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Peripheral low-grade inflammation in depression is increasingly seen as a therapeutic target. We aimed to establish the prevalence of low-grade inflammation in depression, using different C-reactive protein (CRP) levels, through a systematic literature review and meta-analysis.
We searched the PubMed database from its inception to July 2018, and selected studies that assessed depression using a validated tool/scale, and allowed the calculation of the proportion of patients with low-grade inflammation (CRP >3 mg/L) or elevated CRP (>1 mg/L).
After quality assessment, 37 studies comprising 13 541 depressed patients and 155 728 controls were included. Based on the meta-analysis of 30 studies, the prevalence of low-grade inflammation (CRP >3 mg/L) in depression was 27% (95% CI 21–34%); this prevalence was not associated with sample source (inpatient, outpatient or population-based), antidepressant treatment, participant age, BMI or ethnicity. Based on the meta-analysis of 17 studies of depression and matched healthy controls, the odds ratio for low-grade inflammation in depression was 1.46 (95% CI 1.22–1.75). The prevalence of elevated CRP (>1 mg/L) in depression was 58% (95% CI 47–69%), and the meta-analytic odds ratio for elevated CRP in depression compared with controls was 1.47 (95% CI 1.18–1.82).
About a quarter of patients with depression show evidence of low-grade inflammation, and over half of patients show mildly elevated CRP levels. There are significant differences in the prevalence of low-grade inflammation between patients and matched healthy controls. These findings suggest that inflammation could be relevant to a large number of patients with depression.
After five positive randomized controlled trials showed benefit of mechanical thrombectomy in the management of acute ischemic stroke with emergent large-vessel occlusion, a multi-society meeting was organized during the 17th Congress of the World Federation of Interventional and Therapeutic Neuroradiology in October 2017 in Budapest, Hungary. This multi-society meeting was dedicated to establish standards of practice in acute ischemic stroke intervention aiming for a consensus on the minimum requirements for centers providing such treatment. In an ideal situation, all patients would be treated at a center offering a full spectrum of neuroendovascular care (a level 1 center). However, for geographical reasons, some patients are unable to reach such a center in a reasonable period of time. With this in mind, the group paid special attention to define recommendations on the prerequisites of organizing stroke centers providing medical thrombectomy for acute ischemic stroke, but not for other neurovascular diseases (level 2 centers). Finally, some centers will have a stroke unit and offer intravenous thrombolysis, but not any endovascular stroke therapy (level 3 centers). Together, these level 1, 2, and 3 centers form a complete stroke system of care. The multi-society group provides recommendations and a framework for the development of medical thrombectomy services worldwide.
International studies have shown that patients want their spiritual needs attended to at the end of life. The present authors developed a project to investigate people's understanding of spirituality and spiritual care practices in New Zealand (NZ) hospices.
A mixed-methods approach included 52 semistructured interviews and a survey of 642 patients, family members, and staff from 25 (78%) of NZ's hospices. We employed a generic qualitative design and analysis to capture the experiences and understandings of participants' spirituality and spiritual care, while a cross-sectional survey yielded population level information.
Our findings suggest that spirituality is broadly understood and considered important for all three of the populations studied. The patient and family populations had high spiritual needs that included a search for (1) meaning, (2) peace of mind, and (3) a degree of certainty in an uncertain world. The healthcare professionals in the hospices surveyed seldom explicitly met the needs of patients and families. Staff had spiritual needs, but organizational support was sometimes lacking in attending to these needs.
Significance of results:
As a result of our study, which was the first nationwide study in NZ to examine spirituality in hospice care, Hospice New Zealand has developed a spirituality professional development program. Given that spirituality was found to be important to the majority of our participants, it is hoped that the adoption of such an approach will impact on spiritual care for patients and families in NZ hospices.
For the child in residential care who, for whatever reason will not be returning to the natural family, long term foster placement is often seen as a means of providing a suitable alternative family environment. The formation of mutually satisfying emotional ties within a family setting is recognised as being an important ingredient is the healthy psychological development of a child. However, the high rate of foster placement breakdown attests to the fact that these ties are not easily formed.
