Prostate cancer in men aged less than 50 years at diagnosis.

PURPOSE: Prostate cancer (CaP) in younger men (age ≤50 years) appears to present differently compared with older men. This study describes CaP characteristics and outcomes in Australian young men. METHODS: The South Australian Prostate Cancer Clinical Outcomes Collaborative database was used to identify men diagnosed with CaP 1998-2012. Men were stratified by age at diagnosis into groups ≤50, 50-70 and ≥70 years. Primary outcomes of cumulative biochemical recurrence (BCR) and cumulative prostate cancer-specific mortality (PCSM) were assessed at 5 and 10 years. RESULTS: In total, 7018 men were included. At time of diagnosis, 182 (2.6 %) were aged ≤50 years. Median follow-up exceeded 4 years. Younger men had a greater proportion of T stage <2 disease, lower median PSA and higher rates of Gleason score <7 (all p < 0.001). They were more likely to experience active surveillance (AS) (4.9, 3.1, 1.5 %) or radical prostatectomy (RP) (70, 55, 8 %) and less likely radiotherapy (13, 24, 29 %) as their principal modality (all p < 0.001). Although only 4.9 % underwent AS, 48 % of men ≤50 years were eligible for AS. Men ≤50 years had both the lowest unadjusted cumulative BCR and PCSM at 10 years. After multivariate analysis, BCR was not significantly different. Sample size limited multivariate analysis of PCSM. CONCLUSIONS: In our cohort, men ≤50 years with CaP had less aggressive clinical characteristics, but were more likely to undergo RP. They appear to experience lower unadjusted PCSM, but similar rates of adjusted BCR. Further studies are needed to assess whether AS is appropriately utilised in these men.

E-learning vs lecture: which is the best approach to surgical teaching?

AIM: Most medical teaching is still delivered by traditional face-to-face interaction. E-learning has the potential benefit of instilling deeper learning of topics by virtue of repeated and convenient access to content presented in a range of media. We aimed to evaluate objectively the benefit of educating medical students on a common surgical topic (haemorrhoids), through a website and podcast package vs a traditional lecture. METHOD: Baseline knowledge was established by a questionnaire given to two different groups of third-year medical students starting their first clinical attachment. Group A (n = 73) was given a lecture and group B (n = 75) was asked to use a website containing text and pictures augmented by a podcast. Students were reassessed using the same preintervention questionnaire, and satisfaction was acquired from details given in a feedback form. RESULTS: There was no difference in knowledge between the two groups at baseline. Both groups demonstrated significant gains in knowledge after intervention (P < 0.0001). Group B (Web/podcast) showed a significantly greater increase in knowledge (P < 0.05) than group A (lecture). Preintervention subjective assessment of knowledge rated by the students showed no difference between the groups. Both groups of students were equally satisfied with the educational method. CONCLUSION: E-learning supplemented with a podcast results in greater knowledge acquisition when compared with a traditional lecture, without a loss of satisfaction with teaching. Using augmented Web-based educational tools reduces demands on teaching time with no decrease in quality for selected parts of the curriculum.

Overcoming high-field RF problems with non-magnetic Cartesian feedback transceivers.

In extending human MR to field strengths approaching 10 T, the wavelength of electromagnetic radiation at the proton Larmor frequency becomes less than human body size and conventional radio-frequency coil circumference. Consequently, radio-frequency magnetic fields are better generated by an array of small coils than by one large coil. In this article, the primary problem of array coil interactions during transmission is examined, and a standard proposed whereby secondary induced currents should be less than 1% of the primary coil current. The use of cancellation methods and of power amplifiers with high output impedance to reduce interactions is examined in the light of this standard and found wanting. Non-magnetic Cartesian feedback transceivers functioning at the magnet entrance are then proposed as a solution that both reduces instrumentation cost and increases the bandwidth over which the standard may be met. The compromises inherent in instrument design are detailed and examples given of the innovative circuitry used. It is shown experimentally that when connected to interacting coils, two Cartesian feedback instruments function stably in accord with theory and such that the proposed standard is typically attained over a bandwidth of 22 kHz during transmission (much greater during signal reception)-enough for all current MR protocols.

Attention deficit hyperactivity disorder: legal and ethical aspects.

