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Background: Fatigue is commonly reported in population surveys and has been identified in patients with health conditions as a key co-morbidity which makes remaining in work challenging. Such patients, however, rarely have access to programmes to help them manage their fatigue., Aims: To quantify the relationship between fatigue, work impairment and health-related job loss., Methods: We use data from the Health and Employment After Fifty study, a longitudinal study of people aged 50-64 years when recruited through general practices in England in 2013-14. During follow-up, fatigue was measured using the Fatigue Assessment Scale, work impairment was assessed using the Work Productivity and Activity Impairment scale, and changes in employment status were recorded., Results: A total of 2743 participants were eligible for the current analysis; 23% satisfied criteria for being fatigued. People who were fatigued were less likely to have a partner, university degree, be physically active and were more likely to be obese. Their job was more likely to involve shifts, be perceived as insecure, have reported difficulties coping with job demands, and be unsatisfying. After adjustment for socio-economic, lifestyle and work-related factors, they were almost twice as likely to report both work impairment (relative risk 1.8; 95% confidence interval [CI] 1.6, 2.1) and future health-related job loss, although the latter effect was only in those with other morbidities (incidence rate ratio 1.96; 95% CI 1.03-3.72)., Conclusions: Providing evidence-based support for workers with health conditions who experience fatigue may have an important impact at a population level in terms of extending working lives., (© The Author(s) 2024. Published by Oxford University Press on behalf of the Society of Occupational Medicine.)

Background: Fibromyalgia is a common reason for referral to a rheumatologist and is a centralised pain state with symptoms beginning in adolescence/early adulthood and manifests as pain throughout the body, fatigue and cognitive dysfunction. Whilst there is considerable evidence on effective treatments, diagnosis and management are complex. There is almost no evidence on how to organise health services to deliver recommended therapies. The aim of the current study was to understand patient preferences for different features of healthcare services for fibromyalgia., Methodology: We use the Discrete Choice Experiment Method (DCE), a choice-based survey that quantifies preferences for attributes of goods, services or policy interventions, to elicit preferences in relation to alternative models of care for people with fibromyalgia. In this study, attributes describe different models of care for fibromyalgia. We based attributes and levels on earlier phases of the PACFiND project and a literature review on fibromyalgia models of care. The final analysis sample consisted of 518 respondents who completed the survey in full., Results: The final analysis sample consisted of 518 respondents ((patients living in the UK, over 18 years old, with a diagnosis of fibromyalgia), who completed the survey in full. The model of care most preferred is one characterised by earlier diagnosis and ongoing management by a Rheumatologist, via Face-to-face or Phone/video call appointments, with a stronger preference for the latter mode of support. The most preferred treatment was Medication, followed by Physical Therapy, with the least preferred being Talking Therapy. Relative to a Waiting Time for treatment of 6 months, respondents would prefer a lower Waiting Time of 3 months and dislike waiting 12 months for treatment. Respondents showed willingness to receive Ongoing Help and Advice by a Nurse Practitioner or a GP, instead of a Specialist Rheumatologist, provided they were compensated by other changes in the model of care., Conclusion: This study has found that, although respondents express a preference for specialist care, provided by a Rheumatologist, they may be willing to trade-off this preference against other features within a model of care. This willingness to accept a different skill-mix (e.g., appointments with a GP or a Nurse Practitioner) has important implications for practice and policy, as this is a more feasible option in settings where the availability of specialist care is highly constrained., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Norwood et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Objectives: To estimate the cost-effectiveness of a cognitive behavioural approach (CBA) or a personalized exercise programme (PEP), alongside usual care (UC), in patients with inflammatory rheumatic diseases who report chronic, moderate to severe fatigue., Methods: A within-trial cost-utility analysis was conducted using individual patient data collected within a multicentre, three-arm randomized controlled trial over a 56-week period. The primary economic analysis was conducted from the UK National Health Service (NHS) perspective. Uncertainty was explored using cost-effectiveness acceptability curves and sensitivity analysis., Results: Complete-case analysis showed that, compared with UC, both PEP and CBA were more expensive [adjusted mean cost difference: PEP £569 (95% CI: £464, £665); CBA £845 (95% CI: £717, £993)] and, in the case of PEP, significantly more effective [adjusted mean quality-adjusted life year (QALY) difference: PEP 0.043 (95% CI: 0.019, 0.068); CBA 0.001 (95% CI: -0.022, 0.022)]. These led to an incremental cost-effectiveness ratio (ICER) of £13 159 for PEP vs UC, and £793 777 for CBA vs UC. Non-parametric bootstrapping showed that, at a threshold value of £20 000 per QALY gained, PEP had a probability of 88% of being cost-effective. In multiple imputation analysis, PEP was associated with significant incremental costs of £428 (95% CI: £324, £511) and a non-significant QALY gain of 0.016 (95% CI: -0.003, 0.035), leading to an ICER of £26 822 vs UC. The estimates from sensitivity analyses were consistent with these results., Conclusion: The addition of a PEP alongside UC is likely to provide a cost-effective use of health care resources., (© The Author(s) 2023. Published by Oxford University Press on behalf of the British Society for Rheumatology.)

Background: Arm pain is common amongst working-aged adults and causes substantial work disability. The results of a population-based randomized controlled trial (the ARM trial) suggested that advice to remain active reduced disability after 6 months., Aims: To verify ARM trial results amongst people in paid employment., Methods: The ARM trial recruited adults with distal arm pain referred for physiotherapy and randomized equally to three groups: wait-listed for physiotherapy (advised to rest); wait-listed for physiotherapy (advised to remain active) or early physiotherapy. The primary outcome was absence of disability at 26 weeks. Secondary analyses were undertaken amongst participants in paid employment., Results: Amongst 538 trial participants, 347 (64%) were in paid employment, mean age 46.1 years and 47% in manual work. Employed participants were randomized equally to the three arms. Amongst the 271 (78% workers with 26-week data), 43% of those advised to remain active were free from disability, as compared with 37% of those advised to rest. Forty per cent of those who waited for physiotherapy were disability-free as compared with 35% of those treated rapidly. Advice to rest was associated with lower chances of recovery amongst workers who lift/carry weights and those who believed work had caused their symptoms (P = 0.023)., Conclusions: Although not powered as a trial for workers only, our findings suggest that advising activity was as beneficial for people currently in paid work and may be superior to advice to rest in reducing disability. Addressing harmful beliefs about causation of symptoms has the potential to reduce disability., (© The Author(s) 2023. Published by Oxford University Press on behalf of the Society of Occupational Medicine. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Objective: We analyzed the pooled case-control data from the International Head and Neck Cancer Epidemiology (INHANCE) consortium to compare cigarette smoking and alcohol consumption risk factors for head and neck cancer between less developed and more developed countries., Subjects and Methods: The location of each study was categorized as either a less developed or more developed country. We compared the risk of overall head and neck cancer and cancer of specific anatomic subsites associated with cigarette smoking and alcohol consumption. Additionally, age and sex distribution between categories was compared., Results: The odds ratios for head and neck cancer sites associated with smoking duration differed between less developed and more developed countries. Smoking greater than 20 years conferred a higher risk for oral cavity and laryngeal cancer in more developed countries, whereas the risk was greater for oropharynx and hypopharynx cancer in less developed countries. Alcohol consumed for more than 20 years conferred a higher risk for oropharynx, hypopharynx, and larynx cancer in less developed countries. The proportion of cases that were young (<45 years) or female differed by country type for some HNC subsites., Conclusion: These findings suggest the degree of industrialization and economic development affects the relationship between smoking and alcohol with head and neck cancer., (© 2022 Wiley Periodicals LLC.)

