Audit of head injury management in Accident and Emergency at two hospitals: implications for NICE CT guidelines

BACKGROUND: The National Institute for Clinical Excellence (NICE) has produced guidelines on the early management of head injury. This study audits the process of the management of patients with head injury presenting at Accident and Emergency (A&E) departments and examines the impact upon resources of introducing NICE guidelines for eligibility of a CT scan. METHODS: A retrospective audit of consecutive patients of any age, presenting at A&E with a complaint of head injury during one month in two northern District General Hospitals forming part of a single NHS Trust. RESULTS: 419 patients presented with a median age of 15.5 years, and 61% were male. 58% had a Glasgow Coma Score (GCS) recorded and 33 (8%) were admitted. Only four of the ten indicators for a CT scan were routinely assessed, but data were complete for only one (age), and largely absent for another (vomiting). Using just three (incomplete) indicators showed a likely 4 fold increase in the need for a CT scan. CONCLUSIONS: The majority of patients who present with a head injury to Accident and Emergency departments are discharged home. Current assessment processes and associated data collection routines do not provide the information necessary to implement NICE guidelines for CT brain scans. The development of such clinical audit systems in a busy A&E department is likely to require considerable investment in technology and/or staff. The resource implications for radiology are likely to be substantial

Bartonella quintana coinfection with Mycobacterium avium complex and CMV in an AIDS patient: case presentation

BACKGROUND: As a greater number of HIV-infected patients survive despite profound immunodepression due to medical progress, we face complex infection with multiple agents in AIDS-patients. CASE PRESENTATION: We report the case of an AIDS patient with a primary clinical presentation suggestive of bacillary angiomatosis. We also found in cutaneous lesions Mycobacterium avium complex and cytomegalovirus. CONCLUSION: This clinical case illustrates the possibility of multiple coinfections in AIDS patients and the need to be exhaustive in evaluating infectious diseases in severely immunocompromised patients

The relationship between fertility and lifespan in humans

Evolutionary theories of aging predict a trade-off between fertility and lifespan, where increased lifespan comes at the cost of reduced fertility. Support for this prediction has been obtained from various sources. However, which genes underlie this relationship is unknown. To assess it, we first analyzed the association of fertility with age at menarche and menopause, and with mortality in 3,575 married female participants of the Rotterdam Study. In addition, we conducted a candidate gene study where 1,664 single nucleotide polymorphisms (SNPs) in 25 candidate genes were analyzed in relation to number of children as a measure of fertility. SNPs that associated with fertility were analyzed for association with mortality. We observed no associations between fertility and age at menarche (p = 0.38) and menopause (p = 0.07). In contrast, fertility was associated with mortality. Women with two to three children had significantly lower mortality (hazard ratio (HR), 0.82; 95% confidence interval (95% CI), 0.69–0.97) compared to women with no children. No such benefit was observed for women with four or more children, who had a similar mortality risk (HR, 0.93; 95% CI, 0.76–1.13) as women with no children. The analysis of candidate genes revealed four genes that influence fertility after correction for multiple testing: CGB/LHB gene cluster (p = 0.0036), FSHR (p = 0.023), FST (p = 0.023), and INHBA (p = 0.021). However, none of the independent SNPs in these genes predicted mortality. In conclusion, women who bear two to three children live longer than those who bear none or many children, but this relationship was not mediated by the candidate genes analyzed in this study

Delineating ethnic and religious identities in research with British South Asians

The present essay presents a rationale for delineating ethnic and religious identities in empirical research into self-identification among British South Asians. It is argued that the delineation of these identities is important in order to (i) predict and explain the identificatory possibilities available to these individuals; (ii) explore the differential values attributed to these identities; (iii) the level of psychological 'connectedness' between the identities; and (iv) the inter-relations between these identities, particularly in relation to psychological coherence. It is argued that a systematic delineation of these identities may have favourable theoretical, empirical and practical outcomes

Eight common genetic variants associated with serum dheas levels suggest a key role in ageing mechanisms

