolates were members of six major phylogenetic groups of bacteria: the high-G+C and low-G+C Gram-positive bacteria; the alpha-, beta-, and gamma-subdivisions of the Proteobacteria; and the Flexibacter/Cytophaga/Bacteroides group. A small number of the SMCC strains may be members of new bacterial genera, but most of them could be placed with reasonable confidence into more than 35 previously described genera. The majority of the Gram-positive isolates were species of Arthrobacter, Bacillus, or Streptococcus, whereas Acinetobacter, Comamonas, Pseudomonas, Sphingomonas, and Variovorax were among the most frequently encountered Gram-negative genera. A high proportion of the strains were placed in fewer than 10 genera, implying that there is substantial duplication within the SMCC at the genus level. When groups of isolates assigned to Acinetobacter, Arthrobacter, or Sphingomonas were analyzed in more detail, however, it was found that each group consisted of subgroups of strains that probably differed at the species level. Restriction endonuclease analysis (applied to the strains from one sample site) indicated that additional diversity was present at the strain level. Most of the SMCC isolates assigned to some genera (e.g., Acinetobacter) were very closely related to previously described species in those genera, but most of the isolates assigned to other genera (e.g., Arthrobacter and Sphingomonas) appeared (or were shown) to be new species, thereby indicating that a reasonable amount of novelty is present within the SMCC at the species level.

Cyclosporine reduces development of obliterative bronchiolitis in a murine heterotopic airway model.

Obliterative bronchiolitis (OB), an important threat to the long-term survival of lung transplant recipients, is characterized histologically by fibroproliferation within small airways. The pathogenesis of OB is thought to involve chronic allograft rejection, and therapy frequently includes augmentation of immunosuppression. We have developed a model that reproduces the pathologic lesion of OB and allows study of interventions designed to limit airway fibrosis. In this model, heterotopic transplantation of murine airways into immune-mismatched recipients results in epithelial abnormalities and fibroproliferation in the airway lumen, changes not seen in heterotopic isografts. Cyclosporine (CsA) inhibits activation and proliferation of T lymphocytes and is commonly administered after lung transplantation. We hypothesized that use of CsA in our model system would reduce fibroproliferation in tracheal allografts. To test this hypothesis, murine tracheas were transplanted heterotopically into allo matched and allomismatched recipients, and then treated with varying doses (5, 10, 15, or 25 mg/kg i.p. q.d.) of CsA. Controls included allografts and isografts not treated with CsA. After 30 days, tracheas were harvested and examined histologically. CsA markedly reduced the development of fibroproliferation in allografts (19% in treated allografts versus 90% in untreated allografts, P<0.0001), but did not reduce inflammation or airway epithelial cell injury. High-dose (25 mg/kg/day) CsA was more effective than lower doses in reducing fibroproliferation (0% in high dose versus 29% in low dose, P=0.04). These findings demonstrate that CsA significantly reduces development of the pathologic lesion of OB, and supports the role of alloimmunity in the pathogenesis of this disease.

Attrition in an exercise intervention: a comparison of early and later dropouts.

OBJECTIVE: To identify reasons for dropout and factors that may predict dropout from an exercise intervention aimed at improving physical function in frail older persons. DESIGN/SETTING: An 18-month randomized controlled intervention in a community setting. The intervention comprised 2 groups: class-based and self-paced exercise. PARTICIPANTS: 155 community-dwelling older persons, mean age 77.4, with mildly to moderately compromised mobility. MEASUREMENTS: The primary outcome measure was dropout. Dropouts were grouped as: D0, dropout between baseline and 3-month assessment, and D3, dropout after 3-month assessment. MEASUREMENTS: Measurements of demographics, health, and physical performance included self-rated health, SF-36, disease burden, adverse events, PPT-8, MacArthur battery, 6-minute walk, and gait velocity. RESULTS: There were 56 dropouts (36%), 31 in first 3 months. Compared with retained subjects (R), the D0 group had greater disease burden (P = .011), worse self-perceived physical health (P = .014), slower usual gait speed (P = .001), and walked a shorter distance over 6 minutes (P<.001). No differences were found between R and D3. Multinomial logistic regression showed 6-minute walk (P<.001) and usual gait velocity (P<.001) were the strongest independent predictors of dropout. Controlling for all other variables, adverse events after randomization and 6-minute walk distance were the strongest independent predictors of dropout, and self-paced exercise assignment increased the risk of dropout. CONCLUSIONS: We observed baseline differences between early dropouts and retained subjects in disease burden, physical function, and endurance, suggesting that these factors at baseline may predict dropout. Improved understanding of factors that lead to and predict dropout could allow researchers to identify subjects at risk of dropout before randomization. Assigning targeted retention techniques in accordance with these factors could result in decreased attrition in future studies. Therefore, the results of selective attrition of frailer subjects, such as decreased heterogeneity, restricted generalizability of study findings, and limited understanding of exercise effects in this population, would be avoided.

