Psychological risk factors for chronic post-surgical pain after inguinal hernia repair surgery: a prospective cohort study.

A significant proportion of patients experience chronic post-surgical pain (CPSP) following inguinal hernia surgery. Psychological models are useful in predicting acute pain after surgery, and in predicting the transition from acute to chronic pain in non-surgical contexts. This is a prospective cohort study to investigate psychological (cognitive and emotional) risk factors for CPSP after inguinal hernia surgery. Participants were asked to complete questionnaires before surgery and 1 week and 4 months after surgery. Data collected before surgery and 1 week after surgery were used to predict pain at 4 months. Psychological risk factors assessed included anxiety, depression, fear-avoidance, activity avoidance, catastrophizing, worry about the operation, activity expectations, perceived pain control and optimism. The study included 135 participants; follow-up questionnaires were returned by 119 (88.1%) and 115 (85.2%) participants at 1 week and 4 months after surgery respectively. The incidence of CPSP (pain at 4 months) was 39.5%. After controlling for age, body mass index and surgical variables (e.g. anaesthetic, type of surgery and mesh type used), lower pre-operative optimism was an independent risk factor for CPSP at 4 months; lower pre-operative optimism and lower perceived control over pain at 1 week after surgery predicted higher pain intensity at 4 months. No emotional variables were independently predictive of CPSP. Further research should target these cognitive variables in pre-operative psychological preparation for surgery.

Organising a World Congress of Epidemiology (WCE): reflections and lessons from the XIX WCE, Scotland.

The 3-yearly World Congress of Epidemiology is the premier, international, scientific conference organised under the auspices of the International Epidemiological Association (in open competition). This paper explores the justification for seeking to host the Congress and reflects on the structures and processes adopted in making the XIXth Congress in Scotland happen. Preparing the bid was invaluable for forming collaborations, generating scientific ideas, and garnering opinion. After the bid was accepted, we formed a local organising committee, named the Management Executive Committee to signal its decision making authority; and scientific, fundraising, marketing, international and social subcommittees. There was uncertainty about critical matters such as delegate numbers, costs and the total budget. Early decisions had to be made on, for example, the fee and fundraising target (£250,000), despite financial risks. Development of the scientific programme was a critical step that underpinned fundraising and marketing and permitted involvement of the international committee. Overall the 2011 WCE succeeded. The key ingredients to success were: a large collaboration of institutions and individuals; early pledges of financial support mostly from the UK; the valuable and relevant experience of the professional conference organisers; unstinting support and advice from IEA; and the effectiveness of the committee structure. The educational and professional development benefits of this WCE will reach a worldwide community and not just delegates, because of video, PowerPoint and textual accounts being open access on the Internet. This reach is unprecedented for IEA's World Congresses. We anticipate that the Congress will translate into better public health practice, better future Congresses, advances in epidemiology and improved population health.

Hypertensive disorders of pregnancy and future health and mortality: A record linkage study.

The objective of this register-based cohort study was to examine the relationship between hypertensive disorders of pregnancy and future hospital discharges from specified causes including cardiovascular disease, incident cancer registrations and mortality. From the Aberdeen Maternity and Neonatal Databank we identified 34,854 women who were born on or before 31st December 1967 and who had (i) preeclampsia/eclampsia, (ii) gestational hypertension or (iii) normal blood pressure in their first pregnancy. Hospital discharges from selected causes including cardiovascular disease, cancer registrations and deaths in these women were identified from the Scottish Morbidity Records. There were 2026 women who had preeclampsia, 8891 who had gestational hypertension and 23,937 who were normotensive during their first pregnancy. Compared to normotensive women, women with preeclampsia had a higher mortality from ischaemic heart disease (adj. IRR 1.38, 95% CI 1.03, 1.84) and circulatory disease (adj. IRR 1.30, 95% CI 1.06, 1.60). Similar trends were seen with gestational hypertension. There was no difference in all cause mortality in the three groups. The odds of a hypertensive episode were higher in women with preeclampsia (adj. OR 1.79, 95% CI 1.55, 2.05) and gestational hypertension (adj. OR 1.68, 95% CI 1.55, 1.82) compared to normotensives. Compared to normotensives, women with gestational hypertension (adj. IRR 0.91, 95% CI 0.85, 0.96) or preeclampsia (adj. IRR 0.86, 95% CI 0.77, 0.97) had lower incidences of cancer. Women with pregnancy induced hypertension are at a higher risk of incidence and mortality from ischaemic heart disease and a lower risk of cancer.