Background: Chronic fatigue is a poorly managed problem in people with inflammatory rheumatic diseases. Cognitive behavioural approaches (CBA) and personalised exercise programmes (PEP) can be effective, but they are not often implemented because their effectivenesses across the different inflammatory rheumatic diseases are unknown and regular face-to-face sessions are often undesirable, especially during a pandemic. We hypothesised that remotely delivered CBA and PEP would effectively alleviate fatigue severity and life impact across inflammatory rheumatic diseases., Methods: LIFT is a multicentre, randomised, controlled, open-label, parallel-group trial to assess usual care alongside telephone-delivered CBA or PEP against usual care alone in UK hospitals. Patients with any stable inflammatory rheumatic disease were eligible if they reported clinically significant, persistent fatigue. Treatment allocation was assigned by a web-based randomisation system. CBA and PEP sessions were delivered over 6 months by trained health professionals in rheumatology. Coprimary outcomes were fatigue severity (Chalder Fatigue Scale) and impact (Fatigue Severity Scale) at 56 weeks. The primary analysis was by full analysis set. This study was registered at ClinicalTrials.gov (NCT03248518)., Findings: From Sept 4, 2017, to Sept 30, 2019, we randomly assigned and treated 367 participants to PEP (n=124; one participant withdrew after being randomly assinged), CBA (n=121), or usual care alone (n=122), of whom 274 (75%) were women and 92 (25%) were men with an overall mean age of 57·5 (SD 12·7) years. Analyses for Chalder Fatigue Scale included 101 participants in the PEP group, 107 in the CBA group, and 107 in the usual care group and for Fatigue Severity Scale included 101 in PEP, 106 in CBA, and 107 in usual care groups. PEP and CBA significantly improved fatigue severity (Chalder Fatigue Scale; PEP: adjusted mean difference -3·03 [97·5% CI -5·05 to -1·02], p=0·0007; CBA: -2·36 [-4·28 to -0·44], p=0·0058) and fatigue impact (Fatigue Severity Scale; PEP: -0·64 [-0·95 to -0·33], p<0·0001; CBA: -0·58 [-0·87 to -0·28], p<0·0001); compared with usual care alone at 56 weeks. No trial-related serious adverse events were reported., Interpretation: Telephone-delivered CBA and PEP produced and maintained statistically and clinically significant reductions in the severity and impact of fatigue in a variety of inflammatory rheumatic diseases. These interventions should be considered as a key component of inflammatory rheumatic disease management in routine clinical practice., Funding: Versus Arthritis., Competing Interests: We declare no competing interests., (© 2022 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license.)

Background: Fibromyalgia syndrome (FMS) is the most common chronic widespread pain condition in rheumatology. Until recently, no clear pathophysiological mechanism for fibromyalgia had been established, resulting in management challenges. Recent research has indicated that serum immunoglobulin Gs (IgGs) may play a role in FMS. We undertook a research prioritisation exercise to identify the most pertinent research approaches that may lead to clinically implementable outputs., Methods: Research priority setting was conducted in five phases: situation analysis; design; expert group consultation; interim recommendations; consultation and revision. A dialogue model was used, and an international multi-stakeholder expert group was invited. Clinical, patient, industry, funder, and scientific expertise was represented throughout. Recommendation-consensus was determined via a voluntary closed eSurvey. Reporting guideline for priority setting of health research were employed to support implementation and maximise impact., Results: Arising from the expert group consultation (n = 29 participants), 39 interim recommendations were defined. A response rate of 81.5% was achieved in the consensus survey. Six recommendations were identified as high priority- and 15 as medium level priority. The recommendations range from aspects of fibromyalgia features that should be considered in future autoantibody research, to specific immunological investigations, suggestions for trial design in FMS, and therapeutic interventions that should be assessed in trials., Conclusions: By applying the principles of strategic priority setting we directed research towards that which is implementable, thereby expediating the benefit to the FMS patient population. These recommendations are intended for patients, international professionals and grant-giving bodies concerned with research into causes and management of patients with fibromyalgia syndrome., (© The Author(s) 2021. Published by Oxford University Press on behalf of the American Academy of Pain Medicine.)

Objective: To determine whether good versus poor outcome trajectories and predictors of poor outcome obtained in a derivation study could be replicated in an independent sample of persons undergoing knee arthroplasty (KA)., Methods: We used data from TRIO-POPULAR, a prospective cohort study of 926 participants who underwent KA in the United Kingdom. The participants were assessed preoperatively and 6-weeks, 6- and 12-months postoperatively. The Oxford Knee Score was the primary outcome and a variety of pre-operative predictors of outcome were selected. The outcome measure and the predictors were selected to most closely align with a previously published derivation study of good versus poor outcome. Confirmatory two-piece latent class growth curve analyses were used to model outcome and regression was used to identify predictors of outcome class., Results: Trajectories for the Oxford Knee Scores from TRIO-POPULAR replicated trajectories for WOMAC Pain and Function scores from the previously published derivation study. Multivariable predictors of poor outcome were pain catastrophizing (odds ratio = 1.125, 95% CI = 1.048, .206, p = 0.001) and comorbidity (odds ratio = 1.134, 95%CI = 1.049, 1.227, p = 0.002. Pain catastrophizing also predicted poor outcome in the derivation study., Conclusions: Good and poor outcome trajectories replicated those found in the previously published derivation study. Our model-based method produces stable outcome trajectories despite using data from different countries and participants with substantively different characteristics. Predictors of poor outcome were somewhat inconsistent between the cross-validation and derivation studies. Pain catastrophizing was the only consistent poor outcome predictor., (Copyright © 2021 Osteoarthritis Research Society International. All rights reserved.)