Dehydroepiandrosterone sulphate (DHEAS) is the most abundant circulating steroid secreted by adrenal glands-yet its function is unknown. Its serum concentration declines significantly with increasing age, which has led to speculation that a relative DHEAS deficiency may contribute to the development of common age-related diseases or diminished longevity. We conducted a meta-analysis of genome-wide association data with 14,846 individuals and identified eight independent common SNPs associated with serum DHEAS concentrations. Genes at or near the identified loci include ZKSCAN5 (rs11761528; p = 3.15×10-36), SULT2A1 (rs2637125; p = 2.61×10-19), ARPC1A (rs740160; p = 1.56×10-16), TRIM4 (rs17277546; p = 4.50×10-11), BMF (rs7181230; p = 5.44×10-11), HHEX (rs2497306; p = 4.64×10-9), BCL2L11 (rs6738028; p = 1.72×10-8), and CYP2C9 (rs2185570; p = 2.29×10-8). These genes are associated with type 2 diabetes, lymphoma, actin filament assembly, drug and xenobiotic metabolism, and zinc finger proteins. Several SNPs were associated with changes in gene expression levels, and the related genes are connected to biological pathways linking DHEAS with ageing. This study provides much needed insight into the function of DHEAS

Lithic technological responses to Late Pleistocene glacial cycling at Pinnacle Point Site 5-6, South Africa

There are multiple hypotheses for human responses to glacial cycling in the Late Pleistocene, including changes in population size, interconnectedness, and mobility. Lithic technological analysis informs us of human responses to environmental change because lithic assemblage characteristics are a reflection of raw material transport, reduction, and discard behaviors that depend on hunter-gatherer social and economic decisions. Pinnacle Point Site 5-6 (PP5-6), Western Cape, South Africa is an ideal locality for examining the influence of glacial cycling on early modern human behaviors because it preserves a long sequence spanning marine isotope stages (MIS) 5, 4, and 3 and is associated with robust records of paleoenvironmental change. The analysis presented here addresses the question, what, if any, lithic assemblage traits at PP5-6 represent changing behavioral responses to the MIS 5-4-3 interglacial-glacial cycle? It statistically evaluates changes in 93 traits with no a priori assumptions about which traits may significantly associate with MIS. In contrast to other studies that claim that there is little relationship between broad-scale patterns of climate change and lithic technology, we identified the following characteristics that are associated with MIS 4: increased use of quartz, increased evidence for outcrop sources of quartzite and silcrete, increased evidence for earlier stages of reduction in silcrete, evidence for increased flaking efficiency in all raw material types, and changes in tool types and function for silcrete. Based on these results, we suggest that foragers responded to MIS 4 glacial environmental conditions at PP5-6 with increased population or group sizes, 'place provisioning', longer and/or more intense site occupations, and decreased residential mobility. Several other traits, including silcrete frequency, do not exhibit an association with MIS. Backed pieces, once they appear in the PP5-6 record during MIS 4, persist through MIS 3. Changing paleoenvironments explain some, but not all temporal technological variability at PP5-6.Social Science and Humanities Research Council of Canada; NORAM; American-Scandinavian Foundation; Fundacao para a Ciencia e Tecnologia [SFRH/BPD/73598/2010]; IGERT [DGE 0801634]; Hyde Family Foundations; Institute of Human Origins; National Science Foundation [BCS-9912465, BCS-0130713, BCS-0524087, BCS-1138073]; John Templeton Foundation to the Institute of Human Origins at Arizona State Universit

Factors predicting clinically significant fatigue in women following treatment for primary breast cancer

