Cost-effectiveness of nurse-delivered cognitive behavioural therapy (CBT) compared to supportive listening (SL) for adjustment to multiple sclerosis

Background: Cognitive Behavioural Therapy (CBT) reduces distress in multiple sclerosis, and helps manage adjustment, but cost-effectiveness evidence is lacking. Methods: An economic evaluation was conducted within a multi-centre trial. 94 patients were randomised to either eight sessions of nurse-led CBT or supportive listening (SL). Costs were calculated from the health, social and indirect care perspectives, and combined with additional quality-adjusted life years (QALY) or improvement on the GHQ-12 score, to explore cost-effectiveness at 12 months. Results: CBT had higher mean health costs (£1610, 95% CI, −£187 to 3771) and slightly better QALYs (0.0053, 95% CI, −0.059 to 0.103) compared to SL but these differences were not statistically significant. This yielded £301,509 per QALY improvement, indicating that CBT is not cost-effective according to established UK NHS thresholds. The extra cost per patient improvement on the GHQ-12 scale was £821 from the same perspective. Using a £20,000, threshold, CBT in this format has a 9% probability of being cost effective. Although subgroup analysis of patients with clinical levels of distress at baseline showed an improvement in the position of CBT compared to SL, CBT was still not cost-effective. Conclusion: Nurse delivered CBT is more effective in reducing distress among MS patients compared to SL, but is highly unlikely to be cost-effective using a preference-based measure of health (EQ-5D). Results from a diseasespecif ic measure (GHQ-12) produced comparatively lower Incremental Cost-Effectiveness Ratios, but there is currently no acceptable willingness-to-pay threshold for this measure to guide decision-making

On the curvature of vortex moduli spaces

We use algebraic topology to investigate local curvature properties of the moduli spaces of gauged vortices on a closed Riemann surface. After computing the homotopy type of the universal cover of the moduli spaces (which are symmetric powers of the surface), we prove that, for genus g>1, the holomorphic bisectional curvature of the vortex metrics cannot always be nonnegative in the multivortex case, and this property extends to all Kaehler metrics on certain symmetric powers. Our result rules out an established and natural conjecture on the geometry of the moduli spaces.Comment: 25 pages; final version, to appear in Math.

Unhappiness and dissatisfaction in doctors cannot be predicted by selectors from medical school application forms: A prospective, longitudinal study

BACKGROUND: Personal statements and referees' reports are widely used on medical school application forms, particularly in the UK, to assess the suitability of candidates for a career in medicine. However there are few studies which assess the validity of such information for predicting unhappiness or dissatisfaction with a career in medicine. Here we combine data from a long-term prospective study of medical student selection and training, with an experimental approach in which a large number of assessors used a paired comparison technique to predict outcome. METHODS: Data from a large-scale prospective study of students applying to UK medical schools in 1990 were used to identify 40 pairs of doctors, matched by sex, for whom personal statements and referees' reports were available, and who in a 2002/3 follow-up study, one pair member was very satisfied and the other very dissatisfied with medicine as a career. In 2005, 96 assessors, who were experienced medical school selectors, doctors, medical students or psychology students, used information from the doctors' original applications to judge which member of each pair of doctors was the happier, more satisfied doctor. RESULTS: None of the groups of assessors were significantly different from chance expectations in using applicants' personal statements and the referees' reports to predict actual future satisfaction or dissatisfaction, the distribution being similar to binomial expectations. However judgements of pairs of application forms from pairs of doctors showed a non-binomial distribution, indicating consensus among assessors as to which doctor would be the happy doctor (although the consensus was wrong in half the cases). Assessors taking longer to do the task concurred more. Consensus judgements seem mainly to be based on referees' predictions of academic achievement (even though academic achievement is not actually a valid predictor of happiness or satisfaction). CONCLUSION: Although widely used in medical student selection to assess motivation, interest and commitment to a medical career, the personal statement and the referee's report cannot validly be used by assessors, including experienced medical school selectors, to identify doctors who will subsequently be dissatisfied with a medical career

An Integrated-Photonics Optical-Frequency Synthesizer

Integrated-photonics microchips now enable a range of advanced functionalities for high-coherence applications such as data transmission, highly optimized physical sensors, and harnessing quantum states, but with cost, efficiency, and portability much beyond tabletop experiments. Through high-volume semiconductor processing built around advanced materials there exists an opportunity for integrated devices to impact applications cutting across disciplines of basic science and technology. Here we show how to synthesize the absolute frequency of a lightwave signal, using integrated photonics to implement lasers, system interconnects, and nonlinear frequency comb generation. The laser frequency output of our synthesizer is programmed by a microwave clock across 4 THz near 1550 nm with 1 Hz resolution and traceability to the SI second. This is accomplished with a heterogeneously integrated III/V-Si tunable laser, which is guided by dual dissipative-Kerr-soliton frequency combs fabricated on silicon chips. Through out-of-loop measurements of the phase-coherent, microwave-to-optical link, we verify that the fractional-frequency instability of the integrated photonics synthesizer matches the $7.0*10^{-13}$ reference-clock instability for a 1 second acquisition, and constrain any synthesis error to $7.7*10^{-15}$ while stepping the synthesizer across the telecommunication C band. Any application of an optical frequency source would be enabled by the precision optical synthesis presented here. Building on the ubiquitous capability in the microwave domain, our results demonstrate a first path to synthesis with integrated photonics, leveraging low-cost, low-power, and compact features that will be critical for its widespread use.Comment: 10 pages, 6 figure