Objectives: To explore 6-month and 12-month secukinumab effectiveness in patients with axial spondyloarthritis (axSpA) overall, as well as across (1) number of previous biologic/targeted synthetic disease-modifying antirheumatic drugs (b/tsDMARDs), (2) time since diagnosis and (3) different European registries., Methods: Real-life data from 13 European registries participating in the European Spondyloarthritis Research Collaboration Network were pooled. Kaplan-Meier with log-rank test, Cox regression, χ² and logistic regression analyses were performed to assess 6-month and 12-month secukinumab retention, inactive disease/low-disease-activity states (Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) <2/<4, Ankylosing Spondylitis Disease Activity Score (ASDAS) <1.3/<2.1) and response rates (BASDAI50, Assessment of Spondyloarthritis International Society (ASAS) 20/40, ASDAS clinically important improvement (ASDAS-CII) and ASDAS major improvement (ASDAS-MI))., Results: We included 1860 patients initiating secukinumab as part of routine care. Overall 6-month/12-month secukinumab retention rates were 82%/72%, with significant (p<0.001) differences between the registries (6-month: 70-93%, 12-month: 53-86%) and across number of previous b/tsDMARDs (b/tsDMARD-naïve: 90%/73%, 1 prior b/tsDMARD: 83%/73%, ≥2 prior b/tsDMARDs: 78%/66%). Overall 6-month/12-month BASDAI<4 were observed in 51%/51%, ASDAS<1.3 in 9%/11%, BASDAI50 in 53%/47%, ASAS40 in 28%/22%, ASDAS-CII in 49%/46% and ASDAS-MI in 25%/26% of the patients. All rates differed significantly across number of previous b/tsDMARDs, were numerically higher for b/tsDMARD-naïve patients and varied significantly across registries. Overall, time since diagnosis was not associated with secukinumab effectiveness., Conclusions: In this study of 1860 patients from 13 European countries, we present the first comprehensive real-life data on effectiveness of secukinumab in patients with axSpA. Overall, secukinumab retention rates after 6 and 12 months of treatment were high. Secukinumab effectiveness was consistently better for bionaïve patients, independent of time since diagnosis and differed across the European countries., Competing Interests: Competing interests: BM: consultancy fees and research grant from Novartis. UL: None. CC: None. AC: fees for speaking and/or consulting from AbbVie, Celgene, Eli Lilly, Janssen-Cilag, Merck Sharp & Dohme, Novartis, Pfizer and UCB. JZ: none. AGL: research grant from Novartis, consultant for/served on the speakers bureau for AbbVie, MSD, Novartis, Pfizer, Roche, and UCB. MP-S: speaker and consultancy fees from Abbvie, BMS, Janssen, Lilly, MSD and Sanofi. FO: speaker and consultancy fees from Abbvie, Abdi Ibrahim, Amgen, Celltrion, Eli Lilly, Novartis, Pfizer, Roche and UCB and research grant from Pfizer. TKK: fees for speaking and/or consulting from AbbVie, Amgen, Biogen, Celltrion, Egis, Eli Lilly, Hikma, MSD, Mylan, Novartis/Sandoz, Oktal, Orion Pharma, Hospira/Pfizer, Roche, Sanofi and UCB and received research funding to Diakonhjemmet Hospital from AbbVie, BMS, MSD, Pfizer, Roche and UCB. ZR: speaker and consultancy fees from Abbvie, Amgen, Biogen, Eli Lilly, Medis, MSD, Novartis, Pfizer, Roche, Sanofi. MJS: speaker fees from Novartis and Pfizer. FI: speaker and consulting fees from AbbVie, Eli Lilly, Novartis, Pfizer, Roche, Sanofi, UCB, MSD. AMH: research grant from MSD. BG: Speaker fee from Novartis. JA: none. RI: consulting fees from Abbvie, Eli-Lilly, Ewopharma, Novartis, Pfizer, Roche, Sandoz. MJN: fees for speaking and/or consulting from AbbVie, Celgene, Eli Lilly, Novartis and Pfizer. KP: honoraria for lectures from MSD, BMS, AbbVie, UCB, Roche, Biogen, Amgen, Novartis, Pfizer, Medac, Egis. CS-P: none. SA: has received grant/research support from, been a consultant for, and served on the speakers bureau for AbbVie, MSD, Novartis, Pfizer, Roche, and UCB. JS: none. MT: none. HS: speaker fees from Novartis, Pfizer and Abbvie. MS: none. JÖ: none. AjG: None. GM: none. IvdH-B: Fees for speaking and/or consulting from Abbvie, Lilly, Novartis, BMS, MSD, UCB and Pfizer. SG: none. CHB: research grant from Novartis. LØ: research grant from Novartis. MH: grant from AbbVie, Biogen, BMS, Novartis, Pfizer, UCB. Personal fee from CellTrion, MSD, Orion, Samsung. MO: consultancy fees and/or speaker fees form Abbvie, BMS, Boehringer-Ingelheim, Celgene, Eli-Lilly, Hospira, Janssen, Merck, Novartis, Novo, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi and UCB; and research support from Abbvie, BMS, Celgene, Merck, and Novartis., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Telephone cognitive behavioural therapy (tCBT) is an acceptable and effective treatment for patients with chronic widespread pain (CWP). Preventing the onset of CWP offers considerable benefits to the individual and society and the MAmMOTH study is the first aimed at CWP prevention. The study is a two-arm randomised trial testing a course of tCBT against usual care for prevention of CWP. This nested qualitative study explores patients' treatment experiences, with a view to understanding their potential influences on acceptability of the intervention., Methods: The MAmMOTH Study recruited 1002 participants, half of whom were randomised to receive tCBT. Participants were eligible for invitation to the trial if they had pain for which they had consulted their GP, or had pain and visited a doctor frequently, and had 2 of 3 risk factors for development of CWP. Participants randomised to tCBT who had completed treatment were eligible for invitation to qualitative interviews for this study. Individual qualitative interviews were conducted with a sub-sample (n = 33) of patients at high risk of developing CWP who had been allocated to the intervention arm. Semi-structured telephone interviews explored treatment experiences and intervention acceptability. Data was analysed using Framework analysis., Results: Participants presented with a range of musculoskeletal and auto-immune conditions and almost half described their pain as 'chronic' on study entry. Many participants perceived the trial intervention to be aimed at treatment of pain rather than prevention of pain. Initial expectations prior to treatment varied, with scepticism more likely for those who had little prior knowledge of CBT approaches. All participants provided positive feedback post intervention particularly in relation to the modality, therapist experience and skills and the intervention. The majority of participants described positive changes in either their subjective level of pain or pain-management post-intervention and some attributed the positive change directly to the intervention as a result of empowerment, increased self-management and cognitive restructuring., Conclusions: This study extends our understanding of the acceptability and suitability of preventative interventions for chronic widespread pain and provides further evidence for the acceptability of tCBT., Trial Registration: Clinical Trials.gov NCT02668003 (registered 29th January, 2016).

