Making a U-turn on the Purfleet Interchange: Stone Tool Technology in Marine Isotope Stage 9 Britain and the Emergence of the Middle Palaeolithic in Europe

This paper re-examines earlier Palaeolithic core technology from British sites assigned to MIS 11, 9, and 7 using primarily a châine opératoire approach, with the objective of better understanding the earliest occurrence and distribution of Levallois and other prepared-core technologies across the Old World. Contrary to previous interpretations (White and Ashton in Current Anthropology, 44: 598–609, 2003), we find no evidence for a true Levallois concept in MIS 11 or MIS 9 in Britain. Cores previously described as ‘simple prepared cores’ or ‘proto-Levallois’ cores show neither evidence of core management nor predetermination of the resulting flakes. They can instead be explained as the coincidental result of a simpler technological scheme aimed at exploiting the largest surface area of a core, thereby maximising the size of the flakes produced from it. This may be a more widespread practice, or a local solution derived from existing principles. Levallois appears fully formed in Britain during terminal MIS 8/initial MIS 7. Consequently, Britain does not provide evidence for an in situ evolution of Levallois, rather we argue it was introduced by new settlers after a glacial abandonment: the solution to the emergence and significance of Levallois lies in southern Europe, the Levant and Africa

Ovarian cancer symptom awareness and anticipated delayed presentation in a population sample

Background: While ovarian cancer is recognised as having identifiable early symptoms, understanding of the key determinants of symptom awareness and early presentation is limited. A population-based survey of ovarian cancer awareness and anticipated delayed presentation with symptoms was conducted as part of the International Cancer Benchmarking Partnership (ICBP). Methods: Women aged over 50 years were recruited using random probability sampling (n = 1043). Computer-assisted telephone interviews were used to administer measures including ovarian cancer symptom recognition, anticipated time to presentation with ovarian symptoms, health beliefs (perceived risk, perceived benefits/barriers to early presentation, confidence in symptom detection, ovarian cancer worry), and demographic variables. Logistic regression analysis was used to identify the contribution of independent variables to anticipated presentation (categorised as < 3 weeks or ≥ 3 weeks). Results: The most well-recognised symptoms of ovarian cancer were post-menopausal bleeding (87.4%), and persistent pelvic (79.0%) and abdominal (85.0%) pain. Symptoms associated with eating difficulties and changes in bladder/bowel habits were recognised by less than half the sample. Lower symptom awareness was significantly associated with older age (p ≤ 0.001), being single (p ≤ 0.001), lower education (p ≤ 0.01), and lack of personal experience of ovarian cancer (p ≤ 0.01). The odds of anticipating a delay in time to presentation of ≥ 3 weeks were significantly increased in women educated to degree level (OR = 2.64, 95% CI 1.61 – 4.33, p ≤ 0.001), women who reported more practical barriers (OR = 1.60, 95% CI 1.34 – 1.91, p ≤ 0.001) and more emotional barriers (OR = 1.21, 95% CI 1.06 – 1.40, p ≤ 0.01), and those less confident in symptom detection (OR = 0.56, 95% CI 0.42 – 0.73, p ≤ 0.001), but not in those who reported lower symptom awareness (OR = 0.99, 95% CI 0.91 – 1.07, p = 0.74). Conclusions: Many symptoms of ovarian cancer are not well-recognised by women in the general population. Evidence-based interventions are needed not only to improve public awareness but also to overcome the barriers to recognising and acting on ovarian symptoms, if delays in presentation are to be minimised

Improving mental health through the regeneration of deprived neighbourhoods: a prospective controlled quasi-experimental study

AbstractBACKGROUND Policy makers often target deprived neighbourhoods for regeneration with the expectation that population health will improve, since housing and neighbourhoods of low quality, as well as the social and economic determinants of poor health, are concentrated in the most deprived areas. Our aim was to examine the eff ects of Communities First, a Welsh Assembly Government community-led programme of neighbourhood regeneration targeted at the 100 most deprived electoral wards in Wales on mental health. METHODS Information on Communities First regeneration activities in 35 intervention lower super output areas (LSOAs) (n=4197) and 75 control LSOAs (6695) were linked to data from the eCATALyST study, a prospective cohort study, in 2001 (before regeneration) and 2008 (after regeneration) within the Secure Anonymised Information Linkage (SAIL) databank. Communities First was delivered through multiagency partnership boards in all 22 local authorities. Boards worked with residents to identify and secure funding for regeneration activities. The primary outcome was the change in Mental Health Inventory (MHI) score (a population-based measure of anxiety and depressive symptoms) between 2001 and 2008 recorded in eCATALyST. We examined the changes in mental health in intervention LSOAs compared with control LSOAs using propensity score matching (1:1 ratio) to balance the level of socioeconomic disadvantage across groups. Sensitivity analysis examined the impact of length of residence in an intervention area and six types of regeneration activity. FINDINGS 1500 regeneration projects were funded from 2001 to 2008. Before regeneration, mental health was worse in the intervention than in the control group (mean MHI score 66·6, SD 22·3 vs 71·0, SD 20·8). After propensity score matching, regeneration was associated with an improvement in the mental health of intervention compared with control group residents (β=1·54, 95% CI 0·50–2·59), suggesting that inequalities in mental health narrowed. We found evidence of a dose–response association between length of residence and improvements in mental health (ptrend=0·05). We could not attribute improvements to any one type of regeneration activity. Interpretation Targeted regeneration directed by the residents of deprived urban communities can help reduce inequalities in mental health. FUNDING This study was funded by a grant from the National Institute for Social Care and Health Research (RFS-12-05) and undertaken with the support of the Centre for the Development and Evaluation of Complex Interventions for Public Health Improvement (MR/KO232331/1) and the Farr Institute of Health Informatics Research

