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To examine associations between diet and risk of developing gastroesophageal reflux disease (GERD)
Prospective cohort with a median follow-up of 15.8 years. Baseline diet was measured using a food frequency questionnaire. GERD was defined as self-reported current or history of daily heartburn or acid regurgitation beginning at least two years after baseline. Sex-specific logistic regressions were performed to estimate odds ratios for GERD associated with diet quality scores and intakes of nutrients, food groups, and individual foods and beverages. The effect of substituting saturated fat for monounsaturated or polyunsaturated fat on GERD risk was examined.
A cohort of 20,926 participants (62% women) aged 40-59 years at recruitment between 1990-1994
For men, total fat intake was associated with increased risk of GERD (OR 1.05 per 5g/d; 95%CI 1.01-1.09; p=0.016), whereas total carbohydrate (OR 0.89 per 30g/d; 95%CI 0.82-0.98; p=0.010) and starch intakes (OR 0.84 per 30g/d; 95%CI 0.75-0.94; p=0.005) were associated with reduced risk. Nutrients were not associated with risk for women. For both sexes, substituting saturated fat for polyunsaturated or monounsaturated fat did not change risk. For both sexes, fish, chicken, cruciferous vegetables, and carbonated beverages were associated with increased risk, whereas total fruit and citrus were associated with reduced risk. No association was observed with diet quality scores.
Diet is a possible risk factor for GERD, but food considered as triggers of GERD symptoms might not necessarily contribute to disease development. Potential differential associations for men and women warrant further investigation.
Clarifying the relationship between depression symptoms and cardiometabolic and related health could clarify risk factors and treatment targets. The objective of this study was to assess whether depression symptoms in midlife are associated with the subsequent onset of cardiometabolic health problems.
The study sample comprised 787 male twin veterans with polygenic risk score data who participated in the Harvard Twin Study of Substance Abuse (‘baseline’) and the longitudinal Vietnam Era Twin Study of Aging (‘follow-up’). Depression symptoms were assessed at baseline [mean age 41.42 years (s.d. = 2.34)] using the Diagnostic Interview Schedule, Version III, Revised. The onset of eight cardiometabolic conditions (atrial fibrillation, diabetes, erectile dysfunction, hypercholesterolemia, hypertension, myocardial infarction, sleep apnea, and stroke) was assessed via self-reported doctor diagnosis at follow-up [mean age 67.59 years (s.d. = 2.41)].
Total depression symptoms were longitudinally associated with incident diabetes (OR 1.29, 95% CI 1.07–1.57), erectile dysfunction (OR 1.32, 95% CI 1.10–1.59), hypercholesterolemia (OR 1.26, 95% CI 1.04–1.53), and sleep apnea (OR 1.40, 95% CI 1.13–1.74) over 27 years after controlling for age, alcohol consumption, smoking, body mass index, C-reactive protein, and polygenic risk for specific health conditions. In sensitivity analyses that excluded somatic depression symptoms, only the association with sleep apnea remained significant (OR 1.32, 95% CI 1.09–1.60).
A history of depression symptoms by early midlife is associated with an elevated risk for subsequent development of several self-reported health conditions. When isolated, non-somatic depression symptoms are associated with incident self-reported sleep apnea. Depression symptom history may be a predictor or marker of cardiometabolic risk over decades.
To conduct a pilot study implementing combined genomic and epidemiologic surveillance for hospital-acquired multidrug-resistant organisms (MDROs) to predict transmission between patients and to estimate the local burden of MDRO transmission.
Pilot prospective multicenter surveillance study.
The study was conducted in 8 university hospitals (2,800 beds total) in Melbourne, Australia (population 4.8 million), including 4 acute-care, 1 specialist cancer care, and 3 subacute-care hospitals.
All clinical and screening isolates from hospital inpatients (April 24 to June 18, 2017) were collected for 6 MDROs: vanA VRE, MRSA, ESBL Escherichia coli (ESBL-Ec) and Klebsiella pneumoniae (ESBL-Kp), and carbapenem-resistant Pseudomonas aeruginosa (CRPa) and Acinetobacter baumannii (CRAb). Isolates were analyzed and reported as routine by hospital laboratories, underwent whole-genome sequencing at the central laboratory, and were analyzed using open-source bioinformatic tools. MDRO burden and transmission were assessed using combined genomic and epidemiologic data.