Previous mass media campaigns have aimed to influence how people manage back pain, with mixed success. Campaigns should target beliefs which are related to the behaviours they aim to change. This systematic review brings together research that has measured the prevalence of beliefs about back pain in the general population and factors associated with these beliefs, including future pain-related outcomes. Five databases were searched up until April 2017. Quantitative studies which reported a measure of agreement with a belief about back pain, cross-sectional associations, or associations between beliefs and future outcomes were eligible. Eligibility was assessed and data extracted independently by two authors. Results were tabulated and narratively synthesized. Nineteen studies from 10 countries were eligible (median study n [IQR] = 990.5 [524.75-2387.5]). Beliefs were measured using eight questionnaires and 57 stand-alone items. Beliefs about back pain's negative consequences were common across countries and populations, whereas most samples did not hold fear-avoidance beliefs. Beliefs about back pain's consequences were associated with pain and disability, but only one study investigated this specific relationship prospectively. No studies investigated whether beliefs are associated with future pain management behaviours. Agreement with certain beliefs (e.g. about negative consequences) was associated with sociodemographic characteristics (e.g. older age) and poorer self-rated health. Interventions may benefit from targeting beliefs about the perceived negative consequences of back pain in these populations. However, future research should explore how beliefs prospectively influence the management of back pain. SIGNIFICANCE: This review brings together studies which have assessed the prevalence of beliefs about back pain, and factors associated with holding them. It highlights that whether or not these beliefs represent important determinants of how people manage pain remains unknown., (© 2018 The Authors. European Journal of Pain published by John Wiley & Sons Ltd on behalf of European Pain Federation - EFIC®.)

Objective: To assess whether two or more functional somatic symptom complexes (SSCs) showed stronger association with psychosocial correlates than single or no SSC after adjustment for depression/anxiety and general medical disorders., Methods: In a population-based sample we identified, by standardised questionnaire, participants with chronic widespread pain, chronic fatigue and irritable bowel syndrome, excluding those with a medical cause for pain/fatigue. We compared psychosocial variables in three groups: multiple (>1), single or no FSS, adjusting for depression/anxiety and general medical disorders using ordinal logistic regression. We evaluated whether multiple SSCs predicted health status 1 year later using multiple regression to adjust for confounders., Results: Of 1443 participants (58.0% response) medical records were examined in 990: 4.4% (n = 44) had 2 or 3 symptom complexes, 16.2% a single symptom complex. Many psychosocial adversities were significantly associated with number of SSCs in the expected direction but, for many, statistical significance was lost after adjustment for depression/anxiety and medical illness. Somatic symptoms, health anxiety, impairment and number of prior doctor visits remained significantly associated. Impaired health status 1 year later was predicted by multiple somatic symptom complexes even after adjustment for depression, anxiety, medical disorders and number of symptoms., Conclusions: Depression, anxiety, medical illness and health anxiety, demonstrated an exposure-response relationship with number of somatic symptom complexes. These may be core features of all Functional Somatic Syndromes and may explain why number of somatic symptom complexes predicted subsequent health status. These features merit inclusion in prospective studies to ascertain causal relationships., (Crown Copyright © 2018. Published by Elsevier Inc. All rights reserved.)

Background: Opioid prescribing is increasing worldwide with associated increases in misuse and other harms. We studied variations in national opioid prescription rates, indicators of prescribing quality, co-prescribing of benzodiazepines and relationship with pain severity in Scotland., Methods: Electronic linkages of opioid prescribing in Scotland were determined from: (i) national data from Information Services Division, NHS Scotland (2003-2012); and (ii) individual data from Generation Scotland: Scottish Family Health Study. Descriptive analyses were conducted on national data, multilevel modelling to examine factors associated with variations in prescribing rates. χ 2 tests examined associations between individual pain severity and opioid prescriptions., Results: The number of strong opioid prescriptions more than doubled from 474 385 in 2003 to 1 036 446 in 2012, and weak opioid prescribing increased from 3 261 547 to 4 852 583. In Scotland, 938 674 individuals were prescribed an opioid in 2012 (18% of the population). Patients in the most deprived areas were 3.5 times more likely to receive a strong opioid than patients in the least deprived. There was significant variation in prescribing rates between geographical areas, with much of this explained by deprivation. Of women aged 25-40 yr prescribed a strong opioid, 40% were also prescribed a benzodiazepine. There was significant association between pain severity and receipt of opioid prescription. Over 50% of people reporting severe pain were not prescribed an opioid analgesic., Conclusions: We found opioid prescribing in primary care to be common and increasing in Scotland, particularly for severe pain. Co-prescribing of opioids and benzodiazepines was common., (Copyright © 2018 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.)

Background: Epidemiological studies on chronic pelvic pain (CPP) have focused on women of reproductive age. We aimed to determine the prevalence of chronic pelvic pain (CPP) in adult women and the differences in associated factors among women of reproductive age and older women. In addition, to determine whether distinct subgroups existed among CPP cases., Methods: A cross-sectional postal survey was conducted among 5300 randomly selected women aged ≥25 years resident in the Grampian region, UK. Multivariable logistic regression was used to determine pregnancy-related and psychosocial factors associated with CPP. To identify subgroups of CPP cases, we performed cluster analysis using variables of pain severity, psychosocial factors and pain coping strategies., Results: Of 2088 participants, 309 (14.8%) reported CPP. CPP was significantly associated with being of reproductive age (odds ratios (OR) 2.43, 95% CI 1.69-3.48), multiple non-pain somatic symptoms (OR 3.58 95% CI 2.23-5.75), having fatigue (OR mild 1.74 95% CI 1.24-2.44, moderate/severe 1.82, 95% CI 1.25-2.63) and having depression (OR 1.61, 95% CI 1.09-2.38). CPP was less associated with multiple non-pain somatic symptoms in women of reproductive age compared to older women (interaction OR 0.51, 95% CI 0.28-0.92). We identified two clusters of CPP cases; those having little/no psychosocial distress and those having high psychosocial distress., Conclusion: CPP is common in both age groups, though women of reproductive age are more likely to report it. Heightened somatic awareness may be more strongly associated with CPP in older women. There are distinct groups of CPP cases characterized by the absence/presence of psychosocial distress., Significance: Heightened somatic awareness may be more strongly associated with CPP in women of post-reproductive years compared to women of reproductive years. Two subgroups of CPP cases can be differentiated by the absence/presence of psychosocial distress suggesting that stratified management approach may be more efficient., (© 2016 European Pain Federation - EFIC®.)

