A study of HPV 1, 2 and 4 antibody prevalence in patients presenting for treatment with cutaneous warts to general practitioners in N. Ireland

Three hundred and seventy-six patients attending their general practitioner with cutaneous warts at five health centres in Northern Ireland were screened for human papilloma virus (HPV) types 1 and 2 IgM antibody using an indirect immunofluorescence test. Eight-eight (23.4%) patients were positive for HPV type 1 IgM and 156 (41.5%) for HPV type 2 IgM. HPV 1 IgM antibody was significantly more likely to be associated with plantar warts than warts elsewhere (P less than 0.0001). HPV 2 IgM was present in 45 (34.1%) patients with plantar warts and 99 (45.6%) patients with warts at other sites (P = 0.1). Evidence of multiple infection by HPV types 1 and 2 was demonstrated by the finding of HPV 1 and 2 IgM antibodies in the sera of 16 (4.3%). HPV 4 was found in only 1 out of 30 biopsies and HPV 4 IgM was undetectable in 50 randomly chosen sera.

Primary dermatological care in general practice

Out of 2,409 clinical cases analysed over an eight-week period, 199 (8.2 per cent) were of a dermatological nature. Atopic eczema, warts, seborrhoeic eczema and acne vulgaris were encountered most frequently. The reaction to a skin clinic in the general practice, with access to liquid nitrogen, electrocautery and histopathology is described. Treatment of patients is summarized. It is suggested that having a practice skin clinic reduces the rate of hospital referrals by two thirds.

Dissection of Host Cell Signal Transduction during <i>Acinetobacter baumanniii> – Triggered Inflammatory Response

Infected airway epithelial cells up-regulate the expression of chemokines, chiefly IL-8, and antimicrobial molecules including ß-defensins (BD). Acinetobacter baumannii is a cause of hospital-acquired pneumonia. We examined whether A. baumannii induced the expressions of IL-8 and BD2 by airway epithelial cells and the receptors implicated in bacterial detection. A549 and human primary airway cells released IL-8 upon infection. A. baumannii-infected cells also increased the expression of BD2 which killed A. baummannii strains. IL-8 induction was via NF-B and mitogen-activated kinases p38 and p44/42-dependent pathways. A. baumannii engaged Toll-like receptor (TLR) 2 and TLR4 pathways and A549 cells could use soluble CD14 as TLRs co-receptor. A. baumannii lipopolysaccharide stimulated IL-8 release by A549 cells and sCD14 facilitated the recognition of the lipopolysaccharide. Mass spectrometry analysis revealed that A. baumannii lipid A structure matches those with endotoxic potential. These results demonstrate that airway epithelial cells produce mediators important for A. baumannii clearance. © 2010 March et al.

Expression of Toll-Like Receptors 2 and 4 is Upregulated During Hospital Admission in Traumatic Patients:Lack of Correlation with Blunted Innate Immune Responses

Background: There are reports with conflicting results on the expression of toll-like receptors (TLRs) in trauma patients. In addition, these studies analyzed TLR expression only at patients hospital admission but not later when complications usually arise. Objectives: To analyze the surface expression of TLR2 and TLR4 on circulating monocytes from trauma patients during the hospitalization period and to correlate this with cytokine production after stimulation with TLR2 and TLR4 agonists. The phagocytic capacity of monocytes was analyzed at the same time points of TLR expression analysis; to correlate these molecular findings with the presence or absence of infections. Methods: Prospective and observational study from June 2005 to June 2007. In all analysis, a control group composed of healthy subjects was included. Results: We studied 70 trauma patients admitted to the intensive care unit (ICU) of a tertiary hospital, and 30 healthy volunteers. Blood samples were collected at hospital admission, on day 7 and 14. Forty-four patients (63%) developed at least one episode of infection. Monocytes from trauma patients expressed higher levels of TLR2 and TLR4 than monocytes from control subjects at all time points. Expression of TLR2 and TLR4 in monocytes from those patients who developed any infection was significantly lower than in those patients without infection but still significantly higher than in control subjects. Cellular responses to TLR4 agonist were impaired. Monocytes from traumatic patients phagocytosized less efficiently than monocytes from control subjects. Conclusions: These results indicate that trauma patients present a dysregulation of the innate immune system that persists during the first 14 days after hospital admission. Copyright © 2010 by Lippincott Williams & Wilkins.