Dynamic balance in older persons: effects of reduced visual and proprioceptive input.

BACKGROUND: Understanding the motor and sensory contributions to balance function in older persons is important in order to design effective interventions to prevent falls and loss of mobility. We tested the contributions of visual and proprioceptive input, muscle strength, and age to balance performance in 110 subjects free of clinical evidence of neurologic disease (mean age 80 years). METHODS: The EquiTest Sensory Organization Test was used to present sequential conditions that altered sensory input in a 2 (tactile/proprioceptive input) x 3 (visual input) design. Center of force and shear force data were recorded from the platform; the primary outcomes were loss of balance (LOB) and anterior-posterior center of force (COF) displacement as a proportion of foot length (COFD). RESULTS: Subjects had 3.5 +/- 2.7 LOB during testing. Reduction of vision input increased the odds ratio of a LOB 5.7 fold (3.9, 8.4, 95% CI) in unstable surface conditions, but adaptation with repeated trials was substantial. The adjusted odds ratio of a LOB was 0.65 and 0.45 in the second and third trials, respectively, compared to the first. Muscle strength and age were independent predictors of LOB. Gait velocity, single stance balance, and reported difficulty with ambulation, mobility, and instrumental activities of daily living were also associated with LOB. CONCLUSIONS: Performance on clinical tests of strength, balance, and gait was associated with performance on a challenging balance test which reduced sensory input and effectiveness of motor responses. Adaptation to challenging balance conditions was substantial in this group of older subjects, but was diminished in the oldest subjects.

Long-term benzodiazepine users--a mixed bag.

In this article it is argued that long-term benzodiazepine (BZD) users can be classified into four broad groups, namely medical, daytime, night-time and polydrug users. Although the groups are not exhaustive or mutually exclusive, such a classification may go some way to clarify our understanding of the complex psychological and sociological phenomena involved in long-term consumption of BZDs.

Unusual forms of pulmonary embolism.

The first word of the title, unusual, captures the theme of this article. The entities discussed here: fat embolism, tumor embolism, venous air embolism, and amniotic fluid embolism, as well as other unusual embolic events are uncommon disorders that occur in specific circumscribed clinical settings. We have attempted to provide a cognitive jolt to remind the reader to consider these unusual events in appropriate differential diagnoses. No laboratory test, physical finding, or patient complaint will yield a timely diagnosis. Yet, these entities can be acutely life threatening; swift recognition is imperative. Timely and effective therapy rests on the clinical certainty that a test is not likely to establish. It is, perhaps, the greatest demand placed upon the agile clinical mind--to think of it!

The urethral syndrome: a controlled evaluation.

It has long been considered that psychological factors play an important rôle in women with urinary tract symptoms. Where no significant infection can be demonstrated, psychological factors have been claimed as paramount to the extent that the 'irritable urethral syndrome' has been postulated as a parallel to the irritable bowel. This paper reports on a controlled study of psychological and menstrual problems in women presenting in family practice with urinary symptoms. Women were assessed by structured interview. Two groups of women took part: (A) 54 women with urinary symptoms, 15 of whom later proved to have significant bacterial infection on culture. (B) 21 women attending for contraceptive advice also agreed to participate in a comparison group. Women presenting with urinary tract symptoms had higher mean scores on psychological and menstrual measures than comparison women, regardless of the presence of demonstrable infection. Thus, psychological and menstrual symptoms appear to determine whether a woman who experiences urinary tract symptoms attends her doctor, regardless of whether significant infection is present. No evidence was found, for the existence of an irritable urethral syndrome, in which psychological factors are postulated as the predominant cause.

Psychiatric health in a sexually transmitted infections clinic: effect on reattendance.

BACKGROUND AND OBJECTIVES: Sexually transmitted infections (STIs) remain a public health priority, but associated psychological morbidity has recently been ignored. One aspect of STI control is test of cure and further treatment at follow-up clinic appointments. We chose reattendance rates as a measure of compliance and assessed whether reattendance was related to psychological morbidity. METHODS: 938 STI clinic patients were offered the Hospital Anxiety and Depression Scale (HAD) and staff rated each patient's psychological health. Predictors of attendance, caseness and staff recognition were assessed by logistic regression. RESULTS: 401/774 [51.9%; 95% confidence interval (CI): 48.3-55.4%] patients, who completed the HAD, scored above threshold. Staff rated 151/743 (20.4%) patients as having "psychological problems." HAD caseness was not associated with attending arranged follow-up [adjusted odds ratio (adj. OR): 0.83 (0.49-2.05)]. Patients rated with psychological problems by staff were more likely to attend [adj. OR: 1.91 (1.02-3.60)]. CONCLUSIONS: Half of our sample had significant anxiety and staff should be more aware of this suffering. Our work suggests that such awareness might improve subsequent attendance.