In total, 408 isolates were collected from 358 patients; 47.5% were screening isolates. ESBL-Ec was most common (52.5%), then MRSA (21.6%), vanA VRE (15.7%), and ESBL-Kp (7.6%). Most MDROs (88.3%) were isolated from patients with recent healthcare exposure.
Combining genomics and epidemiology identified that at least 27.1% of MDROs were likely acquired in a hospital; most of these transmission events would not have been detected without genomics. The highest proportion of transmission occurred with vanA VRE (88.4% of patients).
Genomic and epidemiologic data from multiple institutions can feasibly be combined prospectively, providing substantial insights into the burden and distribution of MDROs, including in-hospital transmission. This analysis enables infection control teams to target interventions more effectively.
Gravitational waves from coalescing neutron stars encode information about nuclear matter at extreme densities, inaccessible by laboratory experiments. The late inspiral is influenced by the presence of tides, which depend on the neutron star equation of state. Neutron star mergers are expected to often produce rapidly rotating remnant neutron stars that emit gravitational waves. These will provide clues to the extremely hot post-merger environment. This signature of nuclear matter in gravitational waves contains most information in the 2–4 kHz frequency band, which is outside of the most sensitive band of current detectors. We present the design concept and science case for a Neutron Star Extreme Matter Observatory (NEMO): a gravitational-wave interferometer optimised to study nuclear physics with merging neutron stars. The concept uses high-circulating laser power, quantum squeezing, and a detector topology specifically designed to achieve the high-frequency sensitivity necessary to probe nuclear matter using gravitational waves. Above 1 kHz, the proposed strain sensitivity is comparable to full third-generation detectors at a fraction of the cost. Such sensitivity changes expected event rates for detection of post-merger remnants from approximately one per few decades with two A+ detectors to a few per year and potentially allow for the first gravitational-wave observations of supernovae, isolated neutron stars, and other exotica.
Major depressive disorder (MDD) is a leading cause of morbidity and mortality. Shortfalls in treatment quantity and quality are well-established, but the specific gaps in pharmacotherapy and psychotherapy are poorly understood. This paper analyzes the gap in treatment coverage for MDD and identifies critical bottlenecks.
Seventeen surveys were conducted across 15 countries by the World Health Organization-World Mental Health Surveys Initiative. Of 35 012 respondents, 3341 met DSM-IV criteria for 12-month MDD. The following components of effective treatment coverage were analyzed: (a) any mental health service utilization; (b) adequate pharmacotherapy; (c) adequate psychotherapy; and (d) adequate severity-specific combination of both.
MDD prevalence was 4.8% (s.e., 0.2). A total of 41.8% (s.e., 1.1) received any mental health services, 23.2% (s.e., 1.5) of which was deemed effective. This 90% gap in effective treatment is due to lack of utilization (58%) and inadequate quality or adherence (32%). Critical bottlenecks are underutilization of psychotherapy (26 percentage-points reduction in coverage), underutilization of psychopharmacology (13-point reduction), inadequate physician monitoring (13-point reduction), and inadequate drug-type (10-point reduction). High-income countries double low-income countries in any mental health service utilization, adequate pharmacotherapy, adequate psychotherapy, and adequate combination of both. Severe cases are more likely than mild-moderate cases to receive either adequate pharmacotherapy or psychotherapy, but less likely to receive an adequate combination.
Decision-makers need to increase the utilization and quality of pharmacotherapy and psychotherapy. Innovations such as telehealth for training and supervision plus non-specialist or community resources to deliver pharmacotherapy and psychotherapy could address these bottlenecks.
The association between Clostridioides difficile colonization and C. difficile infection (CDI) is unknown in solid-organ transplant (SOT) patients. We examined C. difficile colonization and healthcare-associated exposures as risk factors for development of CDI in SOT patients.
The retrospective study cohort included all consecutive SOT patients with at least 1 screening test between May 2017 and April 2018. CDI was defined as the presence of diarrhea (without laxatives), a positive C. difficile clinical test, and the use of C. difficile-directed antimicrobial therapy as ordered by managing clinicians. In addition to demographic variables, exposures to antimicrobials, immunosuppressants, and gastric acid suppressants were evaluated from the time of first screening test to the time of CDI, death, or final discharge.