Cancer-related fatigue is common, complex, and distressing. It affects 70–100% of patients receiving chemotherapy and a significant number who have completed their treatments. We assessed a number of variables in women newly diagnosed with primary breast cancer (BrCa) to determine whether biological and/or functional measures are likely to be associated with the development of clinically significant fatigue (CSF). Two hundred twenty-three women participated in a study designed to document the impact of the diagnosis and treatment of primary breast cancer on function. Forty-four had complete data on all variables of interest at the time of confirmed diagnosis but prior to treatment (baseline) and ≥9 months post-diagnosis. Objective measures and descriptive variables included history, physical examination, limb volume, hemoglobin, white blood cell count, and glucose. Patient-reported outcomes included a verbal numerical rating of fatigue (0–10, a score of ≥4 was CSF), five subscales of the SF-36, Physical Activity Survey, and Sleep Questionnaire. At baseline, the entire cohort (n = 223) and the subset (n = 44) were not significantly different for demographic, biological, and self-reported data, except for younger age (p = 0.03) and ER+ (p = 0.01). Forty-five percent had body mass index (BMI) ≥ 25, 52% were post-menopause, and 52% received modified radical mastectomy, 39% lumpectomy, 52% chemotherapy, 68% radiation, and 86% hormonal therapy. Number of patients with CSF increased from 1 at baseline to 11 at ≥9 months of follow-up. CSF at ≥9 months significantly correlated with BMI ≥ 25, abnormal white blood cell count, and increase in limb volume and inversely correlated with vigorous activity and physical function (p < 0.05). Fatigue increases significantly following the treatment of BrCa. Predictors of CSF include high BMI and WBC count, increase in limb volume, and low level of physical activity. These are remediable

Medical Conditions of Nursing Home Admissions

<p>Abstract</p> <p>Background</p> <p>As long-term nursing home care is likely to increase with the aging of the population, identifying chronic medical conditions is of particular interest. Although need factors have a strong impact on nursing home (NH) admission, the diseases causing these functional disabilities are lacking or unclear in the residents' file. We investigated the medical reason (primary diagnosis) of a nursing home admission with respect to the underlying disease.</p> <p>Methods</p> <p>This study is based on two independent, descriptive and comparative studies in Belgium and was conducted at two time points (1993 and 2005) to explore the evolution over twelve years. Data from the subjects were extracted from the resident's file; additional information was requested from the general practitioner, nursing home physician or the head nurse in a face-to-face interview. In 1993 we examined 1332 residents from 19 institutions, and in 2005 691 residents from 7 institutions. The diseases at the time of admission were mapped by means of the International Classification of Diseases - 9th edition (ICD-9). Longitudinal changes were assessed and compared by a chi-square test.</p> <p>Results</p> <p>The main chronic medical conditions associated with NH admission were dementia and stroke. Mental disorders represent 48% of all admissions, somatic disorders 43% and social/emotional problems 8%. Of the somatic disorders most frequently are mentioned diseases of the circulatory system (35%) [2/3 sequels of stroke and 1/5 heart failure], followed by diseases of the nervous system (15%) [mainly Parkinson's disease] and the musculoskeletal system (14%) [mainly osteoarthritis]. The most striking evolution from 1993 to 2005 consisted in complicated diabetes mellitus (from 4.3 to 11.4%; p < 0.0001) especially with amputations and blindness. Symptoms (functional limitations without specific disease) like dizziness, impaired vision and frailty are of relevance as an indicator of admission.</p> <p>Conclusion</p> <p>Diseases like stroke, diabetes and mobility problems are only important for institutionalisation if they cause functional disability. Diabetes related complications as cause of admission increased almost three-fold between 1993 and 2005.</p

Apolipoprotein E gene is related to mortality only in normal weight individuals: The Rotterdam study

Objective To investigate the relationship between the apolipoprotein E (APOE) gene and the risk of mortality in normal weight, overweight and obese individuals. Methods and Results In a population-based study of 7,983 individuals aged 55 years and older, we compared the risks of all-cause and coronary heart disease (CHD) mortality by APOE genotype, both overall and in subgroups defined by body mass index (BMI). We found significant evidence for interaction between APOE and BMI in relation to total cholesterol (p = 0.04) and HDL cholesterol (p < 0.001). Overall, APOE*2 carriers showed a decreased risk of all-cause mortality. Analyses within BMI strata showed a beneficial effect of APOE*2 only in normal weight persons (adjusted hazard ratio (HR) 0.7[95% CI 0.5–0.9]). APOE*2 was not associated with a lower risk of all-cause mortality in overweight or obese persons. The effect of APOE*2 in normal weight individuals tended to be due to the risk of CHD mortality (adjusted HR 0.5 [95% CI 0.2–1.2]). Conclusion The APOE*2 allele confers a lower risk of all-cause mortality only to normal weight individuals