Photo-antagonism of the GABAA receptor

Neurotransmitter receptor trafficking is fundamentally important for synaptic transmission and neural network activity. GABAA receptors and inhibitory synapses are vital components of brain function, yet much of our knowledge regarding receptor mobility and function at inhibitory synapses is derived indirectly from using recombinant receptors, antibody-tagged native receptors and pharmacological treatments. Here we describe the use of a set of research tools that can irreversibly bind to and affect the function of recombinant and neuronal GABAA receptors following ultraviolet photoactivation. These compounds are based on the competitive antagonist gabazine and incorporate a variety of photoactive groups. By using site-directed mutagenesis and ligand-docking studies, they reveal new areas of the GABA binding site at the interface between receptor β and α subunits. These compounds enable the selected inactivation of native GABAA receptor populations providing new insight into the function of inhibitory synapses and extrasynaptic receptors in controlling neuronal excitation

Protocol for the saMS trial (supportive adjustment for multiple sclerosis): a randomized controlled trial comparing cognitive behavioral therapy to supportive listening for adjustment to multiple sclerosis

BackgroundMultiple Sclerosis (MS) is an incurable, chronic, potentially progressive and unpredictable disease of the central nervous system. The disease produces a range of unpleasant and debilitating symptoms, which can have a profound impact including disrupting activities of daily living, employment, income, relationships, social and leisure activities, and life goals. Adjusting to the illness is therefore particularly challenging. This trial tests the effectiveness of a cognitive behavioural intervention compared to supportive listening to assist adjustment in the early stages of MS.MethodsThis is a two arm randomized multi-centre parallel group controlled trial. 122 consenting participants who meet eligibility criteria will be randomly allocated to receive either Cognitive Behavioral Therapy or Supportive Listening. Eight one hour sessions of therapy (delivered over a period of 10 weeks) will be delivered by general nurses trained in both treatments. Self-report questionnaire data will be collected at baseline (0 weeks), mid-therapy (week 5 of therapy), post-therapy (15 weeks) and at six months (26 weeks) and twelve months (52 weeks) follow-up. Primary outcomes are distress and MS-related social and role impairment at twelve month follow-up. Analysis will also consider predictors and mechanisms of change during therapy. In-depth interviews to examine participants’ experiences of the interventions will be conducted with a purposively sampled sub-set of the trial participants. An economic analysis will also take place. DiscussionThis trial is distinctive in its aims in that it aids adjustment to MS in a broad sense. It is not a treatment specifically for depression. Use of nurses as therapists makes the interventions potentially viable in terms of being rolled out in the NHS. The trial benefits from incorporating patient input in the development and evaluation stages. The trial will provide important information about the efficacy, cost-effectiveness and acceptability of the interventions as well as mechanisms of psychosocial adjustment.Trial registrationCurrent Controlled Trials ISRCTN91377356<br/

The factors driving evolved herbicide resistance at a national scale

Repeated use of xenobiotic chemicals has selected for the rapid evolution of resistance threatening health and food security at a global scale. Strategies for preventing the evolution of resistance include cycling and mixtures of chemicals and diversification of management. We currently lack large-scale studies that evaluate the efficacy of these different strategies for minimizing the evolution of resistance. Here we use a national scale dataset of occurrence of the weed Alopecurus myosuroides (Blackgrass) in the UK to address this. Weed densities are correlated with assays of evolved resistance, supporting the hypothesis that resistance is driving weed abundance at a national scale. Resistance was correlated with the frequency of historical herbicide applications suggesting that evolution of resistance is primarily driven by intensity of exposure to herbicides, but was unrelated directly to other cultural techniques. We find that populations resistant to one herbicide are likely to show resistance to multiple herbicide classes. Finally, we show that the economic costs of evolved resistance are considerable: loss of control through resistance can double the economic costs of weeds. This research highlights the importance of managing threats to food production and healthcare systems using an evolutionarily informed approach in a proactive not reactive manner

Investigation of the Role of TNF-α Converting Enzyme (TACE) in the Inhibition of Cell Surface and Soluble TNF-α Production by Acute Ethanol Exposure