Of the 348 SOT patients included in our study, 33 (9.5%) were colonized with toxigenic C. difficile. In total, 11 patients (3.2%) developed CDI. Only C. difficile colonization (odds ratio [OR], 13.52; 95% CI, 3.46–52.83; P = .0002), age (OR, 1.09; CI, 1.02–1.17; P = .0135), and hospital days (OR, 1.05; 95% CI, 1.02–1.08; P = .0017) were independently associated with CDI.
Although CDI was more frequent in C. difficile colonized SOT patients, the overall incidence of CDI was low in this cohort.
EPA and DHA are required for normal cell function and can also induce health benefits. Oily fish are the main source of EPA and DHA for human consumption. However, food choices and concerns about the sustainability of marine fish stocks limit the effectiveness of dietary recommendations for EPA + DHA intakes. Seed oils from transgenic plants that contain EPA + DHA are a potential alternative source of EPA and DHA. The present study investigated whether dietary supplementation with transgenic Camelina sativa seed oil (CSO) that contained EPA and DHA was as effective as fish oil (FO) in increasing EPA and DHA concentrations when consumed as a dietary supplement in a blinded crossover study. Healthy men and women (n 31; age 53 (range 20–74) years) were randomised to consume 450 mg/d EPA + DHA provided either as either CSO or FO for 8 weeks, followed by 6 weeks washout and then switched to consuming the other test oil. Fasting venous blood samples were collected at the start and end of each supplementation period. Consuming the test oils significantly (P < 0·05) increased EPA and DHA concentrations in plasma TAG, phosphatidylcholine and cholesteryl esters. There were no significant differences between test oils in the increments of EPA and DHA. There was no significant difference between test oils in the increase in the proportion of erythrocyte EPA + DHA (CSO, 12 %; P < 0·0001 and FO, 8 %; P = 0·02). Together, these findings show that consuming CSO is as effective as FO for increasing EPA and DHA concentrations in humans.
Introduction: Emergency department (ED) syncope management is extremely variable. We developed practice recommendations based on the validated Canadian Syncope Risk Score (CSRS) and outpatient cardiac monitoring strategy with physician input. Methods: We used a 2-step approach. Step-1: We pooled data from the derivation and validation prospective cohort studies (with adequate sample size) conducted at 11 Canadian sites (Sep 2010 to Apr 2018). Adults with syncope were enrolled excluding those with serious outcome identified during index ED evaluation. 30-day adjudicated serious outcomes were arrhythmic (arrhythmias, unknown cause of death) and non-arrhythmic (MI, structural heart disease, pulmonary embolism, hemorrhage)]. We compared the serious outcome proportion among risk categories using Cochran-Armitage test. Step-2: We conducted semi-structured interviews using observed risk to develop and refine the recommendations. We used purposive sampling of physicians involved in syncope care at 8 sites from Jun-Dec 2019 until theme saturation was reached. Two independent raters coded interviews using an inductive approach to identify themes; discrepancies were resolved by consensus. Results: Of the 8176 patients (mean age 54, 55% female), 293 (3.6%; 95%CI 3.2-4.0%) experienced 30-day serious outcomes; 0.4% deaths, 2.5% arrhythmic, 1.1% non-arrhythmic outcomes. The serious outcome proportion significantly increased from low to high-risk categories (p < 0.001; overall 0.6% to 27.7%; arrhythmic 0.2% to 17.3%; non-arrhythmic 0.4% to 5.9% respectively). C-statistic was 0.88 (95%CI0.86–0.90). Non-arrhythmia risk per day for the first 2 days was 0.5% for medium-risk, 2% for high-risk and very low thereafter. We recruited 31 physicians (14 ED, 7 cardiologists, 10 hospitalists/internists). 80% of physicians agreed that low risk patients can be discharged without specific follow-up with inconsistencies around length of ED observation. For cardiac monitoring of medium and high-risk, 64% indicated that they don't have access; 56% currently admit high-risk patients and an additional 20% agreed to this recommendation. A deeper exploration led to following refinement: discharge without specific follow-up for low-risk, a shared decision approach for medium-risk and short course of hospitalization for high-risk patients. Conclusion: The recommendations were developed (with online calculator) based on in-depth feedback from key stakeholders to improve uptake during implementation.
