Routine mortality monitoring for detecting mass murder in UK general practice: test of effectiveness using modelling.

BACKGROUND: The Shipman Inquiry recommended mortality rate monitoring if it could be 'shown to be workable' in detecting a future mass murderer in general practice. AIM: To examine the effectiveness of cumulative sum (CUSUM) charts, cross-sectional Shewhart charts, and exponentially-weighted, moving-average control charts in mortality monitoring at practice level. DESIGN OF STUDY: Analysis of Scottish routine general practice data combined with estimation of control chart effectiveness in detecting a 'murderer' in a simulated dataset. METHOD: Practice stability was calculated from routine data to determine feasible lengths of monitoring. A simulated dataset of 405,000 'patients' was created, registered with 75 'practices' whose underlying mortality rates varied with the same distribution as case-mix-adjusted mortality in all Scottish practices. The sensitivity of each chart to detect five and 10 excess deaths was examined in repeated simulations. The sensitivity of control charts to excess deaths in simulated data, and the number of alarm signals when control charts were applied to routine data were estimated. RESULTS: Practice instability limited the length of monitoring and modelling was consequently restricted to a 3-year period. Monitoring mortality over 3 years, CUSUM charts were most sensitive but only reliably achieved >50% successful detection for 10 excess deaths per year and generated multiple false alarms (>15%). CONCLUSION: At best, mortality monitoring can act as a backstop to detect a particularly prolific serial killer when other means of detection have failed. Policy should focus on changes likely to improve detection of individual murders, such as reform of death certification and the coroner system.     

Intimate partner violence and health outcomes in mid-life women: a population-based cohort study

Summary Aim: To investigate the association between experience of intimate partner violence (IPV) and health outcomes measured prospectively. Method: Eleven-year prospective study of a population-based cohort of 438 Australian-born women aged 45–55 years at baseline (in 1991). Annual face-to-face interviews measured health status and quality of life; questionnaires on intimate partner physical, emotional and sexual violence and on experiences of childhood abuse completed in year 6 of follow-up. Results: In year 11 of follow-up 233 women (mean age 59.9 SD 2.5 years) were interviewed of whom 62 (27%) reported experiencing physical and/or emotional and/or sexual IPV prior to the 6^th year of follow-up. In bi-variate analysis a history of IPV was significantly associated with mental and sexual health variables and marital status at baseline and follow-up. Multivariate analysis found that at follow-up after allowing for baseline measures and other co-variates: Frequency of Sexual Activities was lower in women who had experienced IPV (p < 0.05); and negative mood was higher in women with the experience of IPV during the 12 months prior to completing the violence questionnaire (p < 0.05). Conclusion: IPV was a significant contributor to mental and sexual health status measured prospectively in this cohort of mid-aged Australian-born women.     

Surface-Bound Proteins with Preserved Functionality

Biocompatibility of materials strongly depends on their surface properties. Therefore, surface derivatization in a controllable manner provides means for achieving interfaces essential for a broad range of chemical, biological, and medical applications. Bioactive interfaces, while manifesting the activity for which they are designed, should suppress all nonspecific interaction between the supporting substrates and the surrounding media. This article describes a procedure for chemical derivatization of glass and silicon surfaces with polyethylene glycol (PEG) layers covalently functionalized with proteins. While the proteins introduce the functionality to the surfaces, the PEGs provide resistance against nonspecific interactions. For formation of aldehyde-functionalized surfaces, we coated the substrates with acetals (i.e., protected aldehydes). To avoid deterioration of the surfaces, we did not use strong mineral acids for the deprotection of the aldehydes. Instead, we used a relatively weak Lewis acid for conversion of the acetals into aldehydes. Introduction of α,ω-bifunctional polymers into the PEG layers, bound to the aldehydes, allowed us to covalently attach green fluorescent protein and bovine carbonic anhydrase to the surfaces. Spectroscopic studies indicated that the surface-bound proteins preserve their functionalities. The surface concentrations of the proteins, however, did not manifest linear proportionality to the molar fractions of the bifunctional PEGs used for the coatings. This finding suggests that surface-loading ratios cannot be directly predicted from the compositions of the solutions of competing reagents used for chemical derivatization.     

Medicinal therapy for hearing loss resulting from noise exposure

A large-scale review of the literature concerning the effects of noise on hearing, published primarily during the 1970s, was initiated by the National Institute of Neurological and Communicative Disorders and Stroke in 1981. This review demonstrated a continuing search for medicinal treatment for the adverse effects of noise on hearing. The present article focuses on the results of investigations of human subjects. The literature in this area is primarily European and deals principally with treatment of acoustic trauma, although a few reports have described attempts to render the ear less susceptible to the hazards of chronic noise exposure. Much of the published information is of questionable value because of inadequate experimental design and control. To date, the search for effective medicinal treatment for hearing loss caused by noise has been unsuccessful. Results reported from studies of the effects of carbogen are encouraging and suggest that continued rigorous investigation of this agent is warranted.     

Laryngeal aerodynamics associated with selected voice disorders

Measures of estimated subglottal air pressure and laryngeal air flow during speech production are compared for adults with normal laryngeal function and those with laryngeal abnormalities. The most traditional measure, air flow during sustained vowel production, is not a strong predictor of laryngeal function during speech production. Subglottal air pressure and laryngeal air flow offer insight into voice disorders and provide directions for therapy as well as a method for the quantitative assessment of treatment outcomes.     