Attention deficit-hyperactivity disorder (ADHD) remains a controversial disorder, despite it now being a well validated clinical diagnosis. Ethical and legal issues are important in determining how doctors should behave in offering a diagnosis or treatment that may generate strong and unpredictable reactions from children, their families, or other agencies. A model for routine ethical practice was proposed, based on three sets of assumptions. Firstly, that ethical practice is consistent with the four principles of beneficence, non-maleficence, justice, and respect for autonomy. Secondly, ethical concerns lead to legal processes, whose task is to ensure ethical practice. Thirdly, that we are working in the interests of our patients. Current relevant literature was organised in terms of this model, and recommendations for practice derived from it. Though there is no general ethical problem regarding either the routine diagnosis or treatment of ADHD, ethical difficulties surround some special cases, especially when doctors are working in conjunction with other agencies or coping with non-medical frameworks. Particular care needs to be taken with confidentiality and consent, the limits of which are currently confused. The model worked well with everyday ethical problems, though more difficult cases required careful individual scrutiny.

The association between hyperkinesis and breakdown of parenting in clinic populations.

BACKGROUND: There is increasing recognition that child based, as well as parent based factors may be associated with children being excluded from their families. Despite the distress routinely observed among the parents of hyperactive children, there is little research on this in clinic populations. AIMS: To examine removals from home in a typical secondary care population, where hyperkinesis was accurately diagnosed. METHODS: A total of 201 cases were coded using mulitaxial ICD-10 criteria and Jarman indices derived from census data. RESULTS: Hyperkinetic children were more than three times more likely to have suffered removal from home than children with other psychiatric diagnoses, independent of any psychosocial measure. CONCLUSION: Hyperkinesis is a specific risk factor for removal from home, which can operate in the absence of other psychosocial stressors. Screening children for hyperactivity is now simple, and the routine paediatric examination for children accommodated by the local authority gives an opportunity for early detection and treatment of hyperactivity in children at risk of family breakdown.

Postnatal blues: a risk factor for postnatal depression.

Postnatal blues have been regarded as brief, benign and without clinical significance. However, several studies have proposed a link between blues and subsequent depression but have methodological problems. We report a prospective, controlled study of postpartum women with severe blues which uses systematically devised and validated instruments for that purpose which tests the hypothesis that severe blues increases the risk of depression in the six months following childbirth. 206 first-time mothers were recruited in late pregnancy. Blues status was defined using the Blues Questionnaire and those with severe blues and their controls who had no blues (matched for age, marital status and social class) were followed for 6 months with postal Edinburgh Postnatal Depression Scale. RDC diagnoses were made following SADS-L interview at the end of the protocol. Backwards stepwise Cox regression analysis found severe blues and past history of depression to be independent predictors each raising the risk by almost 3 times. Depression in those with severe blues onset sooner after delivery and lasted longer. The difference was largely accounted for by major depression. Severe postpartum blues are identified as an independent risk factor for subsequent postpartum depression. Screening and intervention programs could be devised.

How should we measure social disadvantage in clinic settings?

BACKGROUND: Despite a large research literature supporting their validity, deprivation indices derived from census data have not been routinely applied to clinic populations. METHOD: A case-note sample of 201 cases was examined, to identify whether such data (Jarman indices) predicted presenting disability separately from diagnostic class (behaviour, emotional, mixed, other, and no diagnosable disorder), or conventional clinic measures of social adversity (ICD-10 psychosocial diagnostic codes). RESULTS: Jarman index scores predicted disability in behaviour disorders or other disorders. Conventional clinic measures of adversity predicted disability in mixed disorders. For emotional disorders, and those cases with no diagnosed disorder, clinically measured adversity and Jarman scores interacted. CONCLUSIONS: Postcode related census data capture information about clinic children's presenting disability that is not available from routine clinic assessment of psychosocial adversity. It should therefore be collected as part of the routine clinical child psychiatry assessment.

Outcome of pseudoseizures in children and adolescents: a 6-year symptom survival analysis.

Outcome was studied of all children and adolescents with pseudoseizures without epilepsy, who were referred and treated as in-patients and/or day patients in the tertiary psychiatric ward at Birmingham Children's Hospital, UK between 1988 and 1994. Information was derived from case-note data. Freedom from seizures for six months was defined as 'cure', as no recurrences after this period were noted. Kaplan-Meier survival analysis was used. Seventeen patients were identified: 15 females and two males; mean age at presentation to the tertiary psychiatric service was 12 years 9 months (SD 26 months; range 8 years 3 months to 15 years 9 months). Fourteen participants recovered and resumed regular school attendance. Three were lost to follow-up due to being referred on to other agencies before recovery because they became too old for the service. Recovery followed an exponential distribution, with a mean symptom survival time following treatment of 1.5 years. These results are consistent with a treatment effect. Younger age at presentation, female sex, having more types of seizures, and not receiving both in-patient and outpatient treatment were associated with better outcome. The deteriorating prognosis with age at treatment suggests prompt identification may be important in ensuring a good outcome.