In South Australia, at any one time, approximately 2,300 children are known to be living apart from their parents. Some 1,500 of these children are in foster care. A 1982 Department for Community Welfare survey of a 50% sample of children who had been in continuous foster care for more than three years revealed that, while 60%of the sample had experienced only one foster placement, 24% had experienced three or more foster placements. Figures are similar In the United States where analysis of eleven foster care studies revealed that some 23% of children had three or more placements. (Westman, 1979).
Altitudinal transects of biodiversity are important to understanding macro-ecological patterns. Hump-shaped altitudinal profiles in species richness are a common pattern in terrestrial small-mammal communities studied previously mostly in New World mountain ranges. Based on capture–mark–recapture live-trapping conducted over four seasons (four nights per session) along an altitudinal transect from 1000 to 1747 m asl on the southern slopes of the Soutpansberg Mountains of northern South Africa, we recorded 12 species of small mammal, including nine rodents, two shrews and one elephant shrew (sengi). Three species of rodent and the sengi dominated the communities whilst six species were recorded with three or fewer captures. Although we found no effect of season, we found a significant linear increase in terrestrial small-mammal richness (but not Simpson's diversity, D) with altitude in the Soutpansberg Mountains located just north of the Tropic of Capricorn in South Africa. This trend could best be explained by an increase in the proportion of rocky cover and a change in vegetation from savanna to grassland. Peak densities of three common rodent species and one common insectivore varied from 10 ha−1 (Elephantulus myurus) to 54 ha−1 (Micaelamys namaquensis) and density showed no significant variation with season. However, density either declined (Aethomys ineptus) or increased (Rhabdomys dilectus and Elephantulus myurus) significantly with altitude; this variation was best explained by the proportion of rocky cover. Seasonal variation had a significant effect on body mass of two rodent species. A review of small-mammal studies from major mountain ranges in Africa and Madagascar found that the hump-shaped pattern is not common. Declines in richness with increasing altitude as well as cases of no significant altitudinal change were the most common patterns noted. Tropical African mountains (including the Soutpansberg with 27 species) have far higher small-mammal diversity than temperate African mountains.
Screening for alcohol use disorders identifies a wide range of needs, varying from hazardous and harmful drinking to alcohol dependence. Stepped care offers a potentially resource-efficient way of meeting these needs, but requires evaluation in a randomised controlled trial.
To evaluate the feasibility, effectiveness and cost-effectiveness of opportunistic screening and a stepped care intervention in primary care.
A total of 1794 male primary care attendees at six practices in South Wales were screened using the Alcohol Use Disorders Identification Test (AUDIT). Of these, 112 participants who scored 8 or more on the AUDIT and who consented to enter the study were randomised to receive either 5 minutes of minimal intervention delivered by a practice nurse (control group) or stepped care intervention consisting of three successive steps (intervention group): a single session of behaviour change counselling delivered by a practice nurse; four 50-minute sessions of motivational enhancement therapy delivered by a trained alcohol counsellor; and referral to a community alcohol treatment agency.
Both groups reduced alcohol consumption 6 months after randomisation with a greater, although not significant, improvement for the stepped care intervention. Motivation to change was greater following the stepped care intervention. The stepped care intervention resulted in greater cost savings compared with the minimal intervention.
Stepped care was feasible to implement in the primary care setting and resulted in greater cost savings compared with minimal intervention.
This chapter describes the key elements of volcanic disaster planning for health sector workers. A simplified way to approach volcanoes and their hazards is to learn whether they are mainly explosive or effusive (a nonexplosive outpouring of fluid lava) in behavior. The main eruptive hazards can be divided into fall and flow processes. Pyroclastic flows and surges, lahars and debris flows, and lava flows can, for emergency planning purposes, be envisaged by thinking visually or intuitively, but their behavior belongs to the world of flow, or fluid dynamics, on which the understanding of the blood circulation, meteorology, and aeronautics is based. Although mitigation of human casualties by timely evacuation is the main goal in emergency management of volcanic threats, disaster planners must also be familiar with rescue and emergency treatment measures and prepare for unique conditions associated with volcanic eruptions.
