Toxic inhalation of sodium metabisulphite by-products from a shipping container.

Logistics workers who handle cargo containers are at risk of toxic inhalation injuries, although prevalence and severities of these injuries are not well characterized. We report on a previously healthy 37-year-old supervisor who was acutely exposed to sodium metabisulphite and its thermal degradation by-products during a routine inspection of a shipping container. The employee developed chemical pneumonitis with acute non-cardiogenic pulmonary oedema and subsequent severe reactive airway dysfunction syndrome.

A pragmatic triage system to reduce length of stay in medical emergency admission: feasibility study and health economic analysis.

BACKGROUND: Departments of Internal Medicine tend to treat patients on a first come first served basis. The effects of using triage systems are not known. METHODS: We studied a cohort in an Acute Medical Unit (AMU). A computer-assisted triage system using acute physiology, pre-existing illness and mobility identified five distinct risk categories. Management of the category of very low risk patients was streamlined by a dedicated Navigator. Main outcome parameters were length of hospital stay (LOS) and overall costs. Results were adjusted for the degree of frailty as measured by the Clinical Frailty Scale (CFS). A six month baseline phase and intervention phase were compared. RESULTS: 6764 patients were included: 3084 in the baseline and 3680 in the intervention phase. Patients with very low risk of death accounted for 40% of the cohort. The LOS of the 1489 patients with very low risk of death in the intervention group was reduced by a mean of 1.85days if compared with the 1276 patients with very low risk in the baseline cohort. This was true even after adjustment for frailty. Over the six month period the cost of care was reduced by £250,158 in very low patients with no increase in readmissions or 30day mortality. CONCLUSIONS: Implementation of an advanced triage system had a measurable impact on cost of care for patients with very low risk of death. Patients were safely discharged earlier to their own home and the intervention was cost-effective.

Glandular neoplasia and borderline endocervical reporting rates before and after conversion to the SurePath(TM) liquid-based cytology (LBC) system.

Reporting rates for glandular neoplasia in 464,754 cervical samples reported at six laboratories in 12-month periods before and after the implementation of Surepath™ LBC processing are compared. The introduction of LBC processing is seen to have resulted in a significant (P = 0.001) increase in the detection rate for endocervical glandular neoplasia (from 2.2 per 10,000 tests to 3.9 per 10,000) while maintaining high levels of reporting specificity. An observed fall in the number of samples reported as showing borderline glandular neoplasia falls short of statistical significance, and the reporting of possible endometrial and 'other' glandular abnormalities appears to be unaffected. The underlying reasons for the observed improvement in detection of endocervical glandular neoplasia are discussed.

Generalized method for adaptive randomization in clinical trials.

A flexible, generalized method of treatment allocation is proposed. The method uses a set of controlling parameters that enables the generic algorithm to produce a family of possible outcomes ranging from simple randomization to deterministic allocation. The method controls balance at stratum level, stratification level and overall without detriment to the predictability of the method. The paper lists the desirable characteristics of allocation methods and shows that the proposed method fulfils the majority and is easy to use in the clinical context, once the coding has been established. An explanation of the method for 2, 3 and 4 treatment group allocations is given. Simulations demonstrate the flexibility of the method.

Incredible Years parent training support for foster carers in Wales: a multi-centre feasibility study.

BACKGROUND: the incidence of conduct disorder in young children is 10% in the general population and 37% among fostered children. Up to 40% of untreated children diagnosed with conduct disorder develop problems later in life including drug misuse, criminal and violent behaviour. There are more than 80,000 looked after children in the UK, with 5000 in Wales. Challenging child behaviour is the main reason for placement breakdown and has huge cost implications as challenging children cost up to 10 times more in service use than children without conduct disorder. The Incredible Years (IY) evidence-based parenting programme is an effective, low cost solution in improving child behaviour and social competence in 'conventional' families and thus has the potential to support foster carers in managing difficult behaviours. Our main aims were to establish: • The feasibility of delivery and the effectiveness of the IY parenting programme in supporting carers in managing difficult behaviour in looked after children. • Service use costs for foster carers and looked after child. METHODS: This was a 12-month trial platform study with 46 foster carers in three authorities in Wales. Carers were allocated 2:1 intervention to waiting-list control. Validated measures were used to assess 'parenting' competency, carers' depression levels, child behaviour and service use. Measures were administered at baseline and 6-month follow-up. Intervention carers received the programme between baseline and follow-up. RESULTS: Analyses showed a significant reduction in child problem behaviour and improvement in carers' depression levels for intervention families at follow-up, compared with control. Unexpectedly, there was a significant improvement in control carers' self-reported 'parenting' strategies. Special education was the greatest service cost for looked after children. CONCLUSIONS: Initial foster carer training could incorporate the IY programme to support carers in establishing positive relationships and managing difficult child behaviour. Programme participation may lead to reduced service use and improved placement stability.