Objective: The original European League Against Rheumatism recommendations for managing fibromyalgia assessed evidence up to 2005. The paucity of studies meant that most recommendations were 'expert opinion'., Methods: A multidisciplinary group from 12 countries assessed evidence with a focus on systematic reviews and meta-analyses concerned with pharmacological/non-pharmacological management for fibromyalgia. A review, in May 2015, identified eligible publications and key outcomes assessed were pain, fatigue, sleep and daily functioning. The Grading of Recommendations Assessment, Development and Evaluation system was used for making recommendations., Results: 2979 titles were identified: from these 275 full papers were selected for review and 107 reviews (and/or meta-analyses) evaluated as eligible. Based on meta-analyses, the only 'strong for' therapy-based recommendation in the guidelines was exercise. Based on expert opinion, a graduated approach, the following four main stages are suggested underpinned by shared decision-making with patients. Initial management should involve patient education and focus on non-pharmacological therapies. In case of non-response, further therapies (all of which were evaluated as 'weak for' based on meta-analyses) should be tailored to the specific needs of the individual and may involve psychological therapies (for mood disorders and unhelpful coping strategies), pharmacotherapy (for severe pain or sleep disturbance) and/or a multimodal rehabilitation programme (for severe disability)., Conclusions: These recommendations are underpinned by high-quality reviews and meta-analyses. The size of effect for most treatments is relatively modest. We propose research priorities clarifying who will benefit from specific interventions, their effect in combination and organisation of healthcare systems to optimise outcome., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

The development of polymeric materials with cell adhesion abilities requires an understanding of cell-surface interactions which vary with cell type. To investigate the correlation between cell attachment and the nature of the polymer, a series of random and block copolymers composed of 2-(dimethylamino)ethyl acrylate and ethyl acrylate are synthesized through single electron transfer living radical polymerization. The polymers are synthesized with highly defined and controlled monomer compositions and exhibited narrow polydispersity indices. These polymers are examined for their performance in the attachment and growth of HeLa and HEK cells, with attachment successfully modeled on monomer composition and polymer chain length, with both cell lines found to preferentially attach to moderately hydrophobic functional materials. The understanding of the biological-material interactions assessed in this study will underpin further investigations of engineered polymer scaffolds with predictable cell binding performance., (© 2016 WILEY-VCH Verlag GmbH & Co. KGaA, Weinheim.)

Objective: Chronic widespread pain and chronic fatigue share common associated factors but these associations may be explained by the presence of concurrent depression and anxiety., Methods: We mailed questionnaires to a randomly selected sample of people in the UK to identify participants with chronic widespread pain (ACR 1990 definition) and those with chronic fatigue. The questionnaire assessed sociodemographic factors, health status, healthcare use, childhood factors, adult attachment, and psychological stress including anxiety and depression. To identify persons with unexplained chronic widespread pain or unexplained chronic fatigue; we examined participant's medical records to exclude medical illness that might cause these symptoms., Results: Of 1443 participants (58.0% response rate) medical records of 990 were examined. 9.4% (N=93) had unexplained chronic widespread pain and 12.6% (N=125) had unexplained chronic fatigue. Marital status, childhood psychological abuse, recent threatening experiences and other somatic symptoms were commonly associated with both widespread pain and fatigue. No common effect was found for few years of education and current medical illnesses (more strongly associated with chronic widespread pain) or recent illness in a close relative, neuroticism, depression and anxiety scores (more strongly associated with chronic fatigue). Putative associated factors with a common effect were associated with unexplained chronic widespread pain or unexplained chronic fatigue only when there was concurrent anxiety and/or depression., Discussion: This study suggests that the associated factors for chronic widespread pain and chronic fatigue need to be studied in conjunction with concurrent depression/anxiety. Clinicians should be aware of the importance of concurrent anxiety or depression., (Copyright © 2015 The Authors. Published by Elsevier Inc. All rights reserved.)

Indwelling urinary catheters are a commonly used invasive medical device within acute and non-acute settings in NHS Scotland. The second National Survey of the Prevalence of Hospital Acquired Infection (HAI) in Scotland 2011 identified that 19.2% of patients surveyed had an indwelling urinary catheter. In this survey, Urinary Tract Infections (UTI) were identified as the most prevalent type of HAI at 22.6% in acute settings and 39% in non-acute settings [1]. In September 2013 the Scottish Government released a Chief Executive Letter (CEL 19) which identified Catheter Associated Urinary Tract Infection (CAUTI) as one of the nine Points of Care Priorities within the Scottish Patient Safety Programme, with the aim of reducing CAUTI by 30% by end of December 2015 measured against a national definition [2]. This quality improvement project saw the development, testing and introduction within NHS Tayside of an evidenced based bundle of care. This was to standardise and drive quality care delivery for the insertion and maintenance of urethral urinary catheters with the intention of reducing catheter associated urinary tract infections in our patients. Data collection tools and data reporting mechanisms were also developed, tested and introduced using a national CAUTI definition to capture data for improvement and local and national reporting of progress.

Background: This study aims to determine whether older adults reporting back pain (BP) are at increased risk of premature mortality, specifically, to examine the association with disabling/non-disabling pain separately., Methods: Participants aged ≥75 years were recruited to the Cambridge City over-75s Cohort (CC75C) study. Participants answered interviewer-administered questions on BP and were followed up until death. The relationship between BP and mortality was examined using Cox regression, adjusted for potential confounding factors. Separate models were computed for men and women., Results: From 1174 individuals with BP data, the date of death was known for 1158 (99%). A significant association was found between disabling BP and mortality (hazard ratio: 1.4; 95% confidence interval: 1.1-1.8) and this remained, albeit of borderline significance, following adjustment for socio-demographic variables and potential disease markers (1.3; 0.99-1.7). Further, this association was found to vary with sex: women experienced a 40% increase in the risk of mortality associated with disabling BP (1.4; 1.1-1.9), whereas no such increase was observed for men (1.0; 0.5-1.9). Participants with non-disabling BP were not at increased risk of mortality., Conclusions: This study confirmed previous findings regarding the relationship between pain and excess mortality. Further, we have shown that, among older adults, this association is specific to disabling pain and to women. Clinicians should be aware not only of the short-term implications of disabling BP but also the longer-term effects. Future research should attempt to understand the mechanisms underpinning this relationship to avoid excess mortality and should aim to determine why the relationship differs in men and women., (© 2014 European Pain Federation - EFIC®)

Background: Previous studies have found an association between chronic pain and cardiovascular (CV) mortality., Objective: To explore the relationship between the severity of pain and non-fatal CV disease., Methods: A total of 45,994 adults randomly selected from general practice registers in Manchester and Aberdeen were posted a survey, which included a Chronic Pain Grade questionnaire, pain manikin and questions about lifestyle and medical history. A single component measuring pain severity was extracted using factor analysis. Logistic regression was used to test for an association between quintiles of pain severity and a history of CV disease, adjusting for confounders., Results: Of the 15,288 responders, 61% (n = 9357) reported pain for ≥ 1 day in the past month. Compared with the first (lowest) pain severity quintile, the fully adjusted odds ratio for heart attack in the second severity quintile was 1.25 (95% confidence interval 0.68, 2.30); third quintile: 1.65 (0.93, 2.94); fourth quintile: 1.76 (1.00, 3.11) and fifth (highest) quintile 2.47 (1.43, 4.28). Corresponding figures for angina (excluding heart attack) were: 1.79 (0.93, 3.45), 1.91 (1.00, 3.62), 1.03 (0.50, 2.11) and 3.17 (1.71, 5.85)., Conclusion: A history of CV disease is reported more often in those with severe pain than would be expected by chance, even when adjusting for shared risk factors., (© 2014 The Authors. European Journal of Pain published by John Wiley & Sons Ltd on behalf of European Pain Federation - EFICC®.)

