Comprehensive systematic review summary: Treatment of tics in people with Tourette syndrome and chronic tic disorders

Objective To systematically evaluate the efficacy of treatments for tics and the risks associated with their use. Methods This project followed the methodologies outlined in the 2011 edition of the American Academy of Neurology\u27s guideline development process manual. We included systematic reviews and randomized controlled trials on the treatment of tics that included at least 20 participants (10 participants if a crossover trial), except for neurostimulation trials, for which no minimum sample size was required. To obtain additional information on drug safety, we included cohort studies or case series that specifically evaluated adverse drug effects in individuals with tics. Results There was high confidence that the Comprehensive Behavioral Intervention for Tics was more likely than psychoeducation and supportive therapy to reduce tics. There was moderate confidence that haloperidol, risperidone, aripiprazole, tiapride, clonidine, onabotulinumtoxinA injections, 5-ling granule, Ningdong granule, and deep brain stimulation of the globus pallidus were probably more likely than placebo to reduce tics. There was low confidence that pimozide, ziprasidone, metoclopramide, guanfacine, topiramate, and tetrahydrocannabinol were possibly more likely than placebo to reduce tics. Evidence of harm associated with various treatments was also demonstrated, including weight gain, drug-induced movement disorders, elevated prolactin levels, sedation, and effects on heart rate, blood pressure, and ECGs. Conclusions There is evidence to support the efficacy of various medical, behavioral, and neurostimulation interventions for the treatment of tics. Both the efficacy and harms associated with interventions must be considered in making treatment recommendations

Practice Guideline Recommendations Summary: Treatment of Tics in People with Tourette Syndrome and Chronic Tic Disorders

Objective To make recommendations on the assessment and management of tics in people with Tourette syndrome and chronic tic disorders. Methods A multidisciplinary panel consisting of 9 physicians, 2 psychologists, and 2 patient representatives developed practice recommendations, integrating findings from a systematic review and following an Institute of Medicine–compliant process to ensure transparency and patient engagement. Recommendations were supported by structured rationales, integrating evidence from the systematic review, related evidence, principles of care, and inferences from evidence. Results Forty-six recommendations were made regarding the assessment and management of tics in individuals with Tourette syndrome and chronic tic disorders. These include counseling recommendations on the natural history of tic disorders, psychoeducation for teachers and peers, assessment for comorbid disorders, and periodic reassessment of the need for ongoing therapy. Treatment options should be individualized, and the choice should be the result of a collaborative decision among patient, caregiver, and clinician, during which the benefits and harms of individual treatments as well as the presence of comorbid disorders are considered. Treatment options include watchful waiting, the Comprehensive Behavioral Intervention for Tics, and medication; recommendations are provided on how to offer and monitor these therapies. Recommendations on the assessment for and use of deep brain stimulation in adults with severe, treatment-refractory tics are provided as well as suggestions for future research

High-frequency water quality monitoring in an urban catchment: hydrochemical dynamics, primary production and implications for the Water Framework Directive

This paper describes the hydrochemistry of a lowland, urbanised river-system, The Cut in England, using in situ sub-daily sampling. The Cut receives effluent discharges from four major sewage treatment works serving around 190,000 people. These discharges consist largely of treated water, originally abstracted from the River Thames and returned via the water supply network, substantially increasing the natural flow. The hourly water quality data were supplemented by weekly manual sampling with laboratory analysis to check the hourly data and measure further determinands. Mean phosphorus and nitrate concentrations were very high, breaching standards set by EU legislation. Though 56% of the catchment area is agricultural, the hydrochemical dynamics were significantly impacted by effluent discharges which accounted for approximately 50% of the annual P catchment input loads and, on average, 59% of river flow at the monitoring point. Diurnal dissolved oxygen data demonstrated high in-stream productivity. From a comparison of high frequency and conventional monitoring data, it is inferred that much of the primary production was dominated by benthic algae, largely diatoms. Despite the high productivity and nutrient concentrations, the river water did not become anoxic and major phytoplankton blooms were not observed. The strong diurnal and annual variation observed showed that assessments of water quality made under the Water Framework Directive (WFD) are sensitive to the time and season of sampling. It is recommended that specific sampling time windows be specified for each determinand, and that WFD targets should be applied in combination to help identify periods of greatest ecological risk. This article is protected by copyright. All rights reserved