The impact of group leaders' behaviour on parents acquisition of key parenting skills during parent training.

BACKGROUND: Parent training (PT) is identified as the most effective intervention for the treatment of conduct disorder (CD). Intervention observational outcomes are often reported as summarised composite scores, providing an overview of overall construct change. METHODS AND AIMS: Parents of children aged 3-5 years identified 'at risk' of developing CD were randomly allocated to either PT intervention or waiting list control group. Parent and child behaviours were assessed before and after the intervention period. The current paper aims to establish which individual observed parenting categories change as a result of PT, and which specific observed leader categories predict these changes. RESULTS: Controlling for baseline scores, ANCOVA demonstrated changes in parent praise and reflective behaviours as significant post-intervention. One-way ANOVAs demonstrated higher levels of leader praise and reflective behaviours resulted in greater change in parental praise and reflective behaviours respectively. Regression analyses indicated these leader behaviours predict positive change in parental praise and reflective behaviours for intervention families. CONCLUSIONS: Composite observational scores provide an account of behaviour constructs, whereas individual behaviour categories provide an insight into the core components of these constructs. The results suggest praise and reflection as key leader behaviours that influence the mechanisms of change in parenting behaviours as a result of PT.

Differential distribution of exchange proteins directly activated by cyclic AMP within the adult rat retina.

The recently discovered exchange protein directly activated by cAMP (Epac), a guanine exchange factor for the G-protein RAP-1, is directly activated by cAMP independently of protein kinase A (PKA). While cAMP is known to be an important second messenger in the retina, the presence of Epac has not been investigated in this tissue. The goal of the present study was to determine if the Epac1 and Epac2 genes are present and to characterize their location within the retina. Western blot analysis revealed that Epac1 and Epac2 proteins are expressed within the retina, and the presence of mRNA was demonstrated with the aid of reverse transcriptase polymerase chain reaction (RT-PCR). Additionally, we used immunofluorescence and confocal microscopy to demonstrate that Epac1 and Epac2 have overlapping as well as unique distributions within the retina. Both are present within horizontal cells, rod and cone bipolar cells, cholinergic amacrine cells, retrograde labeled retinal ganglion cells, and Müller cells. Uniquely, Epac2 was expressed by cone photoreceptor inner and outer segments, cell bodies, and synaptic terminals. In contrast, Epac1 was expressed in vesicular glutamate transporter 1 (VGlut1) and C-terminal binding protein 2 (CtBP2) positive photoreceptor synaptic terminals. Together, these results provide evidence that Epac1 and Epac2 are differentially expressed within the retina and provide the framework for further functional studies of cAMP pathways within the retina.

Religion and psychosis: the effects of the Welsh religious revival in 1904-1905.

BACKGROUND: Psychotic symptoms have been linked to religious experience, but empirical evidence is scarce. We have investigated the impact of the Welsh religious revival (RR) of 1904-1905 on the number of admissions to the regional psychiatric hospital, their diagnostic features and lifelong course. METHOD: All case-notes of patients admitted to the North Wales Hospital between 1902 and 1907 were included. RESULTS: There was a significant increase in admissions for brief polymorphic psychoses (BPP; ICD-10: F23.0 and F23.1) in the revival years, but the number of first admissions for other mental disorders did not change. The vast majority of BPP admissions were linked to a revival meeting and did not result in further admissions. CONCLUSIONS: Intensive religious experience can lead to transient psychotic episodes. Our data also support the view that BPP triggered by life events rarely lead to chronic mental illness, distinguishing them from other psychoses and supporting the validity of the concept of reactive psychosis.