The colonisation and establishment of the intestinal microbiota starts immediately at birth and is essential for the development of the intestine and the immune system. This microbial community gradually increases in number and diversity until the age of two or three years when it becomes a stable ecosystem resembling that of adults. This period constitutes a unique window of opportunity to modulate it through probiotic action, with a potential impact in later health. In the present work we have investigated how putative bifidobacterial probiotics modify the metabolic profiles and immune-modulatory properties of faecal microbiotas. An in vitro pH-controlled single-stage continuous-culture system (CCS) inoculated with infant faeces was employed to characterise the effects of two Bifidobacterium species on the intestinal microbiotas in three children, together with the effects of these modified microbiotas on cytokine production by HT-29 cells. Intestinal bacterial communities, production of short-chain fatty acids and lactate were determined by quantitative PCR and gas chromatography, respectively. Cytokines production by HT-29 cells was measured by ELISA. The combination of CCS with infant faeces and human intestinal cells provided a suitable model to evaluate the specific modulation of the intestinal microbiota and immune system by probiotics. In the CCS, infant faecal microbiotas were influenced by the addition of bifidobacteria, resulting in changes in their ability to induce the production of immune mediators by HT-29 cells. The different metabolic and immunological responses induced by the bifidobacterial species tested indicate the need to assess potential probiotics in model systems including complex intestinal microbiotas. Potential probiotic bifidobacteria can modulate the infant microbiota and its ability to induce the production of mediators of the immune response by intestinal cells.

Background: The aim of the study was to test the hypothesis that associations with specific stress systems [hypothalamic-pituitary-adrenal (HPA) and growth hormone (GH) axes] would increase as the number of unexplained disorders increased while accounting for the possible confounding effects of psychosocial factors., Methods: A cross-sectional study identified those reporting chronic widespread pain, irritable bowel syndrome, chronic orofacial pain and chronic fatigue. Of the 1315 subjects, disorder status was available for 1180 (89.7%), of whom 766 (64.9%) reported no disorders, 277 (23.5%) reported one and 137 (11.6%) reported two or more. Eighty subjects were sought from each group for assessment of HPA (morning 8:00 a.m. and evening 10:00 p.m. saliva, and post-dexamethasone serum cortisol levels) and GH [serum insulin-like growth factor 1 (IGF-1) level] axis function. Validated questionnaires informed current psychological state., Results: Two hundred twenty-seven subjects participated [79 (35%) with no disorders, 78 (34%) with one disorder and 70 (31%) with two or more disorders]. There were no significant associations (p < 0.05) between individual disorders or an increasing disorder load with any of the neuroendocrine levels measured: saliva/serum cortisol, IGF-1 and dehydroepiandrosterone. Psychosocial factors were independently associated with disorders and with an increasing disorder load: health anxiety p < 0.01, anxiety p < 0.01, depression p < 0.01, life events p = 0.03., Conclusion: Although previous studies have shown that stress axis function acts to moderate the risk of onset of some of these disorders, the present study shows that the degree of dysfunction is not correlated with a corresponding increasing load of disorders. The uncertainty surrounding the role of these biomarkers in the aetiology of unexplained disorders needs further investigation., (© 2013 European Pain Federation ‐ EFIC®)

Background: Ageing can result in major changes in the composition and metabolic activities of bacterial populations in the large gut and an impaired immune system., Aim: To investigate the effects of synbiotic consumption on the colonic microbiota, immune function and health status in older people., Methods: A randomised, double-blind placebo-controlled, 4-week crossover study was carried out, involving 43 older volunteers, using a synbiotic comprising the probiotic Bifidobacterium longum and an inulin-based prebiotic Synergy 1 (SudZucker, Mannheim, Germany). Faecal and blood samples were collected, and clinical status scored at the start, and at 2- and 4-week intervals, with a 4-week washout between each feeding period. Faecal bacteria were determined by fluorescent in situ hybridisation. Short-chain fatty acid concentrations, cytokine production, bowel habit and a range of clinical parameters were measured., Results: The synbiotic increased bifidobacterial numbers by 1.4 log units (P < 0.0001) and also increased members of the phyla Actinobacteria and Firmicutes (P = 0.0004, P < 0.0001). Proteobacteria were reduced by 1.0 log units (P < 0.0001). Synbiotic feeding was associated with increased butyrate production (P = 0.0399). The pro-inflammatory response was modified by the synbiotic, with significantly reduced pro-inflammatory cytokine TNF-α in peripheral blood after 2 and 4 weeks of synbiotic consumption (P = 0.02, P = 0.0406). The synbiotic had no effect on bowel habit or any clinical parameters., Conclusion: Short-term synbiotic use can be effective in improving the composition and metabolic activities of colonic bacterial communities and immune parameters in older people. This study was registered at clinicaltrials.gov as NCT01226212., (© 2013 John Wiley & Sons Ltd.)

Summary: Barrett's oesophagus (BO) and gastro-oesophageal reflux disease (GERD) are precursors of oesophageal adenocarcinoma (OAC). There is an oesophageal biofilm, which changes in disease, but its role in aetiopathogenesis remains unclear., Aim: To define the oesophageal microbiota of patients with GERD, BO and OAC compared with controls and to investigate mucosal responses related to the microbiota., Methods: Cultural analysis identified the dominant bacterial species from a subset of each disease group. Based on this, molecular techniques were used to define the cohort. Host responses were analysed in tissues and co-culture experiments., Results: A total of 111 species belonging to 26 genera were isolated. There was a significant decrease in bacterial counts in the GERD and BO groups for all genera except Campylobacter, which colonised GERD and Barrett's patients in increasing numbers. Campylobacter concisus was the dominant species. This relationship was not seen in the cancer group. Significant increases in IL-18 were seen in GERD and BO colonised by Campylobacter., Conclusions: This study defines differences in the oesophageal biofilm in disease states, revealing the emergence of C. concisus as the dominant new colonist in the refluxed oesophagus. We also associate the presence of these bacteria with increased expression of cytokines related to carcinogenesis., (© 2013 Blackwell Publishing Ltd.)