The ‘jumping to conclusions’ (JTC) bias is associated with both psychosis and general cognition but their relationship is unclear. In this study, we set out to clarify the relationship between the JTC bias, IQ, psychosis and polygenic liability to schizophrenia and IQ.
A total of 817 first episode psychosis patients and 1294 population-based controls completed assessments of general intelligence (IQ), and JTC, and provided blood or saliva samples from which we extracted DNA and computed polygenic risk scores for IQ and schizophrenia.
The estimated proportion of the total effect of case/control differences on JTC mediated by IQ was 79%. Schizophrenia polygenic risk score was non-significantly associated with a higher number of beads drawn (B = 0.47, 95% CI −0.21 to 1.16, p = 0.17); whereas IQ PRS (B = 0.51, 95% CI 0.25–0.76, p < 0.001) significantly predicted the number of beads drawn, and was thus associated with reduced JTC bias. The JTC was more strongly associated with the higher level of psychotic-like experiences (PLEs) in controls, including after controlling for IQ (B = −1.7, 95% CI −2.8 to −0.5, p = 0.006), but did not relate to delusions in patients.
Our findings suggest that the JTC reasoning bias in psychosis might not be a specific cognitive deficit but rather a manifestation or consequence, of general cognitive impairment. Whereas, in the general population, the JTC bias is related to PLEs, independent of IQ. The work has the potential to inform interventions targeting cognitive biases in early psychosis.
Geographical separation of psychiatric units from general hospitals may significantly delay provision of optimal treatment for patients in a medical emergency. Following a ‘near miss’ event, we explored how well equipped our unit is for managing such cases. Our objectives were: To explore how confident staff are in dealing with medical emergencies
1. To measure staff confidence levels in emergency care procedures
2. To evaluate staff orientation by exploring how well staff could locate key equipment
Distribution of a questionnaire survey asking respondents to rate their confidence in various emergency skills, for example maintaining an airway. Staff were also asked to rate their confidence in being able to locate emergency equipment and medication when necessary. In addition, suggestions for improvement in provision of any aspect of emergency care were sought.
Following this, data collation was performed by various members of the multi-disciplinary team with scrutiny of current practice. Areas of change include layout of emergency trolley, revision of staff induction to emergency equipment and provision of easily accessible protocols for common medical emergencies. Following these changes, the questionnaire will be re-distributed and the datasets compared.
We anticipate that the survey will be completed by February 2010
This investigation will provide very useful, practical data on how well prepared for an emergency a typical psychiatric ward and staff are for providing immediate emergency care. This will have implications for induction and staff training policy, to ensure patient safety and provision of appropriate medical treatment.
At the European Psychiatric Association's International Congress 2010, we reported on psychiatric staff confidence regarding emergency medical care in our poster: “How Well Prepared is a Psychiatric Ward for Dealing with a Medical Emergency?”. This work highlighted areas for improvement, including staff confidence and familiarity with equipment. Consequently, several aspects of practice were enhanced, including addressing training shortfalls alongside adopting a uniform layout for emergency trolleys. In order to identify improvement, the process was re-audited with a new qualitative component to gather staff opinion.
Our primary objective was to examine whether our interventions had improved staff confidence with regard emergency medical care. Our secondary objectives included exploring staff attitudes toward delivery of such care and to identify further areas for improvement.
Our primary aim was to evaluate the impact of our interventions on delivery of emergency medical care
Our original questionnaire survey was repeated and the results compared with those obtained previously. Additionally, a series of semi-structured qualitative interviews will be performed with staff to compliment the questionnaires.
Results will be available in February 2011.
Given that psychiatric patients often suffer from significant physical health problems, it is imperative that staff are comfortable in delivering initial emergency medical care. We anticipate our results will demonstrate modest improvement. Clinical governance is an ongoing process, therefore the most important conclusions to be drawn will be our recommendations for future work, which will encompass the next step in our efforts to improve delivery of emergency medical care.
