Prospective evaluation of a primary care referral pathway for patients with non-alcoholic fatty liver disease.

BACKGROUND & AIMS: We aimed to develop and evaluate a pathway for management of patients with non-alcoholic fatty liver disease (NAFLD) using blood tests to stratify patients in primary care to improve detection of cases of advanced fibrosis and cirrhosis, and avoid unnecessary referrals to secondary care. METHODS: This was a prospective longitudinal cohort study with before-and-after analysis and comparison to unexposed controls. We used a two-step algorithm combining the use of FIB-4 followed by the ELF test if required RESULTS: In total, 3,012 patients were analysed. Use of the pathway detected 5 times more cases of advanced fibrosis (Kleiner F3) and cirrhosis (OR=5.18; 95%CI=2.97 to 9.04; p<0.0001). Unnecessary referrals from primary care to secondary care fell by 81% (OR=0.193; 95%CI 0.111 to 0.337; p<0.0001). Three times more cases of cirrhosis were diagnosed (OR=3.14; 95%CI=1.57 to 24; p=0.00011). Although it was used for only 48% of referrals, significant benefits were observed across all referrals from the practices exposed to the pathway. Unnecessary referrals fell by 77% (OR=0.23; 95% CI=0.658 to 0.082; p=0.006) with a 4-fold improvement in detection of cases of advanced fibrosis and cirrhosis (OR=4.32; 95% CI=1.52 to 12.25; p=0.006). Compared to referrals made before introduction of the pathway, unnecessary referrals fell from 79/83 referrals (95.2%) to 107/152 (70.4%) representing an 88% reduction in unnecessary referrals when the pathway was followed (OR=0.12; 95%CI=0.042 to 0.349; p<0.0001). CONCLUSIONS: The use of non-invasive blood tests for liver fibrosis to stratify patients with NAFLD improves the detection of cases of advanced fibrosis and cirrhosis and reduces unnecessary referrals to secondary care of patients with lesser degrees of liver fibrosis. This strategy improves resource use and benefits patients. LAY SUMMARY: Non-alcoholic fatty liver disease effects up to 30% of the population but only a minority of cases develop liver disease. Our study has shown that established blood tests can be used in primary care to stratify patients with fatty liver disease to reduce unnecessary referrals by 80% and improve the detection of cases of advanced fibrosis 5 fold and cirrhosis 3 fold

The association between family and community social capital and health risk behaviours in young people: an integrative review

Background: Health risk behaviours known to result in poorer outcomes in adulthood are generally established in late childhood and adolescence. These ‘risky’ behaviours include smoking, alcohol and illicit drug use and sexual risk taking. While the role of social capital in the establishment of health risk behaviours in young people has been explored, to date, no attempt has been made to consolidate the evidence in the form of a review. Thus, this integrative review was undertaken to identify and synthesise research findings on the role and impact of family and community social capital on health risk behaviours in young people and provide a consolidated evidence base to inform multi-sectorial policy and practice.&lt;p&gt;&lt;/p&gt; Methods: Key electronic databases were searched (i.e. ASSIA, CINAHL, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Database of Abstracts of Reviews of Effects, Embase, Medline, PsycINFO, Sociological Abstracts) for relevant studies and this was complemented by hand searching. Inclusion/exclusion criteria were applied and data was extracted from the included studies. Heterogeneity in study design and the outcomes assessed precluded meta-analysis/meta-synthesis; the results are therefore presented in narrative form.&lt;p&gt;&lt;/p&gt; Results: Thirty-four papers satisfied the review inclusion criteria; most were cross-sectional surveys. The majority of the studies were conducted in North America (n=25), with three being conducted in the UK. Sample sizes ranged from 61 to 98,340. The synthesised evidence demonstrates that social capital is an important construct for understanding the establishment of health risk behaviours in young people. The different elements of family and community social capital varied in terms of their saliency within each behavioural domain, with positive parent–child relations, parental monitoring, religiosity and school quality being particularly important in reducing risk.&lt;p&gt;&lt;/p&gt; Conclusions: This review is the first to systematically synthesise research findings about the association between social capital and health risk behaviours in young people. While providing evidence that may inform the development of interventions framed around social capital, the review also highlights key areas where further research is required to provide a fuller account of the nature and role of social capital in influencing the uptake of health risk behaviours.&lt;p&gt;&lt;/p&gt