The novel distribution of phosphodiesterase-4 subtypes within the rat retina.

Phosphodiesterases (PDEs) are important regulators of signal transduction processes. While much is known about the function of cyclic GMP-specific PDEs in the retina, much less is known about the closely related, cyclic AMP-specific PDEs. The purpose of the present study is to characterize and localize PDE4 within the adult rat retina. We have used Western blotting, RT-PCR, and immunohistochemistry together with retrograde labeling to determine the presence and location of each PDE4 subtype. Western blot analysis revealed that multiple isoforms of PDE4A, B, and D subtypes are present within the retina, whereas the PDE4C subtype was absent. These data were confirmed by RT-PCR. Using immunohistochemistry we show that all three PDE4s are abundantly expressed within the retina where they all colocalize with retrograde-labeled retinal ganglion cells, as well as bipolar cells, horizontal cells, and cholinergic amacrine cells, whereas Müller cells lack PDE4 expression. Uniquely, PDE4B was expressed by the inner and outer segments of rod photoreceptors as well as their terminals within the outer plexiform layer. Collectively, our results demonstrate that PDE4s are abundantly expressed throughout the rodent retina and this study provides the framework for further functional studies.

Effects of rolipram on adult rat oligodendrocytes and functional recovery after contusive cervical spinal cord injury.

Traumatic human spinal cord injury (SCI) causes devastating and long-term hardships. These are due to the irreparable primary mechanical injury and secondary injury cascade. In particular, oligodendrocyte cell death, white matter axon damage, spared axon demyelination, and the ensuing dysfunction in action potential conduction lead to the initial deficits and impair functional recovery. For these reasons, and that oligodendrocyte and axon survival may be related, various neuroprotective strategies after spinal cord injury are being investigated. We previously demonstrated that oligodendrocytes in the adult rat epicenter ventrolateral funiculus (VLF) express 3'-5'-cyclic adenosine monophosphate-dependent phosphodiesterase 4 (PDE4) subtypes and that their death was attenuated up to 3 days after contusive cervical SCI when rolipram, a specific inhibitor of PDE4, was administered. Here, we report that (1) there are more oligodendrocyte somata in the adult rat epicenter VLF, (2) descending and ascending axonal conductivity in the VLF improves, and that (3) there are fewer hindlimb footfall errors during grid-walking at 5 weeks after contusive cervical SCI when rolipram is delivered for 2 weeks. This is the first demonstration of improved descending and ascending long-tract axonal conductivity across a SCI with this pharmacological approach. Since descending long-tract axonal conductivity did not return to normal, further evaluations of the pharmacokinetics and therapeutic window of rolipram as well as optimal combinations are necessary before consideration for neuroprotection in humans with SCI.

Treatment fidelity as a predictor of behaviour change in parents attending group-based parent training.

BACKGROUND: Change in parenting skills, particularly increased positive parenting, has been identified as the key component of successful evidence-based parent training (PT), playing a causal role in subsequent child behaviour change for both prevention and treatment of Conduct Disorder. The amount of change in parenting skills observed after PT varies and may be accounted for by both the content of the programme and by the level of PT implementer process skills. Such variation in implementer skills is an important component in the assessment of treatment fidelity, itself an essential factor in successful intervention outcome. AIMS: To establish whether the Leader Observation Tool, a reliable and valid process skills fidelity measure, can predict change in parenting skills after attendance on the Incredible Years PT programme. RESULTS: Positive leader skills categories of the Leader Observation Tool significantly predicted change in both parent-reported and independently observed parenting skills behaviour, which in turn, predicted change in child behaviour outcome. CONCLUSIONS: Delivering an intervention with a high level of treatment fidelity not only preserves the behaviour change mechanisms of the intervention, but can also predict parental behaviour change, which itself predicts child behaviour change as a result of treatment.