Surveillance for ocular hypertension: An evidence synthesis and economic evaluation

OBJECTIVES: To determine effective and efficient monitoring criteria for ocular hypertension [raised intraocular pressure (IOP)] through (i) identification and validation of glaucoma risk prediction models; and (ii) development of models to determine optimal surveillance pathways.

DESIGN: A discrete event simulation economic modelling evaluation. Data from systematic reviews of risk prediction models and agreement between tonometers, secondary analyses of existing datasets (to validate identified risk models and determine optimal monitoring criteria) and public preferences were used to structure and populate the economic model.

SETTING: Primary and secondary care.

PARTICIPANTS: Adults with ocular hypertension (IOP > 21 mmHg) and the public (surveillance preferences).

INTERVENTIONS: We compared five pathways: two based on National Institute for Health and Clinical Excellence (NICE) guidelines with monitoring interval and treatment depending on initial risk stratification, 'NICE intensive' (4-monthly to annual monitoring) and 'NICE conservative' (6-monthly to biennial monitoring); two pathways, differing in location (hospital and community), with monitoring biennially and treatment initiated for a ≥ 6% 5-year glaucoma risk; and a 'treat all' pathway involving treatment with a prostaglandin analogue if IOP > 21 mmHg and IOP measured annually in the community.

MAIN OUTCOME MEASURES: Glaucoma cases detected; tonometer agreement; public preferences; costs; willingness to pay and quality-adjusted life-years (QALYs).

RESULTS: The best available glaucoma risk prediction model estimated the 5-year risk based on age and ocular predictors (IOP, central corneal thickness, optic nerve damage and index of visual field status). Taking the average of two IOP readings, by tonometry, true change was detected at two years. Sizeable measurement variability was noted between tonometers. There was a general public preference for monitoring; good communication and understanding of the process predicted service value. 'Treat all' was the least costly and 'NICE intensive' the most costly pathway. Biennial monitoring reduced the number of cases of glaucoma conversion compared with a 'treat all' pathway and provided more QALYs, but the incremental cost-effectiveness ratio (ICER) was considerably more than £30,000. The 'NICE intensive' pathway also avoided glaucoma conversion, but NICE-based pathways were either dominated (more costly and less effective) by biennial hospital monitoring or had a ICERs > £30,000. Results were not sensitive to the risk threshold for initiating surveillance but were sensitive to the risk threshold for initiating treatment, NHS costs and treatment adherence.

LIMITATIONS: Optimal monitoring intervals were based on IOP data. There were insufficient data to determine the optimal frequency of measurement of the visual field or optic nerve head for identification of glaucoma. The economic modelling took a 20-year time horizon which may be insufficient to capture long-term benefits. Sensitivity analyses may not fully capture the uncertainty surrounding parameter estimates.

CONCLUSIONS: For confirmed ocular hypertension, findings suggest that there is no clear benefit from intensive monitoring. Consideration of the patient experience is important. A cohort study is recommended to provide data to refine the glaucoma risk prediction model, determine the optimum type and frequency of serial glaucoma tests and estimate costs and patient preferences for monitoring and treatment.

FUNDING: The National Institute for Health Research Health Technology Assessment Programme.