Is clinic prevalence of ICD-10 hyperkinesis underestimated? Impact of increasing awareness by a questionnaire screen in an UK clinic.

Hyperactivity is common, but its diagnosis is still controversial, with two contending approaches: ADHD from DSM IV and hyperkinesis from ICD-10. The concept of ADHD predicts higher rates, but its use may lead to overmedication. Hyperkinesis usefully indicates medication, but clinics using it may detect many fewer cases, raising the possibility of underdiagnosis. It has never been shown whether this lower rate results from hyperkinesis' criteria, or to the differing methods used to detect hyperactivity in those centres that prefer it. We report a mirror study, examining rates of all types of hyperkinesis before and after the introduction of a preliminary screen (not originally intended to detect hyperkinesis). Its introduction resulted in an increase of detected hyperkinesis from 2% to 25% of the clinic sample with no change in diagnostic criteria. This was independent of any other change in the sample or clinic staff. We conclude that insensitive assessment may be responsible for low rates of diagnosis of ICD-10 hyperkinesis in secondary care clinics.

Psychopathology in paintings: a meta-analysis of studies using paintings by psychiatric patients.

We classified 242 reliable scales from 12 art-based studies of psychiatric patients into 14 qualitative categories and also by three types of decision: form, objective or subjective content. We used meta-analytic techniques to combine and compare different results from studies testing the asssociation of art characteristics with psychopathology. Distinctions between controls and patients were more apparent than those between diagnoses. The largest effects distinguished patients and controls on categories of content, body details, energy and media control. Diagnostic groups were differentiated on energy and complexity. There were other less distinct differences for both types of comparison. There were serious criticisms of the quality of the literature, and a lack of information on validity and reliability, but this study suggests that art characteristics do relate to psychopathology.

Infant psychiatry--its scope, coherence and clinical utility.

BACKGROUND: Infant psychiatry claims to be a separate discipline within psychiatry. This article sets out to test that claim. Goals were to establish whether the field had meaningful boundaries; whether its practice related to a coherent body of research; and whether its assessments and syndromes had clinical utility. METHODS: A descriptive, conceptually based review of the literature was undertaken. Established opinion was taken from authoritative textbooks and reviews, and compared with other articles from both keyword and citation-based literature searches. RESULTS: Infant psychiatry is defined by three components. It focuses on children young enough to be socially absorbed primarily in the relationship with their main caretaker. It privileges these relationships, attempting to predicate psychopathology and treatment upon them. It then applies this basis to specific syndromes, their assessment and treatment. This approach has been conceptually and practically effective. Limitations include inadequate distinctions between the normal range of individual differences and psychopathology, and poor integration of constitutional hypotheses about infant difficulties. CONCLUSIONS: Infant psychiatry can support its claim to be a separate discipline, with an approach that is both distinctive and useful. Further advances in the field would benefit from collaborative research that would expand its interactionist perspective, and link differences to psychopathology.

The Descriptive Assessment for Psychiatric Art (DAPA): update and further research.

Painting and drawing is used as a treatment modality in psychiatry; however, assessments presently lack valid and reliable measures. We used the DAPA, a published quantitative measure of adult psychiatric artwork on a sample of painting produced in naturalistic conditions by 86 inpatients with four major categories of disabling psychiatric disorders and 23 controls. The replication was successful. Clear broad differences between psychiatric patients and controls and discrete differences in patient type can be differentiated when the conditions under which the patients produce their work are not controlled.

Expression of a single pair of desmosomal glycoproteins renders the corneal epithelium unique amongst stratified epithelia.