Evaluation of the population dose to the UK population from the National Health Service Breast Screening Programme.

In the United Kingdom National Health Service Breast Screening Programme (NHSBSP), women aged between 50 and 70 y are invited for mammography every 3 y. Screening histories for each woman, over four screening rounds, were analysed. Data from five screening programmes were used to select 57,425 women into the study. Cases were selected on the basis of being between the ages of 50 and 53 at the start of the NHSBSP (i.e. between 1989 and 1992). Assessment of the outcome for each screening round for each woman involved assigning a simple outcome code. Each of the possible pathways through the four screening rounds was analysed. This comprises of 500 possible pathways. This data enabled the following information to be determined: (i) The number of times a woman attended the screening programme. (ii) The number of women referred for assessment at each screening round. This information may be used to deduce the population dose to this group of women averaged over four screening rounds. Patient doses have been monitored since the programme's inception and are typically 4.5 mGy for two-view screening. It is possible to determine the mean glandular dose received by this cohort of women over four screening rounds by multiplying the number of examinations by the mean glandular dose for a typical woman. Allowance has to be made for the number of projections taken at each screening round. Once a woman has been screened, she may be invited back for further assessment if an abnormality is found on her mammogram. A stereotactic attachment is used to determine where to place the biopsy device. Although the dose received during a normal screening mammogram is well known, the dose for a stereotactic procedure and other assessment procedures is less well known, partly because only a small part of the breast is directly irradiated during stereotaxis. However, the woman may have multiple exposures during this stage. A prospective survey of doses was completed to deduce the mean glandular dose at the first assessment stage and during stereotaxis. Numbers of films, including magnification films taken at first-stage assessment were established in the North East of England and Scotland by means of a postal survey. Average total mean glandular dose was deduced using previous survey data for the screening programme and a multiplying factor to allow for magnification film dose. On average 1.6 full field and 0.15 collimated contact films are taken for each woman (with 2.25 and 0.75 mGy film(-1)), 1.0 full field and 0.9 collimated magnification views. The mean magnification film dose to the assessed breast was 5.0 and 1.7 mGy for a collimated magnification film. A survey of 134 women at screening centres in the North East of England was performed to deduce the mean glandular dose from digital stereotaxis which is almost universally used in breast screening. A typical woman received a dose to the assessed breast of 4.5 mGy with a range of 1.3-17 mGy. This data may be used to deduce the total mean glandular dose over four screening rounds including the assessment stages. The estimated mean glandular dose to a typical woman invited to the screening programme is approximately 16 mGy, when allowance for attendance rate and assessment rate over each screening round is made. The mean glandular dose to the population is approximately 4700 Sv y(-1).

A descriptive study of the decline in cervical screening coverage rates in the North East and Yorkshire and the Humber regions of the UK from 1995 to 2005.

Since the mid-1990s, there has been a steady decline in coverage rates for cervical screening in the target age group (25-64 years) across England. This article describes the rate of decline from 1995 to 2005 in the old health authority areas of the North East and the Yorkshire and the Humber (NEYH) regions in relation to age group, deprivation, ethnicity and religion. The results show that the rate of decline is faster in these northern regions than that in England as a whole, with a very strong correlation between age and rate of change of coverage rates. Younger age groups experience the fastest rate of decline, and those over 55 years show an increase in coverage rates. There is an association between the deprivation of the old health authority areas and the rate of change of coverage rates, with weaker evidence that areas with high proportions of Black or Mixed ethnicity may have a faster decline. However, the rate of decline is not associated with other ethnic groups or religions. Therefore, interventions could be targeted at younger women and those who live in deprived areas to prevent the widening of inequalities.

Influence of menopausal status and use of hormone replacement therapy on radiation dose from mammography in routine breast screening.