Parental feeding style and the inter-generational transmission of obesity risk

OBJECTIVE: This study was designed to determine whether a community sample of obese mothers with young children used different feeding styles compared with a matched sample of normal-weight mothers. Four aspects of feeding style were assessed: emotional feeding, instrumental feeding (using food as a reward), prompting/encouragement to eat, and control over eating. RESEARCH METHODS AND PROCEDURES: Participants were from 214 families with same-sex twins; 100 families in which both parents were overweight or obese and 114 in which both parents were normal weight or lean. RESULTS: We found that obese mothers were no more likely than normal-weight mothers to offer food to deal with emotional distress, use food as a form of reward, or encourage the child to eat more than was wanted. The obese and normal-weight mothers did differ on "control"; obese mothers reported significantly less control over their children's intake, and this was seen for both first-born and second-born twins. Twin analyses showed that these differences were not in response to children's genetic propensities, because monozygotic correlations were no greater than dizygotic correlations for maternal feeding style. DISCUSSION: These results suggest that the stereotype of the obese mother, who uses food in nonnutritive ways so that her child also becomes obese, is more likely to be myth than fact. However, the results raise the possibility that lack of control of food intake might contribute to the emergence of differences in weight.     

Overview of the diets of lower- and higher-income elderly and their food assistance options

With the elderly becoming an ever-larger proportion of the American population, their dietary well-being is of increasing concern. In particular, lower-income elderly may face special challenges in maintaining a healthful diet. This group makes up a sizeable proportion of the elderly population; we estimate that almost 1 in 5 (19%) of the elderly have household incomes at or below 130% of the federal poverty level, the income level that generally qualifies a household to participate in the federal Food Stamp Program. Here we examine the dietary intakes and related behaviors, as well as the food security status, of lower- and higher-income elderly and review major US government food and nutrition assistance programs that can be of benefit to the elderly, particularly those of low income. Our subjects are individuals 60 years of age and over, living in community (noninstitutionalized) settings. Data on dietary intakes and behaviors were obtained from the US Department of Agriculture's Continuing Survey of Food Intakes by Individuals (CSFII), 1994-96. Food security data were obtained from the 1999 Current Population Survey (CPS), conducted by the US Census Bureau. For both the CSFII and the CPS, sampling weights were used to generate nationally representative estimates. We found that lower-income elderly consume significantly fewer calories than higher-income elderly, fewer servings of major Food Guide Pyramid food groups, and most nutrients. Approximately 6% of elderly households report some degree of food insecurity. Although food and nutrition assistance programs can benefit elderly individuals, many do not participate. Many lower-income elderly also face physiological and social obstacles to obtaining a healthful diet. How best to meet these varied needs is a challenge for nutrition educators, researchers, and policy makers.     

Treating acute stress disorder following mild traumatic brain injury

OBJECTIVE: Acute stress disorder permits early identification of trauma survivors who are at risk of developing chronic posttraumatic stress disorder (PTSD). This study aimed to prevent PTSD in people who developed acute stress disorder after a mild brain injury by early provision of cognitive behavior therapy. METHOD: Twenty-four civilian trauma survivors with acute stress disorder were given five individually administered sessions of either cognitive behavior therapy or supportive counseling within 2 weeks of their trauma. RESULTS: Fewer patients receiving cognitive behavior therapy than supportive counseling met criteria for PTSD at a posttreatment evaluation (8% versus 58%, respectively). There were also fewer cases of PTSD at a 6-month follow-up evaluation among those receiving cognitive behavior therapy (17%) than among those receiving supportive counseling (58%). Patients in the cognitive behavior therapy condition displayed less reexperiencing and avoidance symptoms at the follow-up evaluation than patients receiving supportive counseling. CONCLUSIONS: These findings suggest that PTSD following mild brain injury can be effectively prevented with early provision of cognitive behavior therapy.     

Impact of comorbidity on survival after surgical resection in patients with stage I non-small cell lung cancer

OBJECTIVE: As the mean age in patients with non-small cell lung cancer increases, the proportion of patients with serious comorbidity who are considered for surgical resection also increases. Patients with non-small cell lung cancer have been shown to have a higher burden of comorbidity than do patients with tumors of other sites, such as breast, prostate, colon, and head and neck. The goal of this review was to determine the impact of comorbidity on postoperative and long-term survival after surgical resection in patients with stage I non-small cell lung cancer. METHODS: A database analysis of our hospital's tumor registry included 451 patients who underwent surgical resection for pathologic stage I non-small cell lung cancer between January 1, 1994, and December 31, 1999. Comorbidity severity was prospectively determined with the Kaplan-Feinstein Index. Survival data were collected for each patient from the date of operation, with a mean duration of follow-up of 35.7 months. Bivariate statistics and Cox proportional hazards model analyses were used. RESULTS: The mean age was 64.4 years, and 249 (55%) patients were male. The distribution of overall comorbidity severity was none, 142 (31.5%); mild, 150 (33.3%); moderate, 115 (25.5%); and severe, 44 (9.8%). The overall in-hospital mortality was 2.2% (n = 10/451). There was a nonsignificant trend toward higher hospital mortality with greater comorbidity: none, 0.7% (n = 1/142); mild, 3.3% (n = 5/150); moderate, 0.9% (n = 1/115); and severe, 6.8% (n = 3/44, P =.055). Kaplan-Meier estimated survivals at 3 years for each level of comorbidity were as follows: none, 85.6%; mild, 74.8%; moderate, 68.8%; and severe, 70.0% (P <.002). After adjustment for age, sex, T status, and tumor histologic type, the relative risks of death as a function of comorbidity were mild, 1.44 (95% confidence interval 0.89-2.34); moderate, 2.28 (95% confidence interval 1.43-3.65); and severe; 1.94 (95% confidence interval 1.023-3.70). CONCLUSIONS: Comorbidity has a significant impact on survival after surgical resection of patients with stage I non-small cell lung cancer. These data may help to explain the lower than expected survival results for patients after surgical resection for stage I non-small cell lung cancer.