Is there still a role for benzodiazepines in general practice?

Opinion on benzodiazepines has moved from optimism after their entry onto the market to disillusionment over their potential for dependence. Legal proceedings against manufacturers of benzodiazepines, health authorities and doctors will be taking place this year. Nonetheless, just over 18 million prescriptions for benzodiazepines were issued in 1990, most of which came from general practice. Is there any role left for this group of drugs? This review addresses the issues of dependence on an withdrawal from benzodiazepines and weighs up the evidence for their present vilification.

The economics of employing a counsellor in general practice: analysis of data from a randomised controlled trial.

BACKGROUND: Counselling is currently adopted in many general practices, despite limited evidence of clinical and cost effectiveness. AIM: To compare direct and indirect costs of counsellors and general practitioners (GPs) in providing care to people with emotional problems. METHOD: We carried out a prospective, randomized controlled trial of non-directive counselling and routine general practice care in 14 general practices in north London. Counsellors adhered to a Rogerian model of counselling. The counselling sessions ranged from one to 12 sessions over 12 weeks. As reported elsewhere, there were no differences in clinical outcomes between the two groups. Therefore, we conducted a cost minimisation analysis. We present only the economic outcomes in this paper. Main outcome measures were cost data (service utilisation, travel, and work absence) at baseline, three months, and nine months. RESULTS: One hundred and thirty-six patients with emotional problems, mainly depression, took part. Seventy patients were randomised to the counsellors and 66 to the GPs. The average direct and indirect costs for the counsellor was 162.09 Pounds more per patient after three months compared with costs for the GP group; however, over the following six months the counsellor group was 87.00 Pounds less per patient than the GP group. Over the total nine-month period, the counsellor group remained more expensive per patient. CONCLUSIONS: Referral to counselling is no more clinically effective or expensive than GP care over a nine-month period in terms of direct plus indirect costs. However, further research is needed to establish indirect costs of introducing a counsellor into general practice.

Long term use of benzodiazepines: the views of patients.

All long term benzodiazepine users in one inner London general practice were asked to participate in a study of their attitudes to their drugs. The 64 respondents had mixed views about benzodiazepines and did not conform to the stereotype presented in the media. Although 58% of the sample had attempted to stop taking benzodiazepines, this was usually not until at least one year of taking the drug. At the time of interview, 50% of the sample expressed a desire to stop taking their tablets. However, the majority were uncertain whether their general practitioner wished them to continue taking the drugs or not. It is argued that users' views of their medication must be taken into account in the debate about tranquillizer dependence.

Sexual molestation of men: interviews with 224 men attending a genitourinary medicine service.

Prevalence studies of sexual molestation in men attending genitourinary medicine (GUM) clinics have concentrated on experiences in adulthood or as a child, or on men who report male sexual partners only. Use of questionnaires in such studies can lead to under-reporting of 'sensitive' events. Our aim is to identify the lifetime prevalence of sexual molestation in men attending a GUM clinic using a self-administered, computerized interview via a cross-sectional survey. Eighteen per cent of respondents reported sexual molestation as an adult and 12% reported child sexual abuse (CSA). Sexual molestation in adulthood was more common in men who reported male sexual partners and in men reporting child sexual abuse. Fourteen per cent of victims reported being infected with a sexually transmitted infection (STI) after adult sexual molestation. In conclusion, a significant proportion of men attending GUM services report sexual molestation. Further research is required into effective ways of addressing this unmet need.

Reliability and responsiveness of two physical performance measures examined in the context of a functional training intervention.

BACKGROUND AND PURPOSE: The reliability and responsiveness of 2 physical performance measures were assessed in this nonrandomized, controlled pilot exercise intervention. SUBJECTS: Forty-five older individuals with mobility impairment (mean age=77.9 years, SD=5.9, range=70-92) were sequentially assigned to participate in an exercise program (intervention group) or to a control group. METHODS: The intervention group performed exercise 3 times a week for 12 weeks that targeted muscle force, endurance, balance, and flexibility. Outcome measures were the 8-item Physical Performance Test (PPT-8) and the 6-minute walk test. Test-retest reliability and responsiveness indexes were determined for both tests; interrater reliability was measured for the PPT-8. RESULTS: The intraclass correlation coefficient for interrater reliability for the PPT-8 was. 96. Intraclass correlation coefficients for test-retest reliability were.88 for the PPT-8 and.93 for the 6-minute walk test. The intervention group improved 2.4 points and the control group improved 0.7 point on the PPT-8, as compared with baseline measurements. There was no change in 6-minute walk test distance in the intervention group when compared with the control group. The responsiveness index was.8 for the PPT-8 and.6 for the 6-minute walk test. CONCLUSION AND DISCUSSION: Measurements for both the PPT-8 and the 6-minute walk test appeared to be highly reliable. The PPT-8 was more responsive than the 6-minute walk test to change in performance expected with this functional training intervention.