From 1994–2007 Ceredigion County Council and a network of shore-based, volunteer observers monitored levels of boat traffic and the occurrence of bottlenose dolphins Tursiops truncatus at seven sites on the coast of Cardigan Bay, Wales. We report high rates of site use and site occupancy by this species during the summer: at Mwnt for example, dolphins were recorded in >80% of 2 hours' observation periods; and at New Quay Harbour dolphins were present in >30% of all 15-minute intervals. At Mwnt and Aberporth there was a significant annual trend for increasing sighting rates; at Ynys Lochtyn a positive trend was only marginally non-significant; at New Quay Bird's Rock the trend was ambiguous but appeared stable over the seven most recent years. Although trends in site use may not reflect population trends in the wider region, these data were consistent with recent abundance estimates that indicate that the number of bottlenose dolphins using Cardigan Bay is stable or slightly increasing. Average group size at our study sites was small (<3 animals), which contrasts with observations of larger schools of the same population elsewhere in their range. The predominant behaviour in coastal Cardigan Bay is demersal foraging, often by solitary animals in shallow near-shore habitats. There was evidence that boat traffic suppressed site use by dolphins at New Quay Harbour, the busiest monitoring site: sighting rates fell when high numbers of boats were present and sighting rates were higher in 2007 than in previous years, when boat use was reduced due to poor weather during the main tourist season. This study demonstrates that networks of volunteer observers can provide a cost-effective, non-invasive means of gathering data on marine mammals for the purposes of coastal zone management.
Christie Baxter, Principal Research Scientist, Department of Urban Studies and Planning Massachusetts Institute of Technology (MIT),
Peter Tyler, University Professor of Urban and Regional Economics in the Department of Land Economy University of Cambridge
Many communities around the world want the economic benefits associated with high-technology jobs and companies. But creating and nurturing centers of high-technology, what we call “enterprising places,” is a complex business. Even when a place has the essential resources: an excellent university or research center, land and facilities for companies, and an educated workforce, it is not clear how to sustain a center from them. The efforts of policymakers to do just that comprise a rich source of experimental evidence. In 2002 and 2003, a research team from MIT and the University of Cambridge set out to examine this evidence in five regions known to be centers of high-technology in the United States and United Kingdom.
To guide the research, we focused on four realms that figured prominently in enterprising places: knowledge, finance, policy, and place (figure 12.1). We were especially interested in actions at the intersections of these realms and how they enhanced a location's competitiveness. We defined the “knowledge realm” to include the people, skills and ideas, and related education and research institutions that were located in a particular place. The finance realm represented the capital, institutions, and people that sustain investment in a place over time. The “policy realm” represented the institutional and regulatory context and the public and private policy agents that influenced the development of a place. The “place realm” represented the competencies of the location in terms of proximity, access, and concentration.
‘Normal’ comes from the latin norma, a carpenter's square, and in mediaeval times meant something at a right angle or perpendicular. A few centuries later it came to mean conforming to a standard and was used in physics to refer to the average of a set of variables. If the variable concerned, such as head size or IQ, is continuous and has a normal distribution, by convention the normal range has come to include values falling within two standard deviations either side of the mean – defining about 4.6% of the population as abnormal. By a similar approach, if the variable has a skewed distribution, such as the age of walking, those lying outside the 2nd and 98th centiles are often defined as abnormal, while the normal is equated to the average. This can also lead to misunderstandings, as, for example, in some child-rearing books when parents are told that the normal age of walking is 12 months, which can mistakenly imply that the 50% of children, who by definition are not walking at that age, are abnormal.
One privilege of working in the health service today is the enormous range of effective therapies available to us. Advances in surgical techniques, tools, and materials have been more than matched by the vast number of pharmaceutical products addressing an ever wider range of conditions. Even for conditions where treatments have been available for many years, newer agents may be more potent, have less adverse or unwanted effects, and be easier to take than their predecessors. This is a huge contribution by the pharmaceutical industry.
We know how important it is to diagnose epilepsy correctly, but how to do so is surprisingly little validated. An inadequate history and misinterpretation of the electroencephalogram (EEG) are the major reasons 4 to 26% of children and adults in European studies are misdiagnosed with epilepsy. Error rates are not available for most countries, or for more precise diagnoses of seizure types, epilepsy syndrome, and cause.