It is perceived that negative attitudes towards mental illness in undergraduate medical students can impact student's decision in choosing psychiatry as a medical career. Improvement in psychiatry placements for undergraduate medical students can result in changing student's attitude towards psychiatry as a career choice. We demonstrate how students’ placements from various medical schools at a major psychiatric hospital contributed towards enhancing student's interest towards psychiatry. Medical students who had their placement over the last one year were contacted for an anonymised student perspective survey.
While majority of students did not have psychiatry as their potential career choice before they started their placements more than two third rated psychiatry as a potential career choice based on their experience from the placements. This encouraged us to improve the placement standards based on student's perspective. Students suggested that more use of medical training in psychiatry, improvement in teaching and placement standards and more psychiatry placements before specialised training can contribute towards making psychiatry as one of the popular career choices. Student's preferred interactive teaching sessions including case based discussions and informal teaching sessions during ward rounds and clinics. Overall students found their placements helpful but more so to perform well in their examinations as compared to coverage of full psychiatry curriculum.
It is planned to conduct the survey again after necessary changes based on student's perspective to evaluate whether further improvement in placements can continue in contributing towards increasing medical recruitment in psychiatry.
Pervasive Refusal Syndrome (PRS) is a relatively new diagnostic concept, that describes a rare and potentially life threatening condition, in which children refuse to walk.
talk, eat, drink, engage in self care, and take part in day to day activities (Lask et al, 1991).
PRS is not included in any of the psychiatric classification systems (ICD 10, DSM IV), although consensus exists within the literature as to its existence. Lask comments in his paper on Pervasive Refusal Syndrome that he has consulted on only 50 cases worldwide (Lask, 2004).
The authors will share their clinical experience of treating seven new cases of PRS in a Regional CAMHS inpatient hospital. Patients with PRS often require hospital admission for assessment and exclusion of other medical, neurological and psychiatric disorders. However, because of the rarity many medical and psychiatric professionals have little experience of the treatment and rehabilitation required.
The specific MDT management approach necessary to meet the complex needs of patients with PRS will be discussed, as treatment is often counterintuitive, and some approaches can result in deterioration rather than improvement.
In terms of improvement and recovery from the disorder, less is known about long term follow-up, as only a few studies have reported on immediate outcome. The authors have undertaken a long term follow-up (in press) and will discuss issues relating to prognosis.
A specific MDT treatment approach for PRS will be discussed, alongside the clinical decisions and dilemmas involved in following this approach.
Depression is a highly prevalent disease and its costs can be burdensome to both patients and payers.
To compare the short-term costs, outcomes, and cost-effectiveness associated with major depressive disorder (MDD) treatment with venlafaxine XR and major market comparators (duloxetine and two selective serotonin reuptake inhibitors [SSRIs], namely escitalopram and sertraline HCL) in Italy from the Italian National Health Service perspective.
To inform treatment decisions based on cost effectiveness of MDD treatments.
A decision tree structure was used to model MDD treatment over 1 year. Patients were treated with one of the model comparators and based on published clinical literature; either remained depressed, achieved response but no remission, or achieved remission. Drug costs were set to the reimbursed price for the recommended dose of each treatment. Costs of hospitalization and utility weights were based on depression status.
Venlafaxine XR was estimated to be the most effective treatment (0.736 quality-adjusted life years [QALYs]) followed by the SSRIs (0.731) and duloxetine (0.714). Total annual MDD-related costs for venlafaxine (€691) were estimated to be lower than all comparators (duloxetine=€1,308, escitalopram=€874) except sertraline HCL (€638), owing largely to drug cost differences and hospitalization savings associated with better projected depression status. Venlafaxine was cost-saving (more effective, less costly) compared with duloxetine and escitalopram. The incremental cost per QALY gained vs. sertraline HCL was €9,844.
Based on the model, venlafaxine XR represents a cost-effective treatment option for MDD in Italy and may result in costsavings depending on the comparison.