Background: The relationship between functional somatic syndromes and multiple somatic symptoms is unclear., Purpose: We assessed whether the number of somatic symptoms is a predictor of health status in three functional somatic syndromes (FSS)., Methods: In a population-based study of 990 UK adults we assessed chronic widespread pain (CWP), chronic fatigue (CF) and irritable bowel syndrome (IBS) by questionnaire and medical record data. We assessed health status (Short Form 12 and EQ-5D), number of somatic symptoms (Somatic Symptom Inventory) and anxiety/depression (Hospital Anxiety and Depression Scale) both at baseline and at follow-up 1 year later., Results: The proportion of people with an FSS who also have multiple somatic symptoms (52-55 %) was similar in the three functional syndromes. The presence of multiple somatic symptoms was associated with more impaired health status both at baseline and at follow-up. This finding was not explained by severity of FSS. In the absence of multiple somatic symptoms, the health status of the FSS was fair or good. In multiple regression analysis, the number of somatic symptoms, the presence of a functional syndrome (CWP or CF) and anxiety/depression were predictors of EQ-5D thermometer at follow-up after adjustment for confounders., Conclusions: Multiple somatic symptoms in people with an FSS are associated with impaired health status and this cannot be explained by more severe functional syndrome or the presence of anxiety and depression.

Background: Low back pain (LBP) is one of the most prevalent occupational health problems in industrialized countries. Little is known about the epidemiology of LBP in developing countries., Aims: To determine the prevalence of LBP among Nepalese textile workers and to investigate the influence of exposure to mechanical and other factors on LBP reporting., Methods: Interviewers completed questionnaires with study subjects, and work-related mechanical exposures were measured by self-completed questionnaires. Associations of LBP with mechanical factors and somatic symptoms were determined by logistic regression and reported as odds ratios (ORs) with 95% confidence intervals (CI)., Results: Nine hundred and thirty-eight workers took part, a participation rate of 92%. The 1 month period prevalence of LBP was 35% (n = 324), being higher in females than males (45% versus 28%; P < 0.001). Several work-related mechanical factors were associated with increased odds of reporting LBP: lifting heavy weights with one hand (OR 1.7; 95% CI 1.1-2.8), pushing weights (OR 1.6; 95% CI 1.2-2.3 and pulling weights (OR 1.6; 95% CI 1.1-2.1). No association was found with working posture. Strong associations were found for reporting one (OR 2.4; 95% CI 1.7-3.4) or two somatic symptoms (OR 2.7; 95% CI 1.4-5.1). On multivariable analysis, reporting of somatic symptoms (OR 2.8; 95% CI 1.5-5.4), female gender (OR 2.2; 95% CI 1.5-3.1) and increasing age were significantly associated with increased risk of reporting LBP (OR 1.7; 95% CI 1.2-2.5), but no associations were found with mechanical factors., Conclusions: This study suggests that mechanical load may not be the leading cause of LBP and adds to evidence that psychological factors play an important role in LBP in non-industrialized countries.

Aims: The aim of this study was to determine if genetic variation in the pain-modulating gene DREAM and its pathway genes influence susceptibility to reporting musculoskeletal pain in the population., Methods: Pairwise tag single nucleotide polymorphisms (SNPs) in DREAM, PDYN and OPRK1 were genotyped in a UK population-based discovery cohort in whom pain was assessed using blank body manikins at three time points. Depression and anxiety symptoms were assessed at the first time point. Zero-inflated negative binomial regression was used to test for association between SNPs and the maximum number of pain sites reported (0-29) across the three time points. Significantly associated SNPs (p < 0.05) were subsequently genotyped for validation in a cohort of European men with pain assessed at two time points., Results: Thirty-five SNPs were genotyped in 1055 subjects, of whom 83% reported pain, in the discovery cohort. SNPs in each gene were associated with the maximum number of pain sites reported, were independent of symptoms of anxiety and depression and had a significant cumulative effect (p = 7.0 × 10(-5) ). Significantly associated SNPs were successfully genotyped in 1733 men, 76% of whom reported pain, in the validation cohort, but did not show significant association with the number of pain sites., Conclusions: Genetic variation in the DREAM pathway genes was associated with the extent of pain reporting in a population-based cohort. These findings were not replicated in a single independent cohort; however, given the potential of this pathway as a therapeutic target, further investigation in additional cohorts is warranted., (© 2012 European Federation of International Association for the Study of Pain Chapters.)

Background: Colorectal cancer is a significant cause of death. Removal of precancerous adenomas, and early detection and treatment of cancer, has been shown to reduce the risk of death. The aim of this review and meta-analysis was to determine whether flexible sigmoidoscopy (FS) is an effective population screening method for reducing mortality from colorectal cancer., Methods: MEDLINE (1946 to December 2012) and Embase (1980-2012, week 15) were searched for randomized clinical trials in which FS was used to screen non-symptomatic adults from a general population, and FS was compared with either no screening or any other alternative screening methods. Meta-analysis was carried out using a random-effects Mantel-Haenzsel model., Results: Twenty-four papers met the inclusion criteria, reporting results from 14 trials. Uptake of FS was usually lower than that for stool-based tests, although FS was more effective at detecting advanced adenoma and carcinoma. FS reduced the incidence of colorectal cancer after screening, and long-term mortality from colorectal cancer, compared with no screening in a selected population. Compared with stool-based tests in a general population, FS was associated with fewer interval cancers., Conclusion: FS is efficacious at reducing colorectal cancer mortality compared with no screening. It is more effective at detecting advanced adenoma and carcinoma than stool-based tests. FS may be compromised by poorer uptake. Introduction of FS as a screening method should be done on a pilot basis in populations in which it is not currently used, and close attention should be paid to maximizing uptake. The relative risk of adverse events with FS compared with stool-based tests should be quantified, and its real-world effectiveness evaluated against the most effective stool-based tests., (Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.)

