Persistent physical symptoms reduction intervention: a system change and evaluation (PRINCE) - integrated GP care for persistent physical symptoms: protocol for a feasibility and cluster randomised waiting list, controlled trial

Introduction Persistent physical symptoms (PPS), also known as medically unexplained symptoms are associated with profound physical disability, psychological distress and high healthcare costs. England's annual National Health Service costs of attempting to diagnose and treat PPS amounts to approximately £3 billion. Current treatment relies on a positive diagnosis, life-style advice and drug therapy. However, many patients continue to suffer from ongoing symptoms and general practitioners (GPs) are challenged to find effective treatments. Training GPs in basic cognitive behavioural skills and providing self-help materials to patients could be useful, but availability in primary care settings is limited. Methods and analysis A cluster randomised waiting list, controlled trial will be conducted to assess the feasibility of an integrated approach to care in general practice. Approximately 240 patients with PPS will be recruited from 8 to 12 GP practices in London. GP practices will be randomised to 'integrated GP care plus treatment as usual' or waiting list control. Integrated GP care plus treatment as usual will include GP training in cognitive behavioural skills, GP supervision and written and audio visual materials for both GPs and participants. The primary objectives will be assessment of trial and intervention feasibility. Secondary objectives will include estimating the intracluster correlation coefficient for potential outcome measures for cluster effects in a sample size calculation. Feasibility parameters and identification of suitable primary and secondary outcomes for future trial evaluations will be assessed prerandomisation and at 12 and 24 weeks' postrandomisation, using a mixed-methods approach. Ethics and dissemination Ethical approval was granted by the Camberwell St Giles Ethics Committee. Results will be disseminated via peer-reviewed publications and conference presentations. This trial will inform researchers, clinicians, patients and healthcare providers about the feasibility and potential cost-effectiveness of an integrated approach to managing PPS in primary care. Trial registration number NCT02444520; Pre-results

Crystallization of calcium carbonate and magnesium hydroxide in the heat exchangers of once-through multistage flash (MSF-OT) desalination process

YesIn this paper, a dynamic model of fouling is presented to predict the crystallization of calcium carbonate and magnesium hydroxide inside the condenser tubes of Once-Through Multistage Flash (MSF-OT) desalination process. The model considers the combination of kinetic and mass diffusion rates taking into account the effect of temperature, velocity and salinity of the seawater. The equations for seawater carbonate system are used to calculate the concentration of the seawater species. The effects of salinity and temperature on the solubility of calcium carbonate and magnesium hydroxide are also considered. The results reveal an increase in the fouling inside the tubes caused by crystallization of CaCO3 and Mg(OH)2 with increase in the stage temperature. The intake seawater temperature and the Top Brine Temperature (TBT) are varied to investigate their impact on the fouling process. The results show that the (TBT) has greater impact than the seawater temperature on increasing the fouling

Anomalies in the review process and interpretation of the evidence in the NICE guideline for chronic fatigue syndrome and myalgic encephalomyelitis

Chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME) is a disabling long-term condition of unknown cause. The National Institute for Health and Care Excellence (NICE) published a guideline in 2021 that highlighted the seriousness of the condition, but also recommended that graded exercise therapy (GET) should not be used and cognitive-behavioural therapy should only be used to manage symptoms and reduce distress, not to aid recovery. This U-turn in recommendations from the previous 2007 guideline is controversial.We suggest that the controversy stems from anomalies in both processing and interpretation of the evidence by the NICE committee. The committee: (1) created a new definition of CFS/ME, which 'downgraded' the certainty of trial evidence; (2) omitted data from standard trial end points used to assess efficacy; (3) discounted trial data when assessing treatment harm in favour of lower quality surveys and qualitative studies; (4) minimised the importance of fatigue as an outcome; (5) did not use accepted practices to synthesise trial evidence adequately using GRADE (Grading of Recommendations, Assessment, Development and Evaluations trial evidence); (6) interpreted GET as mandating fixed increments of change when trials defined it as collaborative, negotiated and symptom dependent; (7) deviated from NICE recommendations of rehabilitation for related conditions, such as chronic primary pain and (8) recommended an energy management approach in the absence of supportive research evidence.We conclude that the dissonance between this and the previous guideline was the result of deviating from usual scientific standards of the NICE process. The consequences of this are that patients may be denied helpful treatments and therefore risk persistent ill health and disability

Anomalies in the review process and interpretation of the evidence in the NICE guideline for chronic fatigue syndrome and myalgic encephalomyelitis

Chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME) is a disabling long-term condition of unknown cause. The National Institute for Health and Care Excellence (NICE) published a guideline in 2021 that highlighted the seriousness of the condition, but also recommended that graded exercise therapy (GET) should not be used and cognitive-behavioural therapy should only be used to manage symptoms and reduce distress, not to aid recovery. This U-turn in recommendations from the previous 2007 guideline is controversial.We suggest that the controversy stems from anomalies in both processing and interpretation of the evidence by the NICE committee. The committee: (1) created a new definition of CFS/ME, which 'downgraded' the certainty of trial evidence; (2) omitted data from standard trial end points used to assess efficacy; (3) discounted trial data when assessing treatment harm in favour of lower quality surveys and qualitative studies; (4) minimised the importance of fatigue as an outcome; (5) did not use accepted practices to synthesise trial evidence adequately using GRADE (Grading of Recommendations, Assessment, Development and Evaluations trial evidence); (6) interpreted GET as mandating fixed increments of change when trials defined it as collaborative, negotiated and symptom dependent; (7) deviated from NICE recommendations of rehabilitation for related conditions, such as chronic primary pain and (8) recommended an energy management approach in the absence of supportive research evidence.We conclude that the dissonance between this and the previous guideline was the result of deviating from usual scientific standards of the NICE process. The consequences of this are that patients may be denied helpful treatments and therefore risk persistent ill health and disability

Diagnosis Of Sebaceous Lymphadenoma By Fine Needle Aspiration In A Patient With Cowden Syndrome: Case Report And Review Of The Literature

Sebaceous lymphadenoma (SLA) is a rare benign tumor of the salivary gland that commonly arises in the parotid gland in adults. It is rarely diagnosed correctly preoperatively. In addition, to the best of our knowledge, SLA has not been described yet in the literature in association with Cowden′s syndrome (CS). We present an extremely rare case of parotid SLA that was diagnosed preoperatively by fine needle aspiration in a patient with CS

The Bethesda System Thyroid Diagnostic Categories In The African-American Population In Conjunction With Surgical Pathology Follow-Up

Background: It has been reported that African-Americans (AA) have a higher prevalence of overall malignancy compared to Caucasians, in the United States, yet the incidence of thyroid malignancy is half. The aim of this study is to assess the rate of malignant versus benign thyroid disease in AA from an urban-based hospital with an academic setting. Our study analyzed the AA population with respect to fine needle aspiration (FNA) of thyroid lesions, in correlation with final surgical pathology. This is the first study of its kind to our knowledge. Design: We retrospectively reviewed thyroid FNA cytology between January 2005 and February 2011. Consecutive FNA specimens with corresponding follow-up surgical pathology were included. The patients were categorized as African-American (AA) and Non-African-American (NAA), which included Caucasians (C), Hispanics (H), and Others (O). The FNA results were classified using the latest edition of The Bethesda System for Reporting Thyroid Cytopathology (TBS-Thy) and the follow-up surgical pathology was used for the final categorization. Results: We studied 258 cases: 144 AA (56%) and 114 NAA [43 C (17%), 3 H (1%), and 68 O (28%)]. The average age for AA was 51 years (range 20-88) and for NAA was 53 years (range 25-86). There were more females than males in the AA versus the NAA group (85 vs. 75%). The incidence of thyroid lesions in the FNA specimens was similar between these two populations. The distribution of benign versus malignant diagnosis on follow-up surgical pathology was examined across TBS-Thy class. Conclusion: Our data suggest that distribution of benign versus malignant lesions in the thyroid FNA of AA versus NAA, with follow-up surgical pathology, is comparable for TBS-Thy classes, non-diagnostic (I), benign (II), suspicious for malignancy (V), and malignant (VI) in AA versus NAA. © 2012 Shidham VB, et al.; licensee Cytopathology Foundation Inc

Optimisation of design and operation of MSF desalination process using MINLP technique in gPROMS

NoOptimal design and operation of MSF desalination process is considered here using MINLP technique within gPROMS model builder 2.3.4. gPROMS provides an easy and flexible platform to build a process flowsheet graphically and the corresponding master model connecting automatically individual unit model equations during simulation and optimisation. For different freshwater demand throughout the year and with seasonal variation of seawater temperature, the total annualised cost of desalination is minimised. It is found that seasonal variation in seawater temperature results in significant variation in design and some of the operating parameters but with minimum variation in of process temperatures. The results also reveal the possibility of designing stand-alone flash stages which would offer flexible scheduling in terms of the connection of various units (to build up the process) and efficient maintenance of the units throughout the year as the weather condition changes. In addition, operation at low temperatures throughout the year will reduce design and operating costs in terms of low temperature materials of construction and reduced amount of anti-scaling and anti-corrosion agents

Chemical composition, surface roughness, and ceramic bond strength of additively manufactured cobalt-chromium dental alloys.