Attentional modulation of crowding

Outside the fovea, the visual system pools features of adjacent stimuli. Left or right of fixation the tilt of an almost horizontal Gabor pattern becomes difficult to classify when horizontal Gabors appear above and below it. Classification is even harder when flankers are to the left and right of the target. With all four flankers present, observers were required both to classify the target’s tilt and perform a spatial frequency task on two of the four flankers. This dual task proved significantly more difficult when attention was directed to the horizontally aligned flankers. We suggest that covert attention to stimuli can increase the weights of their pooled features

Iron Age Promontory Fort to Medieval Castle? Excavations at Great Castle Head, Dale, Pembrokeshire 1999

Great Castle Head Iron Age promontory fort has some of the most massive defences of all the coastal forts of Pembrokeshire. However, due to coastal erosion, it has one of the smallest surviving internal areas and the remains are bisected by a former landslip. The threat posed by continuing erosion prompted a survey and rescue excavation in the summer of 1999. The site is characterised by two lines of defences each consisting of a bank, a ditch and a counterscarp bank. It is suggested that the original entrance was adjacent to the cliff edge to the north of the surviving defences and that the present entrance through the outer defences probably dates to the earlier 20th century. The results of the excavation indicated that the inner bank had at least three phases of construction, with the earliest phase possibly dating to the Early or Middle Iron Age. It seems probable that the more massive, second phase of the defences dates to the late Iron Age although a later date cannot be ruled out. Evidence from the interior of the fort indicated intensive occupation during the later prehistoric period. However, no clear structures could be identified due to the fragmentary nature of the results from the small area that was excavated. The third phase of inner bank construction suggests that the site was re-fortified during the late 12th and 13th centuries A.D. Further evidence for mediaeval activity is provided by a spread of pottery within the interior of the fort. It is argued that there is a strong case to suggest that, during this period, Great Castle Head became the site of a small mediaeval castle

The holistic phase model of early adult crisis

The objective of the current study was to explore the structural, temporal and experiential manifestations of crisis episodes in early adulthood, using a holistic-systemic theoretical framework. Based on an analysis of 50 interviews with individuals about a crisis episode between the ages of 25 and 35, a holistic model was developed. The model comprises four phases: (1) Locked-in, (2) Separation/Time-out, (3) Exploration and (4) Rebuilding, which in turn have characteristic features at four levels—person-in-environment, identity, motivation and affect-cognition. A crisis starts out with a commitment at work or home that has been made but is no longer desired, and this is followed by an emotionally volatile period of change as that commitment is terminated. The positive trajectory of crisis involves movement through an exploratory period towards active rebuilding of a new commitment, but ‘fast-forward’ and ‘relapse’ loops can interrupt Phases 3 and 4 and make a positive resolution of the episode less likely. The model shows conceptual links with life stage theories of emerging adulthood and early adulthood, and it extends current understandings of the transitional developmental challenges that young adults encounter

Visual Clutter Causes High-Magnitude Errors

Perceptual decisions are often made in cluttered environments, where a target may be confounded with competing “distractor” stimuli. Although many studies and theoretical treatments have highlighted the effect of distractors on performance, it remains unclear how they affect thequality of perceptual decisions. Here we show that perceptual clutter leads not only to an increase in judgment errors, but also to an increase in perceived signal strength and decision confidence on erroneous trials. Observers reported simultaneously the direction and magnitude of the tilt of a target grating presented either alone, or together with vertical distractor stimuli. When presented in isolation, observers perceived isolated targets as only slightly tilted on error trials, and had little confidence in their decision. When the target was embedded in distractors, however, they perceived it to be strongly tilted on error trials, and had high confidence of their (erroneous) decisions. The results are well explained by assuming that the observers' internal representation of stimulus orientation arises from a nonlinear combination of the outputs of independent noise-perturbed front-end detectors. The implication that erroneous perceptual decisions in cluttered environments are made with high confidence has many potential practical consequences, and may be extendable to decision-making in general