PURPOSE: To determine desmosomal glycoprotein isoform expression in bovine corneal, limbal, and conjunctival epithelium and desmosomal profile and distribution during corneal re-epithelialization. METHODS: Immunofluorescence (IF) for desmosomal components on cryostat sections of fresh epithelia was supported by immunoblot analysis of tissue lysates. Wounded corneas maintained in organ culture were examined by IF at times up to full re-epithelialization (96 hours). RESULT: Immunofluorescence for desmoplakin confirmed desmosome presence throughout all three epithelia. Plakoglobin was also ubiquitous. Of the desmosomal glycoproteins, desmocollin 2 (Dsc2) and desmoglein 2 (Dsg2) were expressed throughout, but Dsc3 and Dsg3 were confined to the limbus and conjunctiva, and Dscl and Dsgl were absent. Dsc2 and Dsg2 IFs were stronger in superficial layers, but Dsc3 and Dsg3 were stronger basally, fading suprabasally. Glycoprotein expression in cornea and conjunctiva was confirmed by immunoblot analysis. No change in glycoprotein expression occurred during re-epithelialization. CONCLUSIONS: Uniquely among stratified epithelia, cornea expresses only a single pair of desmosomal glycoproteins, Dsc2 and Dsg2. Expression of Dsc3 and Dsg3 in limbus and conjunctiva coincides with their association with cell proliferation in other epithelia, but corneal epithelial cells did not express Dsc3 or Dsg3 during re-epithelialization. Absence of Dscl and Dsgl correlates with lack of keratinization in ocular epithelia. These expression patterns may have significance for the specific properties and differentiation patterns of the epithelia. Presence of desmosomes throughout re-epithelialization raises the question of how migrating cells mutually re-position.

Have the Cross-Informant Syndromes of the CBCL any practical value in identifying grouped ICD10 diagnoses?

120 children referred to a child and adolescent psychiatric service in a university clinic were studied with the aim of deriving predictors for grouped ICD10 diagnoses using the CBCL Cross-Informant-Syndromes (CISs). CIS7 (Delinquent Behaviour) and CIS8 (Aggressive Behaviour) were shown to significantly separate Disruptive Behaviour Disorders from all other disorders. As cross-validation, a separate clinical sample of 118 children from a similar service in another part of the country was used to see to what extent the CIS predictors from the first sample held up in the second sample. Positive and Negative Predictive Powers, all corrected for chance, confirmed that the Disruptive Behaviour Disorder group could be usefully separated from all other disorders using the Delinquent Behaviour and the Aggressive Behaviour Cross-Informant Syndrome scores. There was no good evidence that Emotional (Anxiety-Mood) Disturbance could be usefully separated in the same way using the Anxious-Depressed Syndrome (CIS3) or any other syndrome. Discriminant Function Analysis showed that there was no significant improvement in prediction when more elaborate linear combinations of the syndromes were used.

Timing transantarctic disjunctions in the Atherospermataceae (Laurales): evidence from coding and noncoding chloroplast sequences.

Previous studies of the small Southern Hemisphere family Atherospermataceae have drawn contradictory conclusions regarding the number of transantarctic disjunctions and role of transoceanic dispersal in its evolution. Clarification of intergeneric relationships is critical to resolving (1) whether the two Chilean species, Laurelia sempervirens and Laureliopsis philippiana, are related to different Austral-Pacific species, implying two transantarctic disjunctions as suggested by morphology; (2) where the group is likely to have originated; and (3) whether observed disjunctions reflect the breakup of Gondwana. We analyzed chloroplast DNA sequences from six regions (the rbcL gene, the rpl16 intron, and the trnL-trnF, trnT-trnL, psbA-trnH, and atpB-rbcL spacer regions; for all six regions, 4,372 bp) for all genera and most species of Atherospermataceae, using parsimony and maximum likelihood (ML). The family's sister group, the Chilean endemic Gomortega nitida (Gomortegaceae), was used to root the tree. Parsimony and ML yielded identical single best trees that contain three well-supported clades (> or = 75% bootstrap): Daphnandra and Doryphora from south-eastern Australia; Atherosperma and Nemuaron from Australia-Tasmania and New Caledonia, respectively; and Laurelia novac-zelandiac and Laureliopsis philippiana from New Zealand and Chile, respectively. The second Chilean species, Laurelia sempervirens, is sister to this last clade. Likelihood ratio testing did not reject the molecular clock assumption for the rbcL data, which can therefore be used for divergence time estimates. The atherosperm fossil record, which goes back to the Upper Cretaceous, includes pollen, wood, and leaf fossils from Europe, Africa, South America, Antarctica, New Zealand, and Tasmania. Calibration of rbcL substitution rates with the fossils suggests an initial diversification of the family at 100-140 million years ago (MYA), probably in West Gondwana, early entry into Antarctica, and long-distance dispersal to New Zealand and New Caledonia at 50-30 MYA by the ancestors of L. novae-zelandiae and Nemuaron.