Improving Mental Health Through the Regeneration of Deprived Neighborhoods: A Natural Experiment

Neighborhood-level interventions provide an opportunity to better understand the impact of neighborhoods on health. In 2001, the Welsh Government, United Kingdom, funded Communities First, a program of neighborhood regeneration delivered to the 100 most deprived of the 881 electoral wards in Wales. In this study, the authors examined the association between neighborhood regeneration and mental health. Information on regeneration activities in 35 intervention areas (n=4,197 subjects) and 75 control areas (n=6,695 subjects) were linked to data on mental health from a cohort study with assessments in 2001 (before regeneration) and 2008 (after regeneration). Propensity score matching was used to estimate the change in mental health in intervention versus control neighborhoods. Baseline differences between intervention and control areas were of a similar magnitude as produced by paired randomization of neighborhoods. Regeneration was associated with an improvement in the mental health of residents in intervention areas compared to control neighborhoods (β coefficient = 1.54, 95% confidence interval: 0.50, 2.59), suggesting a reduction in socioeconomic inequalities in mental health. There was a dose response relationship between length of residence in regeneration neighborhoods and improvements in mental health (P-for-trend = 0.05). These results show the targeted regeneration of deprived neighborhoods can improve mental health

Change and Exchange: Economies of Literature and Knowledge in Early Modern Europe

The introductory essay outlines the way in which Change and Exchange places literature, and, in a wider sense, imaginative practice, at the centre of early modern economic knowledge. Probing the affinity between economic and metaphorical experience in terms of the transactional processes of change and exchange, it sets up the parameters within which the essays in the volume collectively forge a language to grasp early modern economic phenomena and their epistemic dimensions. It prepares the reader for the stimulating combination of materials that the book presents: the range of generic contexts engendered by emergent economic practices, structures of feeling and modes of knowing made available by new economic relations, and economies of transformation in discursive domains that are distinct from ‘economics’ as we understand it but cognate in their intuition of change and exchange as shaping agents

Investigation of the international comparability of population-based routine hospital data set derived comorbidity scores for patients with lung cancer

Introduction: The International Cancer Benchmarking Partnership (ICBP) identified significant international differences in lung cancer survival. Differing levels of comorbid disease across ICBP countries has been suggested as a potential explanation of this variation but, to date, no studies have quantified its impact. This study investigated whether comparable, robust comorbidity scores can be derived from the different routine population-based cancer data sets available in the ICBP jurisdictions and, if so, use them to quantify international variation in comorbidity and determine its influence on outcome. Methods: Linked population-based lung cancer registry and hospital discharge data sets were acquired from nine ICBP jurisdictions in Australia, Canada, Norway and the UK providing a study population of 233 981 individuals. For each person in this cohort Charlson, Elixhauser and inpatient bed day Comorbidity Scores were derived relating to the 4–36 months prior to their lung cancer diagnosis. The scores were then compared to assess their validity and feasibility of use in international survival comparisons. Results: It was feasible to generate the three comorbidity scores for each jurisdiction, which were found to have good content, face and concurrent validity. Predictive validity was limited and there was evidence that the reliability was questionable. Conclusion: The results presented here indicate that interjurisdictional comparability of recorded comorbidity was limited due to probable differences in coding and hospital admission practices in each area. Before the contribution of comorbidity on international differences in cancer survival can be investigated an internationally harmonised comorbidity index is required

Interference with work in fibromyalgia - effect of treatment with pregabalin and relation to pain response