Toll-like receptors (TLRs) play a fundamental role in the immune system by detecting pathogen associated molecular patterns (PAMPs) to sense host infection. Ethanol at doses relevant for humans inhibits the pathogen induced cytokine response mediated through TLRs. The current study was designed to investigate the mechanisms of this effect by determining whether ethanol inhibits TLR3 and TLR4 mediated TNF-α secretion through inhibition of transcription factor activation or post-transcriptional effects. In NF-κB reporter mice, activation of NF-κB in vivo by LPS was inhibited by ethanol (LPS alone yielded 170,000±35,300 arbitrary units of light emission; LPS plus ethanol yielded 56,120±16880, p = 0.04). Inhibition of protein synthesis by cycloheximide revealed that poly I:C- or LPS-induced secreted TNF-α is synthesized de novo, not released from cellular stores. Using real time RT-PCR, we found inhibition of LPS and poly I:C induced TNF-α gene transcription by ethanol. Using an inhibitor of tumor necrosis factor alpha converting enzyme (TACE), we found that shedding caused by TACE is a prerequisite for TNF-α release after pathogen challenge. Flow cytometry was used to investigate if ethanol decreases TNF-α secretion by inhibition of TACE. In cells treated with LPS, ethanol decreased both TNF-α cell surface expression and secretion. For example, 4.69±0.60% of untreated cells were positive for cell surface TNF-α, LPS increased this to 25.18±0.85%, which was inhibited by ethanol (86.8 mM) to 14.29±0.39% and increased by a TACE inhibitor to 57.88±0.62%. In contrast, cells treated with poly I:C had decreased secretion of TNF-α but not cell surface expression. There was some evidence for inhibition of TACE by ethanol in the case of LPS, but decreased TNF-α gene expression seems to be the major mechanism of ethanol action in this system

Brexit and the everyday politics of emotion: methodological lessons from history

The 2016 European Union referendum campaign has been depicted as a battle between ‘heads’ and ‘hearts’, reason and emotion. Voters’ propensity to trust their feelings over expert knowledge has sparked debate about the future of democratic politics in what is increasingly believed to be an ‘age of emotion’. In this article, we argue that we can learn from the ways that historians have approached the study of emotions and everyday politics to help us make sense of this present moment. Drawing on William Reddy’s concept of ‘emotional regimes’, we analyse the position of emotion in qualitative, ‘everyday narratives’ about the 2016 European Union referendum. Using new evidence from the Mass Observation Archive, we argue that while reason and emotion are inextricable facets of political decision-making, citizens themselves understand the two processes as distinct and competing

Stratospheric gravity waves over the mountainous island of South Georgia: testing a high-resolution dynamical model with 3-D satellite observations and radiosondes

Atmospheric gravity waves (GWs) play an important role in atmospheric dynamics but accurately representing them in general circulation models (GCMs) is challenging. This is especially true for orographic GWs generated by wind flow over small mountainous islands in the Southern Ocean. Currently, these islands lie in the “grey zone” of global model resolution, where they are neither fully resolved nor fully parameterised. It is expected that as GCMs approach the spatial resolution of current high-resolution local-area models, small-island GW sources may be resolved without the need for parameterisations. But how realistic are the resolved GWs in these high-resolution simulations compared to observations? Here, we test a high-resolution (1.5 km horizontal grid, 118 vertical levels) local-area configuration of the Met Office Unified Model over the mountainous island of South Georgia (54∘ S, 36∘ W), running without GW parameterisations. The island's orography is well resolved in the model, and real-time boundary conditions are used for two time periods during July 2013 and June–July 2015. We compare simulated GWs in the model to coincident 3-D satellite observations from the Atmospheric Infrared Sounder (AIRS) on board Aqua. By carefully sampling the model using the AIRS resolution and measurement footprints (denoted as model sampled as AIRS hereafter), we present the first like-for-like comparison of simulated and observed 3-D GW amplitudes, wavelengths and directional GW momentum flux (GWMF) over the island using a 3-D S-transform method. We find that the timing, magnitude and direction of simulated GWMF over South Georgia are in good general agreement with observations, once the AIRS sampling and resolution are applied to the model. Area-averaged zonal GWMF during these 2 months is westward at around 5.3 and 5.6 mPa in AIRS and model sampled as AIRS datasets respectively, but values directly over the island can exceed 50 mPa. However, up to 35 % of the total GWMF in AIRS is actually found upwind of the island compared to only 17 % in the model sampled as AIRS, suggesting that non-orographic GWs observed by AIRS may be underestimated in our model configuration. Meridional GWMF results show a small northward bias (∼20 %) in the model sampled as AIRS that may correspond to a southward wind bias compared to coincident radiosonde measurements. Finally, we present one example of large-amplitude (T′≈15–20 K at 45 km altitude) GWs at short horizontal wavelengths (λH≈30–40 km) directly over the island in AIRS measurements that show excellent agreement with the model sampled as AIRS. This suggests that orographic GWs in the full-resolution model with T′≈45 K and λH≈30–40 km can occur in reality. Our study demonstrates that not only can high-resolution local-area models simulate realistic stratospheric GWs over small mountainous islands but the application of satellite sampling and resolution to these models can also be a highly effective method for their validation