Cytokine and protein markers of leprosy reactions in skin and nerves: baseline results for the North Indian INFIR cohort.

BACKGROUND: Previous studies investigating the role of cytokines in the pathogenesis of leprosy have either been on only small numbers of patients or have not combined clinical and histological data. The INFIR Cohort study is a prospective study of 303 new multibacillary leprosy patients to identify risk factors for reaction and nerve damage. This study characterised the cellular infiltrate in skin and nerve biopsies using light microscopic and immunohistochemical techniques to identify any association of cytokine markers, nerve and cell markers with leprosy reactions. METHODOLOGY/PRINCIPAL FINDINGS: TNF-α, TGF-ß and iNOS protein in skin and nerve biopsies were detected using monoclonal antibody detection immunohistochemistry techniques in 299 skin biopsies and 68 nerve biopsies taken from patients at recruitment. The tissues were stained with hematoxylin and eosin, modified Fite Faraco, CD68 macrophage cell marker and S100. CONCLUSIONS/SIGNIFICANCE: Histological analysis of the biopsies showed that 43% had borderline tuberculoid (BT) leprosy, 27% borderline lepromatous leprosy, 9% lepromatous leprosy, 13% indeterminate leprosy types and 7% had no inflammation. Forty-six percent had histological evidence of a Type 1 Reaction (T1R) and 10% of Erythema Nodosum Leprosum. TNF-α was detected in 78% of skin biopsies (181/232), iNOS in 78% and TGF-ß in 94%. All three molecules were detected at higher levels in patients with BT leprosy. TNF-α was localised within macrophages and epithelioid cells in the granuloma, in the epidermis and in dermal nerves in a few cases. TNF-α, iNOS and TGF-ß were all significantly associated with T1R (p<0.001). Sixty-eight nerve biopsies were analysed. CD68, TNF-α and iNOS staining were detectable in 88%, 38% and 28% of the biopsies respectively. The three cytokines TNF-α, iNOS and TGF-ß detected by immunohistochemistry showed a significant association with the presence of skin reaction. This study is the first to demonstrate an association of iNOS and TGF-ß with T1R.

The changing pattern of referral in acute kidney injury.

BACKGROUND: Acute kidney injury (AKI) is not only managed by nephrologists, but also by several other subspecialists. The referral rate to nephrologists and the factors influencing it are unknown. AIMS: To determine the referral rate, factors affecting referral and outcomes across the spectrum of AKI in a population based study. METHODS: We identified all patients with serum creatinine concentrations ≥150 µmol/l (male) or ≥130 µmol/l (female) over a 6-month period. AKI was defined according to the RIFLE classification (risk, injury, failure, loss, end stage renal disease [ESRD]). Clinical information and outcomes were obtained from each patient's case records. RESULTS: A total of 562 patients were identified as having AKI (incidence 2147 per million population/year [pmp/y]). One hundred and sixty-four patients (29%) were referred to nephrologists-referral rate 627 pmp/y. Forty-nine percent of patients whose serum creatinine rose to >300 µmol/l were referred compared with 22% in our previous study of 1997. Forty-eight patients required renal replacement therapy-incidence 184 pmp/y in comparison to 50 pmp/y in our previous study of 1997. Patients had higher odds of referral if they were male, of younger age and were in the F category of the RIFLE classification. Patients had lower odds of referral if they had multiple co-morbid conditions or if they were managed in a hospital without a nephrology service. CONCLUSION: There has been a significant rise in the referral rate of patients with AKI to nephrologists but even during our period of study only one-third of such patients were being referred. With rising incidence and increased awareness, the referral rate will certainly rise putting a significant burden on the nephrology services.

The risk factors for unexplained antepartum stillbirths in Scotland, 1994 to 2003.