BACKGROUND: Clinical trials in chronic pain often collect information about interference with work as answers to component questions of commonly used questionnaires but these data are not normally analysed separately. METHODS: We performed a meta-analysis of individual patient data from four large trials of pregabalin for fibromyalgia lasting 8-14 weeks. We analysed data on interference with work, inferred from answers to component questions of Fibromyalgia Impact Questionnaire (FIQ), Short Form 36 Health Survey, Sheehan Disability Scale, and Multidimensional Assessment of Fatigue, including "How many days in the past week did you miss work, including housework, because of fibromyalgia?" from FIQ. Analyses were performed according to randomised treatment group (pregabalin 150-600 mg daily or placebo), pain improvement (0-10 numerical pain rating scale scores at trial beginning vs. end), and end of trial pain state (100 mm visual analogue pain scale [VAS]). RESULTS: Comparing treatment group average outcomes revealed modest improvement over the duration of the trials, more so with active treatment than with placebo. For the 'work missed' question from FIQ the change for patients on placebo was from 2.2 (standard deviation [SD] 2.3) days of work lost per week at trial beginning to 1.9 (SD 2.1) days lost at trial end (p &lt; 0.01). For patients on 600 mg pregabalin the change was from 2.1 (SD 2.2) days to 1.6 (SD 2.0) days (p &lt; 0.001). However, the change in days of work lost was substantial in patients with a good pain response: from 2.0 (SD 2.2) days to 0.97 (SD 1.6) days (p &lt; 0.0001) for those experiencing &gt;/= 50% pain improvement and from 1.9 (SD 2.2) days to 0.73 (SD 1.4) days (p &lt; 0.0001) for those achieving a low level of pain at trial end (&lt;30 mm on the VAS). Patients achieving both &gt;/= 50% pain improvement and a pain score &lt;30 mm on the VAS had the largest improvement, from 2.0 (SD 2.2) days to 0.60 (SD 1.3) days (p &lt; 0.0001). Analysing answers to the other questions yielded qualitatively similar results. CONCLUSIONS: Effective pain treatment goes along with benefit regarding work. A reduction in time off work &gt;1 day per week can be achieved in patients with good pain responses

Extracellular volume quantification in isolated hypertension - changes at the detectable limits?

The funding source (British Heart Foundation and UK National Institute for Health Research) provided salaries for research training (FZ, TT, DS, SW), but had no role in study design, collection, analysis, interpretation, writing, or decisions with regard to publication. This work was undertaken at University College London Hospital, which received a proportion of funding from the UK Department of Health National Institute for Health Research Biomedical Research Centres funding scheme. We are grateful to King’s College London Laboratories for processing the collagen biomarker panel

Nonsteroidal anti-inflammatory drugs (NSAIDs), cyxlooxygenase-2 selective inhibitors (coxibs) and gastrointestinal harm: review of clinical trials and clinical practice

BACKGROUND: Gastrointestinal harm, known to occur with NSAIDs, is thought to be lower with NSAID and gastroprotective agent, and with inhibitors selective to cyclooxygenase-2 (coxibs) at usual plasma concentrations. We examine competing strategies for available evidence of reduced gastrointestinal bleeding in clinical trials and combine this evidence with evidence from clinical practice on whether the strategies work in the real world, whether guidance on appropriate prescribing is followed, and whether patients adhere to the strategies. METHODS: We used a series of systematic literature searches to find full publications of relevant studies for evidence about the efficacy of these different gastroprotection strategies in clinical trials, and for evidence that they worked and were adhered to in clinical practice – whether they were effective. We chose to use good quality systematic reviews and meta-analyses when they were available. RESULTS: Evidence of efficacy of coxibs compared to NSAIDs for upper gastrointestinal bleeding was strong, with consistent reductions in events of about 50% in large randomised trials (34,460 patients), meta-analyses of randomised trials (52,474 patients), and large observational studies in clinical practice (3,093 bleeding events). Evidence on the efficacy of NSAID plus gastroprotection with acid suppressants (proton pump inhibitors, PPIs, and histamine antagonists, H2As) was based mainly on the surrogate measure of endoscopic ulcers. The limited information on damage to the bowel suggested that NSAID plus PPI was more damaging than coxibs. Eleven observational studies studied 1.6 million patients, of whom 911,000 were NSAID users, and showed that 76% (range 65% to 90%) of patients with at least one gastrointestinal risk factor received no prescription for gastroprotective agent with an NSAID. The exception was a cohort of US veterans with previous gastrointestinal bleeding, where 75% had gastroprotection with an NSAID. When gastroprotection was prescribed, it was often described as inadequate. A single study suggested that patient adherence to prescribed gastroprotection was low. CONCLUSION: Evidence for efficacy of gastroprotection strategies with NSAIDs is limited. In clinical practice few patients who need gastroprotection get it, and those who get it may not take it. For coxibs, gastroprotection is inherent, although probably not complete