The influence of the new general ophthalmic services (GOS) contract in optometrist referrals for glaucoma in Scotland

Purpose: To assess the quality of referrals from community optometrists in the northeast of Scotland to the hospital glaucoma service before and after the implementation of the new General Ophthalmic Services (GOS) contract in Scotland. Methods: Retrospective study encompassing two 6-month periods, one before the implementation of the new GOS (Scotland) contract in April 2006 (from June to November 2005), and the other after (from June to November 2006). The community optometrist referral forms and hospital glaucoma service notes were reviewed. Comparisons were performed using the t-test and ?- test. Results: In all, 183 referrals were made during the first 6-month period from June to November 2005, and 120 referrals were made during the second 6-month period from June to November 2006. After the introduction of the new GOS contract, there was a statistically significant increase in true-positive referrals (from 18.0 to 31.7%; P=0.006), decrease in false-positive referrals (from 36.6 to 31.7%; P=0.006), and increase in the number of referrals with information on applanation tonometry (from 11.8 to 50.0%; P=0.000), dilated fundal examination (from 2.2 to 24.2%; P=0.000), and repeat visual fields (from 14.8 to 28.3%; P=0.004) when compared to the first 6-month period. However, only 41.7% of referrals fulfilled the new GOS contract requirements, with information on applanation tonometry the most commonly missing. Conclusions: After the implementation of the new GOS (Scotland) contract in April 2006, there has been an improvement in the quality of the glaucoma referrals from the community optometrists in the northeast of Scotland, with a corresponding reduction in false-positive referrals. Despite the relatively positive effect so far, there is still scope for further improvement. © 2009 Macmillan Publishers Limited All rights reserved.

Finding exoplanets orbiting young active stars - I. Technique

Stellar activity, such as starspots, can induce radial velocity (RV) variations that can mask or even mimic the RV signature of orbiting exoplanets. For this reason RV exoplanet surveys have been unsuccessful when searching for planets around young, active stars and are therefore failing to explore an important regime which can help to reveal how planets form and migrate. This paper describes a new technique to remove spot signatures from the stellar line-profiles of moderately rotating, active stars (v sin i ranging from 10 to 50 km s(-1)). By doing so it allows planetary RV signals to be uncovered. We used simulated models of a G5V type star with differing dark spots on its surface along with archive data of the known active star HD 49933 to validate our method. The results showed that starspots could be effectively cleaned from the line-profiles so that the stellar RV jitter was reduced by more than 80 per cent. Applying this procedure to the same models and HD 49933 data, but with fake planets injected, enabled the effective removal of starspots so that Jupiter mass planets on short orbital periods were successfully recovered. These results show that this approach can be useful in the search for hot-Jupiter planets that orbit around young, active stars with a v sin i of similar to 10-50 km/s.

USING ‘NUTRITIONAL NARRATIVE’ AND FOCUS GROUPS TO UNDERSTAND HOW NUTRITIONAL CARE CAN BETTER PRIORITISED FOR OLDER PEOPLE IN HOSPITAL SETTINGS

Introduction: Poor nutritional status among older people is well documented with 40% of older people reported as malnourished on hospital admission. Poor nutrition contributes to increased infection, poorer patient outcomes and death and longer hospital stays. In this study, we assessed the ‘nutrition narrative’ from older hospital patients together with nutrition knowledge among nursing and medical staff and students.
Methods: The study used a convenience sample of older people (30, mean age 82 years) in two large geographically separate city hospitals. Patients mentally alert and consenting, gave a recorded ‘nutrition narrative’ to get a sense of how they felt their nutritional needs were being met in hospital. Main themes were identified by grounded analysis framework. Focus groups were recruited from medical/nursing teachers and students to assess their working knowledge of nutrition and the nutritional needs of the older patient group.
Results: Analysis of the ‘nutrition narrative’ suggested several themes (i) staff should listen to patients' needs/wishes in discussion with themselves and family members (ii) staff should continue to encourage and progress a positive eating experience (iii) staff should monitor food eaten/or not eaten and increase regular monitoring of weight. The focus groups with medical and nursing students suggested a limited knowledge about nutritional care of older people and little understanding about roles or cross-talk about nutrition across the multidisciplinary groups.
Conclusions: The ‘nutrition narrative’ themes suggested that the nutritional experience of older people in hospital can and must be improved. Nursing and medical staff providing medical and nursing care need better basic knowledge of nutrition and nutritional assessment, an improved understanding of the roles of the various multidisciplinary staff and of hospital catering pathways. Care professionals need to prioritise patient nutrition much more highly and recognise nutritional care as integral to patient healing and recovery