Crystallographic characteristics of plasma-sprayed calcium phosphate coatings on Ti-6Al-4V.

The purpose of this study was to investigate the crystallographic characteristics of 3 sets of plasma-sprayed hydroxyapatite (HA) coatings prepared with different degrees of crystallinity on Ti-6Al-4V substrates. X-ray diffraction analyses were performed on the coatings to determine mean percent crystallinity, calcium phosphate phases present, average crystallite size, and residual strain. The mean percent crystallinity for the 3 sets of coatings ranged from 49 to 60%. The coatings that achieved the highest crystallinity consisted almost entirely of HA. As the coating crystallinity decreased, increasing amounts of alpha- and beta-tricalcium phosphate and tetracalcium phosphate were detected. The mean HA crystallite size for the 3 sets of coatings ranged from 0.02 to 0.05 micron. Differences in mean interplanar spacing for selected crystallographic planes of HA, compared with the pure ICDD (International Center for Diffraction Data) powder standards, implied that the coatings were in an uneven state of tensile strain.

Immunolocalisation of the VEGF receptors FLT-1, KDR, and FLT-4 in diabetic retinopathy.

AIM: To determine the spatial and temporal changes in the staining pattern of the VEGF receptors FLT-1, KDR, and the putative receptor FLT-4 during the pathogenesis of diabetic retinopathy. METHODS: Immunohistochemical localisation of VEGF receptors, using antibodies against FLT-1, FLT-4, and KDR, was carried out on specimens of normal human retina (n = 10), diabetic retinas (a) with no overt retinopathy (n = 12), (b) with intraretinal vascular abnormalities but no proliferative retinopathy (n = 5), (c) with active proliferative retinopathy (n = 6), and (d) with no residual proliferative retinopathy after scatter photocoagulation therapy (n = 14), and surgically excised diabetic fibrovascular membranes (n = 11). The degree and pattern of immunostaining was recorded. RESULTS: FLT-1 staining was apparent in the retinas from both non-diabetic and diabetic retinas; weak to moderate staining was generally confined to the inner nuclear layer, the ganglion cell layer, and the retinal vessels during all stages of the disease process. Staining of the retinal vessels was raised in diabetic tissue compared with non-diabetic tissue. The preretinal vessels of the diabetic subjects stained moderately to intensely for FLT-1. In contrast with FLT-1 staining minimal immunostaining for KDR was demonstrated in the non-diabetic eyes and the unlasered eyes; however, weak staining for KDR was observed in the inner nuclear layer and the ganglion cell layer of the unlasered eyes with diabetic changes. In those retinas with preretinal neovascularisation KDR immunoreactivity was moderate to intense in the intra- and preretinal vessels. However, in the excised membranes, where the vessels may have been in a quiescent state, the levels of KDR were weak to moderate. After apparently successful laser treatment KDR staining was reduced in the intraretinal vessels. Minimal FLT-4 staining was observed throughout normal eyes while weak to moderate FLT-4 staining was generally confined to the inner nuclear layer and the ganglion cell layer of the unlasered diabetic eyes. Weak to moderate levels of FLT-4 staining were observed in the intraretinal vessels except after apparently successful laser treatment where reduced levels of staining were observed. Weak to moderate staining was observed in the preretinal vessels. CONCLUSIONS: This study supports a role for FLT-1, KDR, and possibly FLT-4 in the pathogenesis of diabetic retinopathy; however, their specific roles in the progression of the disease may differ.

The family rule: a framework for obtaining ethical consent for medical interventions from children.

Children's consent to treatment remains a contentious topic, with confusing legal precepts and advice. This paper proposes that informed consent in children should be regarded as shared between children and their families, the balance being determined by implicit, developmentally based negotiations between child and parent--a "family rule" for consent. Consistent, operationalized procedures for ethically obtaining consent can be derived from its application to both routine and contentious situations. Therefore, use of the "family Rule" concept can consistently define negligent procedure in obtaining consent from children, and could be used as a unifying framework in the development of new professional guidelines. A "guideline"-based approach to children's consent to treatment may offer greater individuality than a "rights"-based approach, though careful training and oversight will be needed for it to be effective.