Simplifying Algebra in Feynman Graphs, Part III: Massive Vectors

A T-dualized selfdual inspired formulation of massive vector fields coupled to arbitrary matter is generated; subsequently its perturbative series modeling a spontaneously broken gauge theory is analyzed. The new Feynman rules and external line factors are chirally minimized in the sense that only one type of spin index occurs in the rules. Several processes are examined in detail and the cross-sections formulated in this approach. A double line formulation of the Lorentz algebra for Feynman diagrams is produced in this formalism, similar to color ordering, which follows from a spin ordering of the Feynman rules. The new double line formalism leads to further minimization of gauge invariant scattering in perturbation theory. The dualized electroweak model is also generated.Comment: 39 pages, LaTeX, 8 figure

The development of perceptual averaging: learning what to do, not just how to do it

The mature visual system condenses complex scenes into simple summary statistics (e.g., average size, location, orientation, etc.). However, children, often perform poorly on perceptual averaging tasks. Children's difficulties are typically thought to represent the suboptimal implementation of an adult-like strategy. This paper examines another possibility: that children actually make decisions in a qualitatively different way to adults (optimal implementation of a non-ideal strategy). Ninety children (6-7, 8-9, 10-11 years) and 30 adults were asked to locate the middle of randomly generated dot-clouds. Nine plausible decision strategies were formulated, and each was fitted to observers' trial-by-trial response data (Reverse Correlation). When the number of visual elements was low (N < 6), children used a qualitatively different decision strategy from adults: appearing to "join up the dots" and locate the gravitational center of the enclosing shape. Given denser displays, both children and adults used an ideal strategy of arithmetically averaging individual points. Accounting for this difference in decision strategy explained 29% of children's lower precision. These findings suggest that children are not simply suboptimal at performing adult-like computations, but may at times use sensible, but qualitatively different strategies to make perceptual judgments. Learning which strategy is best in which circumstance might be an important driving factor of perceptual development

On the nature of the galactic early-B hypergiants

Despite their importance to a number of astrophysical fields, the lifecycles of very massive stars are still poorly defined. In order to address this shortcoming, we present a detailed quantitative study of the physical properties of four early-B hypergiants (BHGs); Cyg OB2 #12, zeta Sco, HD190603 and BP Cru. These are combined with an analysis of their long-term spectroscopic and photometric behaviour in order to determine their evolutionary status. The long-term datasets revealed that they are remarkably stable over long periods (>40yr), with the possible exception of zeta Sco prior to the 20th century, in contrast to the typical excursions that characterise luminous blue variables (LBVs). Zeta Sco, HD190603 and BP Cru possess physical properties intermediate between B supergiants and LBVs; we therefore suggest that BHGs are the immediate descendants and progenitors (respectively) of such stars (for initial masses in the range ~30-60Msun). In contrast, while the wind properties of Cyg OB2 #12 are consistent with this hypothesis, the combination of extreme luminosity and spectroscopic mass (~110Msun) and comparatively low temperature means it cannot be accommodated in such a scheme. Likewise, despite its co-location with several LBVs above the Humphreys-Davidson (HD) limit, the lack of long term variability and its unevolved chemistry apparently excludes such an identification. Since such massive stars are not expected to evolve to such cool temperatures, the properties of Cyg OB2 #12 are difficult to understand under current evolutionary paradigms. [ABRIDGED]Comment: 36 pages, 19 figures (of which 17 pages are online supplemental material). Accepted for publication in Astronomy and Astrophysic