High population prevalence of cardiac troponin I measured by a high-sensitivity assay and cardiovascular risk estimation: the MORGAM Biomarker Project Scottish Cohort

Aims
Our aim was to test the prediction and clinical applicability of high-sensitivity assayed troponin I for incident cardiovascular events in a general middle-aged European population.

Methods and results
High-sensitivity assayed troponin I was measured in the Scottish Heart Health Extended Cohort (n = 15 340) with 2171 cardiovascular events (including acute coronary heart disease and probable ischaemic strokes), 714 coronary deaths (25% of all deaths), 1980 myocardial infarctions, and 797 strokes of all kinds during an average of 20 years follow-up. Detection rate above the limit of detection (LoD) was 74.8% in the overall population and 82.6% in men and 67.0% in women. Troponin I assayed by the high-sensitivity method was associated with future cardiovascular risk after full adjustment such as that individuals in the fourth category had 2.5 times the risk compared with those without detectable troponin I (P < 0.0001). These associations remained significant even for those individuals in whom levels of contemporary-sensitivity troponin I measures were not detectable. Addition of troponin I levels to clinical variables led to significant increases in risk prediction with significant improvement of the c-statistic (P < 0.0001) and net reclassification (P < 0.0001). A threshold of 4.7 pg/mL in women and 7.0 pg/mL in men is suggested to detect individuals at high risk for future cardiovascular events.

Conclusion
Troponin I, measured with a high-sensitivity assay, is an independent predictor of cardiovascular events and might support selection of at risk individuals.

It's not that I don't care, I just don't care very much: confounding between attribute non-attendance and taste heterogeneity

With the growing interest in the topic of attribute non-attendance, there is now widespread use of latent class (LC) structures aimed at capturing such behaviour, across a number of different fields. Specifically, these studies rely on a confirmatory LC model, using two separate values for each coefficient, one of which is fixed to zero while the other is estimated, and then use the obtained class probabilities as an indication of the degree of attribute non-attendance. In the present paper, we argue that this approach is in fact misguided, and that the results are likely to be affected by confounding with regular taste heterogeneity. We contrast the confirmatory model with an exploratory LC structure in which the values in both classes are estimated. We also put forward a combined latent class mixed logit model (LC-MMNL) which allows jointly for attribute non-attendance and for continuous taste heterogeneity. Across three separate case studies, the exploratory LC model clearly rejects the confirmatory LC approach and suggests that rates of non-attendance may be much lower than what is suggested by the standard model, or even zero. The combined LC-MMNL model similarly produces significant improvements in model fit, along with substantial reductions in the implied rate of attribute non-attendance, in some cases even eliminating the phenomena across the sample population. Our results thus call for a reappraisal of the large body of recent work that has implied high rates of attribute non-attendance for some attributes. Finally, we also highlight a number of general issues with attribute non-attendance, in particular relating to the computation of willingness to pay measures.

Creating an Inclusive Society… How Close are We in Relation to Autism Spectrum Disorder? A General Population Survey

BackgroundChildren with autism spectrum disorder are increasingly educated in mainstream classrooms in the United Kingdom (Wilkinson & Twist, Autism and Educational Assessment: UK Policy and Practice. NFER, Slough, 2010), and some employers are now specifically seeking out staff on the autism spectrum. Does that mean that we are living in an inclusive society' [United Nations Department of Economic and Social Affairs (UNDESA), Creating an Inclusive Society: Practical Strategies to Promote Social Integration 2008], in the sense that inequalities are reduced and full economic, social and cultural participation is advanced for individuals with autism?