Duchenne muscular dystrophy is the most common life-limiting muscle disorder of childhood. Survival has improved, largely due to more effective orthopaedic and respiratory management. However, abnormal cardiac muscle function (cardiomyopathy) develops in most patients by the age of 18 years and can cause heart failure, leading to 10–40% of deaths. This percentage may be increasing as management of the respiratory complications becomes more successful. As a result, in 2003 a European group recommended an ECG and echocardiogram at diagnosis, then every 2 years until the age of 10, and annually thereafter. If progressive abnormalities occurred they recommended treatment with angiotensin-converting enzymes (ACE) inhibitors and, if needed, beta-blockers. They commented that there was no evidence behind these recommendations and called for multicentre trials. At the end of 2005, the Cardiology section of the American Academy of Pediatrics published similar recommendations and commented on the minimal evidence base. However, as shown by the review article by English and Gibbs in this issue, not all cardiologists agree with these guidelines.
The recently proposed definition and classification of cerebral palsy (CP) is still up for debate – see the correspondence in this issue – and additional comments via the Castang website are warmly invited before the final version is completed next month (www.castangfoundation.net/workshops_washington_public.asp). The Castang Foundation funds ‘research into the causes of CP and other neurodevelopmental disorders leading to their prevention’. Rightly, the document does not specify the ‘non-progressive disturbances’ to which CP is attributed, with the exception of cerebral dysplasia. It is unclear why this should be picked out since in developed countries white matter disorders and perinatal vascular events currently appear more common. Data from other parts of the world are less available, but emphasize the continuing importance of post-neonatal causes. As the relative importance of different disturbances changes with medical knowledge, geography, and over time, a non-specific definition is understandable.
Home parenteral nutrition is an established method of supporting patients with intestinal failure, but this treatment may be life long and imposes severe restrictions on daily life. Impact on quality of life is an important outcome when considering the management of home parenteral nutrition patients. This paper reviews studies in which the quality of life of patients receiving home parenteral nutrition has been assessed. A systematic search of electronic databases and relevant publications was undertaken to identify generic or treatment-specific questionnaires used with home parenteral nutrition patients. Many of the thirty-four reports discovered were small studies. Nineteen used non-specific generic instruments, eight used non-validated questionnaires, four used a combination of both, and three did not use any formal tool. Few systematic patterns emerged. There are few available data on the quality of life of home parenteral nutrition patients, and there is a need for standardised, scientifically validated, treatment-specific instruments to measure quality of life in this population.
Several articles in this issue reinforce Aicardi's dictum that in epilepsy, seizures are only the tip of the iceberg. They remind us that epilepsy is a symptom of a brain disorder and that children with epilepsy can have extra needs that may or may not be due to the epilepsy itself. Rightly, there has been increasing emphasis that proper medical management encompasses more than ‘just’ seizure control. Quality of life measures in childhood epilepsy are still not perfect, but they suggest only a moderate association with seizure control. Social inclusion, lifestyle restrictions, effects on family life, associated physical impairments, learning and/or behaviour difficulties, and unwanted effects from treatment are all recognized as major factors, as well as seizure frequency and severity. More recently we are finding how prevalent attentional difficulties, including attention-deficit–hyperactivity disorder, are in children with epilepsy and the importance of sleep problems.
Volcanoes can hold a deep fascination. Images of erupting volcanoes grab our attention as we marvel at the sight of the Earth in violent movement, and tourists flock to view steaming craters to sense the enormous energy lying dormant beneath their feet. Volcanoes are often striking features in landscapes of great beauty, and people have been drawn over the centuries to live on their flanks with the promise of verdant agricultural land. But many communities have learned that years of peace can be brutally interrupted by the return of volcanic activity, and in some parts of the world such as Hawaii and Indonesia, volcanoes have even been granted the status of gods.
In most active volcanic areas, however, burgeoning populations have no memory of past eruptions when they recur with intervals of hundreds or thousands of years, and no feeling for the disaster that can lie ahead when the sleeping giant awakes. The destruction of Pompeii and Herculaneum in the eruption of Vesuvius in AD 79 has the same hold on the popular imagination as the sinking of the Titanic by an iceberg, with the spectacle of normal living being abruptly halted by catastrophe and the evidence of extinguished life locked deep beneath the ground or sea. The collapse of the Minoan culture after the eruption of Santorini some 3600 years ago is perhaps the stuff of legend, but a huge eruption did occur which buried or swept away the settlements on the island and had impacts on other islands of the Aegean, such as Crete.