OBJECTIVE: To determine the factors contributing to unexplained antepartum stillbirth in Scotland. STUDY DESIGN: A 10-year birth database in Scotland was used to compare the unexplained antepartum stillbirth with other birth outcomes. The sample unit was a pregnant mother with a gestational age of 20 weeks and above and with a fetal birth weight of 200 g and above. RESULT: Maternal age of 35 years and above, lower deprivation category, inaccessible area of residence, maternal smoking, maternal height of <160 cm and gestational age of above 39 weeks were significantly associated with unexplained antepartum stillbirth. In multivariable analysis only maternal age (adjusted odds ratio (OR): 1.8, confidence interval (CI): 1.1 to 3.0, P=0.02), smoking during pregnancy (adjusted OR: 2.0, CI: 1.1 to 3.5, P=0.02), and maternal height (adjusted OR: 1.4, CI: 1.1 to 1.8, P=0.01), remain significant. Screening of pregnancies based on these three risk factors had 4.2% sensitivity and 99.4% specificity. The prevalence of stillbirth for this population was 0.2%. A positive predictive value of only 1.2% implies that only 1 in 83 women with these three risk factors will have antepartum stillbirth. The remaining 82 will suffer needless anxiety and potentially diagnostic procedures. CONCLUSION: Advanced maternal age, maternal smoking, and shorter maternal height were associated risk for unexplained antepartum stillbirth but screening based on these factors would be of limited value.

Weight loss interventions in young people (18 to 25 year olds): a systematic review.

This systematic review assesses weight loss interventions in young adults (18-25 years), who are vulnerable to weight gain. This age group experience critical life course points (leaving home for higher studies or job, pregnancy, cohabitation) and develop/establish lifestyle and behavioural patterns making this an opportune intervention period. Medline, Embase, Cinahl, PsychINFO and Cochrane Library were searched (1980 to March 2008). All trials and cohort studies with control groups that assessed weight loss interventions in this specific age group were included finally identifying 14 studies. Before and after comparison of behavioural/motivational interventions (-2.40 kg; 95% CI -5.4 to 0.6) and combination interventions (-2.96; 95% CI -4.4 to -1.5) consistently showed weight loss. Behavioural/motivational interventions increased self-efficacy, the desire to control weight, boosted self-esteem, and increased satisfaction with body areas and appearance. Interventions also showed improvements in HDL cholesterol, insulin, glucose and maximum oxygen uptake. However, recruitment to participation in interventions was a barrier for this age group with small sample sizes and short-term interventions. There may be gender differences in preference to participation in certain type of interventions. Further research to understand attitudes towards healthy lifestyle and preferences of interventions is needed to develop suitable interventions for this vulnerable age group.

Obesity as an independent risk factor for elective and emergency caesarean delivery in nulliparous women--systematic review and meta-analysis of cohort studies.

The objective of the study was to investigate the association between increasing maternal body mass index (BMI) and elective/emergency caesarean delivery rates. Systematic review and meta-analysis of published cohort studies were used. The bibliographic databases, MEDLINE, EMBASE, CINAHL, were searched systematically, with no language restrictions, from 1996 to May 2007. MeSH terms and key words for 'pregnancy', 'obesity', 'overweight,''body mass index' and 'caesarean section' were combined with the Cochrane Collaboration strategy for identifying primary studies. Finally, 11 papers were considered eligible for inclusion in the review. Although all the papers were cohort studies, only three were prospective in nature. Compared with women with normal BMI (20-25 kg m(-2)), the crude pooled odds ratios (95% confidence intervals) for caesarean section in overweight (BMI 25-30 kg m(-2)), obese (BMI 30-35 kg m(-2)) and morbidly obese (BMI > 35 kg m(-2)) women were 1.53 (1.48, 1.58), 2.26 (2.04, 2.51) and 3.38 (2.49, 4.57) respectively. The pooled odds of having an emergency caesarean section were 1.64 (95% confidence intervals 1.55, 1.73) in overweight and 2.23 (2.07, 2.42) in obese women. Caesarean delivery risk is increased by 50% in overweight women and is more than double for obese women compared with women with normal BMI.

Effects of treating postnatal depression on mother-infant interaction and child development: systematic review.

BACKGROUND: Postnatal depression has detrimental effects on the child's cognitive and emotional development. AIMS: To assess the benefits of treating postnatal depression for mother-infant interaction and child development. METHOD: A systematic search was made of 12 electronic bibliographic databases for randomised controlled trials and controlled clinical trials on treatment of mothers with postnatal depression, where outcomes were assessed in children; findings were assessed. RESULTS: Only eight trials met the inclusion criteria. Of those included, interventions varied widely but all involved therapies directed at the mother-infant relationship. One study with intensive and prolonged therapy showed cognitive improvement, whereas two others with briefer interventions improved maternal-infant relationships but did not affect the child's cognitive or behavioural development. All five studies assessing only mother-infant relationships showed improvements. CONCLUSIONS: Cognitive development in children of depressed mothers, along with better mother-infant relationships, might be improved with sustained interventions. Trials assessing treatments for postnatal depression would benefit from looking more closely at benefits for children as well as mothers, using validated objective measures.