MethodsA general population survey was conducted to assess how close we, as a society, are to an inclusive society for individuals with autism in Northern Ireland. Public attitudes were examined to (i) visibility and social interaction, (ii) aetiology, needs and interventions, and (iii) rights and resources.

ResultsA stratified, representative sample of 1204 adults took part in the survey; of these, 989 were aware of autism and their attitudes and behavioural projections reflected a mix of acceptance and denunciation. The level of confusion with regard to interventions reflected the general uncertainty within UK policy regarding meeting the needs of individuals on the autism spectrum (International Journal of Disability, Development and Education 61, 134, 2014a).

ConclusionTherefore, it seems that inclusion is working to an extent, but more clarity is needed with regard to adequate education, intervention and support for individuals with autism.

Perceptions of collaboration between general practitioners and community pharmacists: Findings from a qualitative study based in Spain

According to the theory of reasoned action (TRA), collaboration is only possible when it is perceived as useful by the participants involved. This paper describes a qualitative study using semi-structured interviews to explore the preceived usefulness of general practitioner (GPs)-community pharmacists (CPs)' collaboration from these professionals' perspectives based in two Spanish regions. Thirty-seven interviews were conducted with GPs and CPs with and without previous experience of collaborating with the other groups of professionals. Analysis of the data indicated that the GPs and CPs considered that collaboration between practitioners and pharmacists to have different forms of usefulness, ranging from positive to negative perceptions of usefulness. Negative and neutral opinions (collaboration generates conflict and/or is not benefitial) could prevent practitioners from initiating collaboration with the other group of professionals, which is explained by the TRA. These perceptions were only found among those participants without experience in collaboration. When collaboration was perceived as advantageous, it could be beneficial on three levels: health system (i.e. provision of integrated care, increased efficiency of the system), GPs and CPs (i.e. increased job satisfaction and patient loyalty) and patients (i.e. improved patient safety). Although GPs and CPs with experience identified benefits using a range of examples, GPs and CPs who had never collaborated also believed that if collaboration was undertaken there would be benefits for the health system, patients and health professionals. These results should be considered when developing strategies to encourage and improve the implementation of collaborative working relationships between GPs and pharmacists in primary care.

The distribution of COPD in UK general practice using the new GOLD classification

The new Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2011 document recommends a combined assessment of chronic obstructive pulmonary disease (COPD) based on current symptoms and future risk.

A large database of primary-care COPD patients across the UK was used to determine COPD distribution and characteristics according to the new GOLD classification. 80 general practices provided patients with a Read code diagnosis of COPD. Electronic and hand searches of patient medical records were undertaken, optimising data capture.

Data for 9219 COPD patients were collected. For the 6283 patients with both forced expiratory volume in 1 s (FEV1) and modified Medical Research Council scores (mean¡SD age 69.2¡10.6 years, body mass index 27.3¡6.2 kg?m-2), GOLD 2011 group distributions were: A (low risk and fewer symptoms) 36.1%, B (low risk and more symptoms) 19.1%, C (high risk and fewer symptoms) 19.6% and D (high risk and more symptoms) 25.3%. This is in contrast with GOLD 2007 stage classification: I (mild) 17.1%, II (moderate) 52.2%, III (severe) 25.5% and IV (very severe) 5.2%. 20% of patients with FEV1 o50% predicted had more than two exacerbations in the previous 12 months. 70% of patients with FEV1 ,50% pred had fewer than two exacerbations in the previous 12 months.

This database, representative of UK primary-care COPD patients, identified greater proportions of patients in the mildest and most severe categories upon comparing 2011 versus 2007 GOLD classifications. Discordance between airflow limitation severity and exacerbation risk was observed.