Menopausal status and hormone replacement therapy (HRT) cause alterations in breast structure which can affect mammographic image quality. Here we present the results of a study to discover the effect of menopausal status and HRT use on breast dose. Women attending routine screening completed questionnaires which included questions regarding menopausal status and HRT use. Details of the radiographic technique factors were recorded, from which the mean glandular dose (MGD) per film for each woman was calculated. MGD values were analysed with regard to the woman's menopausal status and HRT use. The data from 516 women were analysed. Among the women who had never used HRT, women who had not undergone the menopause had a mean MGD of 2.94 mGy per film, whereas post-menopausal women had a lower mean MGD of 2.52 mGy per film: a difference which was found to be highly significant (p = 0.0045). Post-menopausal women who had never used HRT and those who had previously used HRT, but had ceased using it, had identical mean MGDs (2.54 mGy per film), whereas current HRT users had a significantly greater mean MGD (2.89 mGy per film, p = 0.003). Women currently using HRT receive a statistically significantly larger radiation dose from routine breast screening than other women. However, this effect is small and only occurs during the period of HRT use. Women who have ceased using HRT show no difference in MGD compared with women who have never taken HRT.

Accuracy of task recall for epidemiological exposure assessment to construction noise.

AIMS: To validate the accuracy of construction worker recall of task and environment based information; and to evaluate the effect of task recall on estimates of noise exposure. METHODS: A cohort of 25 construction workers recorded tasks daily and had dosimetry measurements weekly for six weeks. Worker recall of tasks reported on the daily activity cards was validated with research observations and compared directly to task recall at a six month interview. RESULTS: The mean L(EQ) noise exposure level (dBA) from dosimeter measurements was 89.9 (n = 61) and 83.3 (n = 47) for carpenters and electricians, respectively. The percentage time at tasks reported during the interview was compared to that calculated from daily activity cards; only 2/22 tasks were different at the nominal 5% significance level. The accuracy, based on bias and precision, of percentage time reported for tasks from the interview was 53-100% (median 91%). For carpenters, the difference in noise estimates derived from activity cards (mean 91.9 dBA) was not different from those derived from the questionnaire (mean 91.7 dBA). This trend held for electricians as well. For all subjects, noise estimates derived from the activity card and the questionnaire were strongly correlated with dosimetry measurements. The average difference between the noise estimate derived from the questionnaire and dosimetry measurements was 2.0 dBA, and was independent of the actual exposure level. CONCLUSIONS: Six months after tasks were performed, construction workers were able to accurately recall the percentage time they spent at various tasks. Estimates of noise exposure based on long term recall (questionnaire) were no different from estimates derived from daily activity cards and were strongly correlated with dosimetry measurements, overestimating the level on average by 2.0 dBA.

Use of cue configuration geometry for spatial orientation in human infants (Homo sapiens).

Research with both rats and human infants has found that after inertial disorientation, the geometry of an enclosed environment is used in preference over distinctive featural information during goal localization. Infants (Homo sapiens, 18-24 months) were presented with a toy search task involving inertial disorientation in 1 of 2 conditions. In the identical condition, 4 identical hiding boxes in a rectangular formation were set within a circular enclosure. In the distinctive condition, 4 distinctive hiding boxes were used. Infants searched the goal box and its rotational equivalent significantly more than would be expected by chance in the identical condition, showing that they were sensitive to the geometric configuration of the array of boxes. Unlike the results of studies using a rectangular enclosure, however, in the distinctive condition, infants searched at the correct location significantly more than at other locations.

The use of TENS for pruritus relief in the burns patient: an individual case report.

The case report outlines the use of transcutaneous electrical nerve stimulation (TENS) for the relief of pruritus in a 19-year-old patient who had sustained 70% mixed-thickness flame burns. Once healed, two electrodes were applied to the region of most severe itching, which was the lumbar spine. They were applied at 10 AM and remained in place until he went to bed. A visual analog scale (VAS) rating of itching was used to measure the sensation subjectively before application, immediately after application, and 4 hours after continuous application. Readings were taken for 5 consecutive days and then followed up during a 2-week period. At this time the patient discontinued the use of TENS, because itching had decreased significantly. Results showed that between day 1 and day 16 there was a 50% improvement before application and a 100% improvement 4 hours after application of TENS. These results suggest that a study to investigate the effect of TENS for the relief of pruritus in the burn patient would be justified to provide an alternative, noninvasive treatment approach.