Long-term weight loss effects on all cause mortality in overweight/obese populations.

This systematic review assesses the long-term effectiveness of weight loss on all cause mortality in overweight/obese people. Medline, Embase and Cinahl were searched (1966-2005). Cohort studies and trials on participants with body mass index > or =25 kg m(-2), with weight change and mortality with > or =2-year follow-up, were included finally identifying 11 papers based on eight studies. There may be gender differences in the benefits for all cause mortality. The impact of weight loss in men on mortality was not clear with some studies indicating weight loss to be detrimental, while a recent cohort study showed benefits, if it were a personal decision. Other studies with no gender separation had similarly mixed results. However, one study indicated that overweight/obese women with obesity-related illness, who lost weight intentionally within 1 year, had significantly reduced mortality rates of 19-25%. In contrast, studies of overweight/obese diabetics irrespective of gender showed significant benefit of intentional weight loss on mortality in a meta-analysis, hazard ratios = 0.75 (0.67-0.83). There is some evidence that intentional weight loss has long-term benefits on all cause mortality for women and more so for diabetics. Long-term effects especially for men are not clear and need further investigation.

Corticosteroids for treating nerve damage in leprosy.

BACKGROUND: Leprosy causes nerve damage which can result in nerve function impairment and disability. Corticosteroids are commonly used for treating nerve damage, although the long-term effect is uncertain. OBJECTIVES: To assess the effects of corticosteroids on nerve damage in leprosy. SEARCH STRATEGY: We searched the Cochrane Neuromuscular Disease Group Register, the Cochrane Central Register of Controlled Trials (Issue 4), MEDLINE (from 1966), EMBASE (from 1980), CINAHL (from 1980), LILACS (from 1982) in January 2006. We checked reference lists of the studies identified, the Current Controlled Trials Register (www.controlled-trials.com), conference proceedings and contacted trial authors. SELECTION CRITERIA: Randomised and quasi-randomised controlled trials of corticosteroids for nerve damage in leprosy. DATA COLLECTION AND ANALYSIS: The primary outcome was improvement in sensory and motor nerve function after one year. Secondary outcomes were improvement in nerve function after two years, change in nerve pain and tenderness, and adverse events. Two authors independently extracted data and assessed trial quality. We contacted trial authors for additional information. We collected adverse effects and cost effectiveness information from the trials and non-randomised studies. MAIN RESULTS: We included three randomised controlled trials involving 513 people. Two trials compared prednisolone with placebo. One trial treated mild sensory impairment of less than six months duration and the other trial treated nerve function impairment of 6 to 24 months duration. Both trials examined an effect twelve months from the start of treatment. There was no significant difference in nerve function improvement between people treated with prednisolone or with placebo. The third trial compared three corticosteroid regimens for severe type 1 reactions. This trial did not report the prespecified outcomes. However, after 12 months, a significantly higher proportion of individuals on a 3-month course of prednisolone required extra corticosteroids compared to the groups with a high-dose and low-dose regimen of five months duration. Diabetes and peptic or infected ulcer were sometimes reported as serious adverse events in the placebo-controlled trials, but not significantly more often in the corticosteroid than placebo groups. AUTHORS' CONCLUSIONS: Corticosteroids are used for treating acute nerve damage in leprosy, but evidence from randomised controlled trials does not show a significant long-term effect. Randomised controlled trials are needed to establish their effectiveness, the optimal regimens and to examine new therapies.

Multi-centre, double blind, randomized trial of three steroid regimens in the treatment of type-1 reactions in leprosy.

OBJECTIVE: The objective of this randomized trial was to compare three different steroid regimens in treating type 1 reactions in leprosy in routine clinical practice. DESIGN: The study design was a multicentre, double-blind, randomized, controlled, parallel group trial in patients with acute reversal reactions. The trial was conducted in six leprosy treatment centres in India. A total of 334 participants with acute type 1 reaction were recruited to the trial and randomized to one of three prednisolone regimens: high dose (60 mg per day) or low dose (30 mg per day) both tapered over 20 weeks, and short duration (60 mg per day tapered over 12 weeks). The main outcome measure was the proportion of patients failing to respond to treatment and requiring additional steroids. RESULTS: At the end of 12 months, 46% on the short course required additional steroids compared with 31% on the low dose and 24% on the high dose regimen. CONCLUSIONS: The two 20-week regimens were significantly better than the 12-week regimen. The high dose 20-week regimen was marginally and non-significantly better than the low dose regimen, but the high dose regimen contained 50% more steroid. Reactions in leprosy persist over many months and require long courses of steroids.