Airborne radio-echo sounding (RES) surveys are widely used to measure ice-sheet bed topography. Measuring bed topography as accurately and widely as possible is of critical importance to modelling ice dynamics and hence to constraining better future ice response to climate change. Measurement accuracy of RES surveys is influenced both by the geometry of bed topography and the survey design. Here we develop a novel approach for simulating RES surveys over glaciated terrain, to quantify the sensitivity of derived bed elevation to topographic geometry. Furthermore, we investigate how measurement errors influence the quantification of glacial valley geometry. We find a negative bias across RES measurements, where off-nadir return measurement error is typically −1.8 ± 11.6 m. Topographic highlands are under-measured an order of magnitude more than lowlands. Consequently, valley depth and cross-sectional area are largely under-estimated. While overall estimates of ice thickness are likely too high, we find large glacier valley cross-sectional area to be under-estimated by −2.8 ± 18.1%. Therefore, estimates of ice flux through large outlet glaciers are likely too low when this effect is not taken into account. Additionally, bed mismeasurements potentially impact our appreciation of outlet-glacier stability.
The measurement of thin film mechanical properties free from substrate influence remains one of the outstanding challenges in nanomechanics. Here, a technique based on indentation of a supported film with a flat punch whose diameter is many times the initial film thickness is introduced. This geometry generates a state of confined uniaxial strain for material beneath the punch, allowing direct access to intrinsic stress versus strain response. For simple elastic–plastic materials, this enables material parameters such as elastic modulus, bulk modulus, Poisson's ratio, and yield stress to be simultaneously determined from a single loading curve. The phenomenon of confined plastic yield has not been previously observed in thin films or homogeneous materials, which we demonstrate here for 170 -470 nm thick polystyrene (PS), polymethyl-methacrylate (PMMA) and amorphous Selenium films on silicon. As well as performing full elastic -plastic parameter extraction for these materials at room temperature, we used the technique to study the variation of yield stress in PS to temperatures above the nominal glass transition of 100 °C.
The flat oyster Ostrea edulis has declined significantly in European waters since the 1850s as a result of anthropogenic activity. Ostrea edulis was designated a UK Biodiversity Action Plan Species and Habitat in 1995, and as a Feature of Conservation Importance (FOCI) within the UK Marine & Coastal Access Act 2009. To promote the recovery of oyster beds, a greater understanding of its abundance and distribution is required. Distribution of O. edulis across the proposed Blackwater, Crouch, Roach and Colne MCZ in Essex was determined between 2008 and 2012. Ostrea edulis were present in four estuary zones; with highest sample abundance in the Blackwater and Ray Sand zones. Size structure of populations varied, with the Ray Sand and Colne zones showing a significant lack of individuals with shell height <39 mm. Ostrea edulis occurred in highest number on shell substratum, followed by silty sediments. There were no significant associations between O. edulis abundance or size structure with water column Chl a, suspended solids, oxygen, nitrate or ammonium concentrations, temperature or pH. Highest abundance and most equitable population shell-size distribution for O. edulis were located within, or adjacent to, actively managed aquaculture zones. This suggests that traditional seabed management contributed to the maintenance or recovery of the species of conservation concern. Demonstration that the Essex estuaries were a stronghold for Ostrea edulis in the southern North sea area led to the designation of the Blackwater, Crouch, Roach and Colne estuaries Marine Conservation Zone in 2013.
New δ13Ccarb and microfacies data from Hereford–Worcestershire and the West Midlands allow for a detailed examination of variations in the Homerian carbon isotope excursion (Silurian) and depositional environment within the Much Wenlock Limestone Formation of the Midland Platform (Avalonia), UK. These comparisons have been aided by a detailed sequence-stratigraphic and bentonite correlation framework. Microfacies analysis has identified regional differences in relative sea-level change and indicates an overall shallowing of the carbonate platform interior from Hereford–Worcestershire to the West Midlands. Based upon the maximum δ13Ccarb values for the lower and upper peaks of the Homerian carbon isotope excursion (CIE), the shallower depositional setting of the West Midlands is associated with values that are 0.7 ‰ and 0.8 ‰ higher than in Hereford–Worcestershire. At the scale of parasequences the effect of depositional environment upon δ13Ccarb values can also be observed, with a conspicuous offset in the position of the trough in δ13Ccarb values between the peaks of the Homerian CIE. This offset can be accounted for by differences in relative sea-level change and carbonate production rates. While such differences complicate the use of CIEs as a means of high-resolution correlation, and caution against correlations based purely upon the isotopic signature, it is clear that a careful analysis of the depositional environment can account for such differences and thereby improve the use of carbon isotopic curves as a means of correlation.