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

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

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

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

"Choice" and place of delivery: a qualitative study of women in remote and rural Scotland.

OBJECTIVE: To explore women's perceptions of "choice" of place of delivery in remote and rural areas where different models of maternity services are available. SETTING AND METHODS: Remote and rural areas of the North of Scotland. A qualitative study design involved focus groups with women who had recent experience of maternity services. RESULTS: Women had varying experiences and perceptions of choice regarding place of delivery. Most women had, or perceived they had, no choice, though some felt they had a genuine choice. When comparing different places of birth, women based their decisions primarily on their perceptions of safety. Consultant-led care was associated with covering every eventuality, while midwife-led care was associated with greater quality in terms of psycho-social support. Women engaged differently in the choice process, ranging from "acceptors" to "active choosers." The presentation of choice by health professionals, pregnancy complications, geographical accessibility and the implications of alternative places of delivery in terms of demands on social networks were also influential in "choice." CONCLUSIONS: Provision of different models of maternity services may not be sufficient to convince women they have "choice." The paper raises fundamental questions about the meaning of "choice" within current policy developments and calls for a more critical approach to the use of choice as a service development and analytical concept.

Nurse specialist led flexible sigmoidoscopy in an outpatient setting.

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

Effect of intravenous vasopressor on spread of spinal anaesthesia and fetal acid-base equilibrium.

BACKGROUND: We previously found rostral spread of spinal plain levobupivacaine to be less with prophylactic i.v. phenylephrine than with ephedrine during Caesarean delivery. This study investigated whether rostral spread of spinal hyperbaric bupivacaine is also less with phenylephrine than with ephedrine. METHODS: The study was randomized and double blind. It compared phenylephrine 100 microg ml-1 (phenylephrine group, n=27), and ephedrine 4.5 mg ml-1 (ephedrine group, n=27), given by infusion during spinal anaesthesia for Caesarean delivery. Block height was assessed to cold and light touch sensation at 15, 30, 60, and 90-min after the spinal injection of 2.8 ml of hyperbaric 0.5% w/v bupivacaine, combined with 0.4 ml diamorphine (1 mg ml-1). Umbilical blood gas values were monitored during the study. RESULTS: Block height was similar for both groups at all of the assessment times. Umbilical artery pH was higher with phenylephrine [median 7.32 (IQR 7.28-7.34)] than with ephedrine [7.20 (7.10-7.28)] (P<0.0001). There was a strong negative correlation between umbilical artery pH and spinal-delivery interval, but only with ephedrine: phenylephrine group, r2=0.09 (P=0.17), and ephedrine group, r2=0.53 (P<0.0001). Five-minute Apgar scores were higher with phenylephrine [10 (9-10)] than ephedrine [9 (9-9)] (P=0.009). CONCLUSIONS: In contrast to its effect on spinal plain levobupivacaine, we did not find rostral spread of spinal hyperbaric bupivacaine to be less with prophylactic phenylephrine than with ephedrine. We observed an unexpectedly high incidence of fetal acidosis with ephedrine and found evidence that longer spinal-delivery intervals increase the risk of fetal acidosis developing with ephedrine, but not phenylephrine.

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

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

Removal of metals from aqueous solutions using natural chitinous materials.

Four naturally derived chitinous materials, commercial cryogenically milled carapace (CCMC), mechanically milled carapace (MMC), chitin and chitosan, were assessed for their ability to remove a range of alkali, alkaline earth, transition and heavy metals from aqueous media in flow-through column trials: The materials showed a poor affinity for the alkali metals and alkaline earth metals but significantly greater affinity for transition and heavy metals. In general, chitin was the least efficient material for removal of transition and heavy metals (approximately 35%) while chitosan was most effective (> 99%). CCMC and MMC both removed > 90% of transition and heavy metals tested from solution. Batch studies conducted using copper as a reference metal demonstrated that removal was dependent on a number of variables including pH, contact time, particle size, metal concentration, metal type and the physio-chemical characteristics of the materials. Detailed analysis of the results from these studies indicate that removal is a complex process and that metals can be sequestered from solution by a number of mechanisms including adsorption, absorption and precipitation.

Slow transit constipation in children.