The water quality of the River Enborne, UK: observations from high-frequency Monitoring in a rural, lowland river system

This paper reports the results of a 2-year study of water quality in the River Enborne, a rural river in lowland England. Concentrations of nitrogen and phosphorus species and other chemical determinands were monitored both at high-frequency (hourly), using automated in situ instrumentation, and by manual weekly sampling and laboratory analysis. The catchment land use is largely agricultural, with a population density of 123 persons km−2. The river water is largely derived from calcareous groundwater, and there are high nitrogen and phosphorus concentrations. Agricultural fertiliser is the dominant source of annual loads of both nitrogen and phosphorus. However, the data show that sewage effluent discharges have a disproportionate effect on the river nitrogen and phosphorus dynamics. At least 38% of the catchment population use septic tank systems, but the effects are hard to quantify as only 6% are officially registered, and the characteristics of the others are unknown. Only 4% of the phosphorus input and 9% of the nitrogen input is exported from the catchment by the river, highlighting the importance of catchment process understanding in predicting nutrient concentrations. High-frequency monitoring will be a key to developing this vital process understanding

Guidelines and interventions for obesity during pregnancy

BackgroundObesity is a growing worldwide epidemic among women of reproductive age, including pregnant women. The increased prevalence of obesity has been accompanied by an increase in gestational weight gain. Maternal obesity has deleterious consequences for both mother and child.ObjectiveTo review the recent guidelines from the National Institute for Health and Clinical Excellence and the Institute of Medicine regarding gestational weight gain and interventions to treat obesity during pregnancy.MethodsGuidelines on gestational weight gain from these organizations, as well as reports of gestational weight gain in the published literature, are summarized.ResultsMany normal and overweight parturients exceed the recommendations in the guidelines, which may contribute to postpartum obesity.ConclusionLifestyle changes, including dieting and increased activity, may help to limit excessive gestational weight gain but the optimal strategy remains unclear.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/135575/1/ijgo6.pd

High-frequency phosphorus monitoring of the River Kennet, UK: are ecological problems due to intermittent sewage treatment works failures?

The River Kennet in southern England has exhibited excessive benthic algal growth and associated ecological problems, such as loss of macrophytes and invertebrates, since the 1980s. These ecological problems were attributed to regular peaks in phosphorus concentration, which were widely attributed to intermittent failures of the Marlborough sewage treatment works (STW). This study deployed highfrequency phosphorus auto-analysers to monitor the total reactive phosphorus (TRP) concentrations of Marlborough STW final effluent and the downstream River Kennet at hourly and 30 minute resolution respectively, between 2008 and 2009. This monitoring confirmed that the Marlborough STW was operating well within its 1000 mg l-�1 annual mean total phosphorus consent limit, with mean total P and soluble reactive P concentrations of 675 and 345 mg l-�1 respectively. There were two occasions where effluent TRP concentration exceeded 1000 mg l-�1, and only one of these resulted in a peak in TRP concentration of over 100 mg l-�1 in the River Kennet at Mildenhall. The other nine peaks of over 100 mg l-�1 in the River Kennet during the monitoring period were associated with storm events, indicating that diffuse-source inputs and remobilisation of stored within-channel phosphorus were the cause of the peaks in river concentration, rather than Marlborough STW. The value of high-frequency environmental monitoring and the problems associated with using nutrient auto-analysers in the field are discussed. Seasonal phosphorus consents for STWs could provide a useful and cost effective means to improve both water quality and river ecology in the upper River Kennet

Continuous monitoring to assess phosphorus dynamics and ecological status in the River Kennet, UK

Introduction The links between ecological status of lowland rivers and diffuse and point-source nutrient inputs are of key scientific importance under the EU Water Framework Directive (WFD) (EU, 2000). Many previous studies on the sources and effects of phosphorus in rivers have been based on weekly, storm event or even monthly sampling. However phosphorus concentrations are sensitive to a wide range of shortterm dynamics and diurnal cycles that are not captured by conventional sampling programmes. Hence phosphorus loads may be under estimated and valuable information about the variability in P concentrations and links with in-stream processes and ecology may be missed. In this study, we use in-situ ‘continuous’ (hourly) measurements of total reactive phosphorus (TRP; unfiltered molybdatereactive P), chlorophyll, dissolved oxygen (DO), conductivity, turbidity and flow to examine dynamics in P concentrations and sources and ecological status for the River Kennet, a lowland chalk river in south east England