STATEMENT OF PROBLEM Selective laser melting (SLM) additive manufacturing (AM) technology is a current option to fabricate cobalt-chromium (Co-Cr) metal frameworks for dental prostheses. However, the Co-Cr alloy composition, surface roughness, and ceramic bond strength values that SLM metals can obtain are not well-defined. PURPOSE The purpose of this in vitro study was to compare the chemical composition, surface roughness, and ceramic shear bond strength of the milled and SLM Co-Cr dental alloys. MATERIAL AND METHODS A total of 50 disks of 5 mm in diameter and 1 mm in thickness were fabricated by using subtractive (control group) and AM with each of following SLM providers: SLM-1 (EOS), SLM-2 (3D systems), and SLM-3 (Concept Laser). The milled disks were airborne-particle abraded with 100-μm aluminum oxide particles. All the specimens were cleaned before surface roughness (Ra), weight (Wt%), and atomic (At%) percentages were analyzed. Three-dimensional profilometry was used to analyze the topographical properties of the surface parameters Ra (mean surface roughness). The chemical composition of Co-Cr alloy specimens was determined by using energy dispersive X-ray (EDAX) elemental analysis in a scanning electron microscope (SEM). Thereafter, the specimens were bonded to a ceramic (Dentine A3 and Enamel S-59; Creation CC) interface. Specimens were stored for 24 hours at 23 °C. The bond strength of the SLM-ceramic interface was measured by using the macroshear test (SBT) method (n=10). Adhesion tests were performed in a universal testing machine (1 mm/min). The Shapiro-Wilk test revealed that the chemical composition data were not normally distributed. Therefore, the atomic (At%) and weight percentages (Wt%) were analyzed by using the Kruskal-Wallis test, followed by pairwise Mann-Whitney U tests between the control and AM groups (AM-1 to AM-4). However, the Shapiro-Wilk test revealed that the surface roughness (Ra) and ceramic bond strength data were normally distributed. Therefore, data were analyzed by using 1-way ANOVA, followed by the post hoc Sidak test (α=.05). RESULTS Significant differences were obtained in Wt%, At%, and Ra values among the Co-Cr alloys evaluated (P<.05). Furthermore, the control group revealed significantly lower mean ±standard deviation Ra values (0.79 ±0.11 μm), followed by AM-3 (1.57 ±0.15 μm), AM-2 (1.80 ±0.43 μm), AM-1 (2.43 ±0.34 μm), and AM-4 (2.84 ±0.27 μm). However, no significant differences were obtained in the metal-ceramic shear bond strength among the different groups evaluated, ranging from mean ±standard deviation 75.77 ±11.92 MPa to 83.65 ±12.21 MPa. CONCLUSIONS Co-Cr dental alloys demonstrated a significant difference in their chemical compositions. Subtractive and additive manufacturing procedures demonstrated a significant influence on the surface roughness of the Co-Cr alloy specimens. However, the metal-ceramic shear bond strength of Co-Cr alloys was found to be independent of the manufacturing process

Human Papillomavirus Testing And Reporting Rates In 2012: Results Of A College Of American Pathologists National Survey

Context. - College of American Pathologists (CAP) surveys are used to establish national benchmarks for laboratory parameters. Objective. - To evaluate changes in laboratory human papillomavirus (HPV) testing patterns in laboratories incorporating HPV testing with Papanicolaou tests in 2012. Design. - Data were analyzed from the CAP HPV Supplemental Questionnaire distributed to 1771 laboratories participating in either CAP HPV or CAP Papanicolaou proficiency testing in 2013. Results. - A total of 1022 laboratories (58%) responded. There were more high-risk (HR) HPV tests performed per institution as compared to previous surveys. There were more HPV tests performed within an institution as compared to previous surveys. Hybrid Capture 2 (HC2) remains the most common method (42.4%, 239 of 564); Cervista and cobas methods are used in 37.2% (210 of 564) and 14.9% (84 of 564) of laboratories, respectively. Human papillomavirus testing is offered as a reflex test after a Papanicolaou test result of atypical squamous cells of undetermined significance (ASC-US) in 89.6% of laboratories (476 of 531); as a cotest for women aged 30 years and older in 60.3% (404 of 531); as reflex testing after atypical squamous cells, cannot exclude high-grade squamous intraepithelial lesion (ASC-H) in 42.7% (320 of 531); and as reflex testing after atypical glandular cells (AGC) in 27.3% (145 of 531). The HPV-positive rates for ASC-US and ASC-H were similar in 2012 and 2006. Cervista (49.2%, 88 of 179) and Roche cobas (27.4%, 49 of 179) are the most common methods used for genotyping. Most laboratories use the CAP Human Papillomavirus for Cytology Program for proficiency testing. Conclusions. - There was an increase in annual volume of HR-HPV testing with a shift toward in-house HR-HPV testing. Genotyping volumes also increased. HC2 and Cervista are most commonly used, with an increasing volume of Roche cobas testing. The most common indication for HPV testing among all laboratories was ASC-US reflex testing, but an increase in HPV cotesting was observed. The data provide an update into persisting and newer trends in HPV testing practices

CytoJournal BioMed Central Commentary Fast drying of Fine Needle Aspiration slides using a hand held fan: impact on turn around time and staining quality

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