Promoting early detection in leprosy--a literature review to identify proven and potential interventions addressing patient-related delay.

OBJECTIVES: The objective of the literature review was to identify proven and potential interventions to promote early diagnosis and start of treatment in leprosy, specifically, forms of intervention addressing needs at the local or primary level. DESIGN: Using a structured search procedure, we identified recent leprosy-related publications describing proven interventions. To identify potential interventions the search was extended to publications assessing knowledge and attitudes towards leprosy and extended again to identify publications relating to patient-related delay in the context of other infectious diseases. RESULTS: The review identified just 19 publications reporting leprosy-related interventions that included a form of evaluation of which only 10 directly addressed patient-related delay. These included health education interventions focussed on people directly affected by leprosy, their family members and other key individuals or groups within the local community. We identified no reports of interventions focussed specifically on the needs of women. CONCLUSIONS: Our conclusion is that the evidence base available to inform the choice of small-scale interventions to promote early detection at the primary level is extremely limited. There is an urgent need to develop and extend the range of proven interventions, specifically those that address the needs of women, those that explore and develop the health promotion potential of people previously affected by,leprosy and those that exploit the potential of individuals with leadership roles within the community. This will require careful attention to planning, implementation, evaluation and reporting of interventions.

Factors contributing to delay in diagnosis and start of treatment of leprosy: analysis of help-seeking narratives in northern Bangladesh and in West Bengal, India.

The objective of our research was to identify factors contributing to delay in diagnosis and start of treatment in leprosy, focussing on patients' narratives of help-seeking behaviour. Our research took place in Purulia, West Bengal, India and in Nilphamari, northern Bangladesh. Between January and August 2000, we conducted semi-structured interviews with 104 patients that explored each individual's narrative of help-seeking behaviour and the context of beliefs and attitudes towards leprosy. Subsequently we surveyed 356 patients currently receiving treatment for leprosy and recorded specific aspects of each help-seeking action and their reports of local beliefs and attitudes towards leprosy. Delay was estimated from time of first symptoms through to start of effective treatment (mean 18 months, median 9 months in Purulia and mean 20 months, median 12 months in Nilphamari). The number of help-seeking actions ranged from 1 to 7. Time committed to first actions contributed 86% (Nilphamari) and 79% (Purulia) to total delay. The most important contributor to delay in the first action occurred when people simply monitored or ignored first symptoms, 80% in Nilphamari and 67% in Purulia. With delay longer than 12 months as outcome, logistic regression analyses identified age over 35 years, multiple visits to practitioners in traditional medicine and multiple visits to health service practitioners as predictive of delay. Attending a nearby clinic and exposure to health education materials were predictive of early presentation reduced delay.

Long-term follow-up of breast cancer survivors with post-mastectomy pain syndrome.

Post-mastectomy pain syndrome (PMPS) is a recognised complication of breast surgery although little is known about the long-term outcome of this chronic pain condition. In 1996, Smith et al identified a prevalence rate of PMPS of 43% among 408 women in the Grampian Region, Northeast Scotland. The aim of this study was to assess long-term outcome at 7-12 years postoperatively in this cohort of women, to describe the natural history of PMPS and impact of pain upon quality of life. Chronic pain and quality of life were assessed using the McGill Pain Questionnaire (MPQ) and Short Form-36 (SF-36). Of 175 women reporting PMPS in 1996, 138 were eligible for questionnaire follow-up in 2002. Mean time since surgery was 9 years (s.d. 1.8 years). A response rate of 82% (113 out of 138) was achieved; 59 out of 113 (52%) women reported continued PMPS and 54 out of 113 (48%) women reported their PMPS had resolved since the previous survey in 1996. Quality of life scores were significantly lower in women with persistent PMPS compared to those women whose pain had resolved. However, for women with persistent PMPS, SF-36 scores had improved over time. Risk factors for persistent PMPS included younger age and heavier weight. This study found that, of women reporting PMPS in 1996, half of those surveyed in 2002 continued to experience PMPS at a mean of 9 years after surgery.