Maternal adipose tissue expansion, a missing link in the prediction of birth weight centile

Context Maternal body mass index (BMI) is associated with increased birth weight but does not explain all the variance in fetal adiposity. Objective To assess the contribution of maternal body fat distribution to offspring birth weight and adiposity. Design Longitudinal study throughout gestation and at delivery. Setting Women recruited at 12 weeks of gestation and followed up at 26 and 36 weeks. Cord blood was collected at delivery. Patients Pregnant women (n = 45) with BMI 18.0 to 46.3 kg/m2 and healthy pregnancy outcome. Methods Maternal first trimester abdominal subcutaneous and visceral adipose tissue thickness (SAT and VAT) was assessed by ultrasound. Main Outcome Measures Maternal body fat distribution, maternal and cord plasma glucose and lipid concentrations, placental weight, birth weight, and fetal adiposity assessed by cord blood leptin. Results VAT was the only anthropometric measure independently associated with birth weight centile (r2 adjusted 15.8%, P = .002). BMI was associated with trimester 2 and trimesters 1 through 3 area under the curve (AUC) glucose and insulin resistance (Homeostatic Model Assessment). SAT alone predicted trimester 2 lipoprotein lipase (LPL) mass (a marker of adipocyte insulin sensitivity) (11.3%, P = .017). VAT was associated with fetal triglyceride (9.3%, P = .047). Placental weight was the only independent predictor of fetal adiposity (48%, P \u3c .001). Maternal trimester 2 and AUC LPL were inversely associated with fetal adiposity (r = -0.69, P = .001 and r = -0.58, P = .006, respectively). Conclusions Maternal VAT provides additional information to BMI for prediction of birth weight. VAT may be a marker of reduced SAT expansion and increased availability of maternal fatty acids for placental transport

Stream-bed phosphorus in paired catchments with different agricultural land use intensity

Stream-bed sediments from three paired catchments, each draining a lower agricultural intensity system and a higher agricultural intensity system, were analysed for (a) total P (TP), (b) bioavailable-P (Resin-P), (c) equilibrium phosphorus concentration (EPC0), and (d) degree of phosphorus saturation (DPS). The influence of agriculture on sediment P was explored within the context of other key variables that may control the sediment P concentrations such as particle size, Fe, Ca and organic matter content, and in terms of potential implications of sediment P to in-stream biota. TP concentrations, EPC0, and the proportion of fine sediment were highest at the sites with the greater agricultural impact. Higher concentrations of bioavailable-P were also found in higher intensity agricultural systems. However, the highest concentrations of bioavailable-P were found at sites with point source inputs. Sites with high Fe concentrations had higher TP concentrations relative to agricultural intensity, but also had lower DPS values, illustrating that the sediment still had the capacity to take up P in a strongly bound form. The results from this study show that higher risk agricultural practices (intensive arable production and dairy and beef production) can lead either directly, or indirectly through increased inputs of fine sediment, to increased sediment TP concentrations. The importance of geochemical and physical controls on the bed sediments’ capacity to mitigate high P inputs in headwater lowland streams, especially under low flows and times of eutrophication risk in spring and summer is illustrated

Phosphorus dynamics and productivity in sewage-impacted lowland chalk stream

Hourly in situ phosphorus, conductivity, turbidity, dissolved oxygen, pH, and chlorophyll measurements were collected from January 2004 to November 2006 for the River Kennet, 2 km downstream of a sewage effluent inlet. Excess carbon dioxide pressure (EpCO2) was calculated from continuous pH and spot alkalinity measurements. EpCO2 and dissolved oxygen were used to estimate rates of photosynthesis and respiration. These parameters were examined alongside flow, water temperature and solar radiation to explore controls on phosphorus dynamics and in-stream productivity. Diurnal, event and seasonal patterns were observed in phosphorus concentrations. The diurnal and seasonal variations appeared to be related to the upstream sewage treatment works. The event patterns coincided with periods of high flow, and were attributed to diffuse sources. Chlorophyll behaved independently of phosphorus concentration and returned to baseline levels before photosynthesis rate. This indicated that, during the period of study, in-stream productivity was primarily controlled by aquatic plants other than phytoplankton