Patients with chronic constipation that fails to respond to treatment remain a challenge for paediatricians and surgeons. Ongoing work in our institution suggests that a number of children with intractable symptoms have slow transit constipation, which has only been described recently in paediatrics. Common features of slow transit are: delayed passage of the first meconium stool beyond 24 h of age, symptoms of severe constipation within a year, or treatment-resistant 'encopresis' at 2-3 years, soft stools despite infrequent bowel actions, and delay in colonic transit on a transit study. A proportion of children with slow transit constipation have an abnormality of intestinal innervation associated with the dysfunctional colonic motility, recognized as intestinal neuronal dysplasia (IND). Intestinal neuronal dysplasia type B, the most common variant of IND, is defined on rectal biopsy by hyperplasia of the submucosal plexus. On laparoscopic colon muscle biopsy, many specimens show reduced numbers of excitatory substance P-immunoreactive nerve fibres in the circular muscle. Functional markers of the nerves allow new diagnostic criteria to be developed which may also allow a more rational approach to treatment. The aetiology remains obscure and the optimal management poorly defined, although subtotal colectomy, proximal colostomy or appendicostomy (for antegrade enemas) have been tried. Once the anatomy and physiology of the colon in children with slow colonic transit is better understood, we will have defined not only a new form of constipation, but also will be able to consider new therapies.

A technique for the determination of trimethylamine-N-oxide in natural waters and biological media.

Trimethylamine-N-oxide (TMAO) is a nitrogenous osmolyte widely distributed in marine organisms. The reduction of TMAO to TMA has long been implicated as characteristic reaction associated with fish and seafood spoilage. However, it is now apparent that, in the marine environment, TMAO can act as precursor to a range of reduced nitrogenous biogases that can play a significant role in the biogeochemical cycle of nitrogen and in the regulation of atmospheric pH. Although methods exist for the analysis of TMAO in some biological samples, they lack the sensitivity required for measurement of TMAO in natural waters. Here we present a new, safe and sensitive method for the determination of TMAO in aqueous and biological media, where TMAO is enzymatically reduced to TMA and subsequently quantified using Flow Injection Gas Diffusion-Ion Chromatography (Gibb et al. J. Autom. Chem. 1995, 17 (6), 205-212). The limit of detection was calculated to be 1.35 nmol dm-3 TMAO, and the response was linear for both fresh and seawater (R2 = 0.996 and 0.993, respectively). Precision (RSD) for standards in the range 40-600 nmol dm-3 was within 3%. The specificity and competitive inhibition of the enzyme are addressed and the applicability of the technique demonstrated through analysis of a number of natural water and biological samples.

Molecular evidence of cryptic speciation in planktonic foraminifers and their relation to oceanic provinces.

The fossil record of planktonic foraminifers is a key source of data on the biodiversity and evolution of marine plankton. One of the most distinctive foraminiferal taxa, Orbulina universa, widely used as a stratigraphic and paleoclimatic index, has always been regarded as a single species. Here we present a phylogenetic analysis of Orbulina small subunit rDNA sequences from 25 pelagic stations covering 100 degrees latitude in the Atlantic Ocean. The genetic data reveal the presence of three cryptic species, whose distribution is clearly correlated to hydrographic provinces, and particularly to sea-surface total chlorophyll a concentration. Our results, together with previous studies, suggest that a considerable part of the diversity among planktonic foraminifers has been overlooked in morphological taxonomies. Our data also support the idea that planktonic foraminifers, even if adapted to particular hydrographic conditions, are high-dispersal organisms whose speciation may be similar to that of other high-dispersal taxa in which reproductive mechanisms and behavior, rather than just geographic barriers to dispersal, play key roles in species formation and maintenance.

Assessing strength of preference for abortion method using 'willingness to pay': a useful research technique for measuring values.

Policy makers and practitioners need to differentiate between patient preferences which are strongly held, and those which are not. This study measured not only women's preferences for medical abortion versus surgical vacuum aspiration, but also the strength of these preferences, using a 'willingness to pay' (WTP) technique. Fifty women were recruited and interviewed prior to and following termination of early pregnancy. Due to the sensitivity of the situation, the WTP approach was administered by interview. Results revealed that 34 (64%) preferred to have the medical method. The amounts offered for each method were similar; however, a minority gave higher values for the medical method, thus for those women their strength of preference for that method was more intense. Validity of the technique was supported by the finding of a positive association with social class and the importance women attached to having choice. It is argued that WTP is an acceptable method for the elicitation of strength of treatment preferences. Its further use by nurses and midwives to assess health care preferences should be explored, particularly when considering aspects of care which are traditionally difficult to identify and measure.

Protectionism or competition in managing British nursing research? Current debate among nurse and midwifery teachers.

AIM: The intention is to highlight key issues related to research by nurse and midwifery teachers. BACKGROUND: The debate centres on the 'culture change' facing teachers from traditional colleges moving to universities where a more formal research requirement prevails. ORIGINS OF INFORMATION: Data were drawn from selected official reports and other literature informing the introductory discussion. Emerging themes were discussed by 25 nurse and midwife teachers at Forresterhill College, Aberdeen in March 1996 and their views were recorded and analysed. DATA ANALYSIS: Selected documents and discussion records were reviewed, using a thematic approach. KEY ISSUES: Main themes concerned nursing as art and science, balance between multidisciplinary and unidisciplinary research and ring-fencing nursing research funds. CONCLUSIONS: Anxieties among teachers centred on the increased research requirement in universities with possible neglect of teaching excellence.

Esophageal achalasia and adenocarcinoma in Barrett's esophagus: a report of two cases and a review of the literature.

Two cases of a rare combination of conditions, achalasia and adenocarcinoma in Barrett's esophagus are reported. Cancer developed 26 years after the onset of gastroesophageal reflux in one and 30 years after esophagomyotomy in the other. Twenty-one cases of Barrett's esophagus and achalasia have now been reported; adenocarcinoma developed in six patients. Only one has survived more than five years after treatment. Long-term surveillance of patients with achalasia is recommended.

Current status of cricopharyngeal myotomy for cervical esophageal dysphagia.

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

Reoperation after failed antireflex surgery. Review of 101 cases.

Between January 1970 and July 1994, 101 patients underwent reoperation for a failed antireflux procedure. These patients had previously had 160 upper gastrointestinal tract operations, usually a Nissen fundoplication or one of its modifications (87). The chief reason for failure of the original antireflux procedure was faulty surgical technique (65). An incorrect diagnosis accounted for most of the remaining failure (22). Of patients who had follow-up studies, 80% were improved by reoperation, which consisted of takedown or refashioning of the original wrap in the majority of patients (63). A more radical approach is justified after two failed reoperations. Our current preference is for vagotomy, antrectomy, and Roux-en-Y diversion coupled, when indicated, with resection of the esophagogastric junctional area.

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

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

Automation of flow injection gas diffusion-ion chromatography for the nanomolar determination of methylamines and ammonia in seawater and atmospheric samples.

The automation and improved design and performance of Flow Injection Gas Diffusion-Ion Chromatography (FIGD-IC), a novel technique for the simultaneous analysis of trace ammonia (NH(3)) and methylamines (MAs) in aqueous media, is presented. Automated Flow Injection Gas Diffusion (FIGD) promotes the selective transmembrane diffusion of MAs and NH(3) from aqueous sample under strongly alkaline (pH > 12, NaOH), chelated (EDTA) conditions into a recycled acidic acceptor stream. The acceptor is then injected onto an ion chromatograph where NH(3) and the MAs are fully resolved as their cations and detected conductimetrically. A versatile PC interfaced control unit and data capture unit (DCU) are employed in series to direct the selonoid valve switching sequence, IC operation and collection of data. Automation, together with other modifications improved both linearily (R(2) > 0.99 MAs 0-100 nM, NH(3) 0-1000 nM) and precision (<8%) of FIGD-IC at nanomolar concentrations, compared with the manual procedure. The system was successfully applied to the determination of MAs and NH(3) in seawater and in trapped particulate and gaseous atmospheric samples during an oceanographic research cruise.

Vagotomy, antrectomy, and Roux-en-Y diversion for complex reoperative gastroesophageal reflux disease.

OBJECTIVE: Failure of conventional surgical therapy for treatment of patients with gastroesophageal reflux disease (GERD) taxes the ingenuity of the esophageal surgeon. This study defines the role of vagotomy, antrectomy, and Roux-en-Y diversion coupled, when necessary, with resection of the esophagogastric junction as an alternative to other surgical procedures currently employed for these complicated cases. SUMMARY BACKGROUND DATA: Currently, the operation in question rarely is performed in the United States. Other procedures, such as interposition of short or long segments of intestine and total esophagectomy with gastric pull-up, are preferred. However, surgeons from Scandinavia, Great Britain, and Europe have published widely on the subject, some even preferring its use as a primary procedure in GERD. METHODS: This report reviews the indications and results of the operation in 36 patients who underwent operation between January 1970 and January 1994. Follow-up evaluation was available for review in 33 patients observed from 1 to 20 years postoperatively (average, 6 2/3 years). Of these patients, 32 had undergone 66 previous operative procedures on the distal esophagus and stomach ranging from 1 to 6 per patient. There were no hospital deaths, but complications developed in nine patients (25%); only half of these complications were major. Of patients available for follow-up, 85% were improved by the operation, 24 of the 33 having excellent or good results. CONCLUSIONS: The operation of vagotomy, antrectomy, and Roux-en-Y diversion, embodying the principles of acid suppression and alkaline diversion, has proved to be a successful alternative to other operative procedures currently favored in the United States for the treatment of the complex reoperative patient with GERD.