The Sydney rock oyster, Saccostrea glomerata, has been demonstrated as a useful biomonitor of estrogenic compounds following laboratory exposures, yet its utility in the assessment of estrogenic exposure and effects under field conditions requires investigation. To achieve this aim, S. glomerata were deployed in Newcastle, Australia in the effluent receiving marine waters of Burwood Beach WWTP (Burwood Beach "near", <50 m from outfall and Burwood Beach "far", 100-150 m from outfall) and reference locations (Redhead, Fingal Island 1 and Fingal Island 2) at depths of 4, 8 and 12 m for six weeks. Effluent receiving waters of Burwood Beach WWTP were found to be a suitable impact location, demonstrated via measurement of estrogenic compounds and activity throughout the deployment. Estrogenic compounds were detected (average of combined solids and liquid fractions) at average concentrations of: 1.42 ng/L for estrone, 0.69 ng/L for 17β estradiol, 3.83 ng/L for estriol (E3), 0.56 ng/L for 17α-ethynylestradiol, 64.2 ng/L for bisphenol A, 7.51 ng/L for 4-nonylphenol and 5.93 ng/L for 4-tert-octylphenol. Total estrogenic activity was estimated at 4.48 ng/L EEQ via the Yeast Estrogen Screen (YES(®)) assay (average of combined solid and liquid fractions). Female vitellogenin gene expression was highest at Burwood Beach locations, yet no significant differences were detected among locations for either sex. Vitellogenin protein was significantly higher (p<0.05) in S. glomerata at Burwood Beach Near compared to reference locations for the 4 and 12 m depths. Increased proportions of females were found at Burwood Beach Near, at 4m depth (p<0.05). Both Burwood Beach locations had higher proportions of mature female gonadal development stages compared to reference locations (p<0.05). Oocyte area was highest at both Burwood Beach locations, but no significant differences were detected among locations. Findings provided further evidence that female S. glomerata may be a suitable candidate species for assessment of effects of estrogenic compounds in Australian waters., (Copyright © 2012 Elsevier B.V. All rights reserved.)

Background/aims: To test whether mechanical hyperalgesia is associated with multiple idiopathic pain disorders (IPDs) and whether this relationship is independent of the confounding effects of psychosocial factors., Methods: One hundred eighteen subjects with chronic orofacial pain (COFP) were identified from their questionnaire responses to a population study in North West England. All subjects had a tender point examination according to the American College of Rheumatology classification. Validated tools on the questionnaire were used to identify presence of other IPDs (irritable bowel syndrome and chronic widespread pain) and psychosocial factors (anxiety, depression, health anxiety, sleep disturbance and reporting of somatic symptoms and adverse life events)., Results: Of the 118 subjects, 47.6% (n = 56) had COFP, 34.7% (n = 41) had COFP plus one IPD and 17.8% (n = 21) had all three IPDs. Univariate analysis revealed a dose-response relationship between number of tender points (TPs) and number of IPDs [2-6 TPs (OR 2.6, 95% CI 1.0-7.3), ≥ 7 TPs (OR 10.5, 95% CI 3.8-29.3)] and number of IPDs and psychological distress [anxiety (OR 2.8, 95% CI 1.2-6.4), depression (OR 4.3, 95% CI 1.7-10.6), sleep disturbance (OR 4.8, 95% CI 1.6-14.6)]. The relationship between IPDs and TPs persisted after adjusting for psychosocial factors in multivariate analyses [2-6 TPs (OR 2.5, 95% CI 0.8-7.8) ≥ 7 TPs (OR 10.7, 95% CI 3.4-33.7)]., Conclusion: The dose-response relationship between TPs and IPDs needs further investigation to determine the temporal nature of these relationships and to disentangle the complex gene-environment relationships that may influence the occurrence of multiple IPDs., (© 2012 European Federation of International Association for the Study of Pain Chapters.)

Objective: To assess whether the number of somatic symptoms and health anxiety are independent predictors of future health care use after adjusting for confounders., Methods: In a random sample of the adult UK population, questionnaires assessed the number of somatic symptoms (Somatic Symptom Inventory), health anxiety (Whiteley Index), anxiety/depression (Hospital Anxiety and Depression Scale), the number of physical illnesses and demographic variables. The number of consultations in primary care was obtained from medical records for 1 year before and after questionnaire assessment, and negative binomial regression analyses identified predictors of consultation rate., Results: The sample included 961 participants (58.0% response) with complete medical record data for 609 participants. After adjustment for consultation rate in the prior year, the predictors of subsequent consultation rate in primary care were the number of physical illnesses, off work through illness, Whiteley Index (incidence rate ratio [IRR] = 1.22, 95% confidence interval [CI] = 1.09-1.35), and the Whiteley Index-by-Somatic Symptom Inventory interaction term. Reported physical abuse predicted an increased consultation rate in women (IRR = 2.30, 95% CI = 1.08-4.90) but a reduced rate in men (IRR = 0.43, 95% CI = 0.22-0.84), interaction p = 0.003., Conclusions: These data raise the possibility that both increased health anxiety and number of bothersome somatic symptoms predict frequent medical consultations. A more complex model of predicting future health care use is needed than has been studied previously, which is potentially relevant to the current discussions of the proposed DSM-V and International Classification of Diseases, 11th Revision, diagnostic guidelines regarding complex somatic symptom disorders.

Background: The risk factors for a high total somatic symptom count are unclear; and it is not known whether total somatic symptoms count is a predictor of impaired health status., Method: A prospective population-based cohort study in North West England. Randomly sampled residents (1443 participants; 58% response) completed questionnaires to determine number of somatic symptoms (SSI), health status and a wide range of risk factors; 741 completed questionnaires 1 year later. We used logistic regression to identify risk factors for high SSI at follow-up and for persistently high SSI. We used ANCOVAR and multiple regression to assess whether baseline SSI predicted health status at follow-up., Results: Twenty-one percent of participants scored over 25 on the Somatic Symptom Inventory (SSI) at baseline and 14% at both baseline and follow-up. Risk factors for a persistent high SSI were: fewer than 12 years of education, separated, widowed or divorced status, reported psychological abuse during childhood, co-existing medical illnesses, anxiety and depression. In multivariate analysis baseline SSI predicted health status (SF12 physical component score and health-related quality of life (EuroQol)) 12 months later. Persistent high SSI was a clinically meaningful predictor of these outcomes., Conclusions: Our data support a biopsychosocial approach to somatic symptoms rather than the dualistic approach of identifying "medically unexplained" symptoms. The risk factors for total somatic symptom count were those associated with psychiatric disorders including physical illness. A persistent high somatic symptom count provides a readily measured dimension of importance in epidemiology as a predictor of health status., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Background: The study aimed to investigate the role of medical history (skin warts, Candida albicans, herpetic lesions, heartburn, regurgitation) and medication use (for heartburn; for regurgitation; aspirin) in the aetiology of upper aerodigestive tract (UADT) cancer., Methods: A multicentre (10 European countries) case-control study [Alcohol-Related CAncers and GEnetic susceptibility (ARCAGE) project]., Results: There were 1779 cases of UADT cancer and 1993 controls. History of warts or C. albicans infection was associated with a reduced risk [odds ratio (OR) 0.80, 95% confidence interval (CI) 0.68-0.94 and OR 0.73, 95% CI 0.60-0.89, respectively] but there was no association with herpetic lesions, heartburn, regurgitation or medication for related symptoms. Regurgitation was associated with an increased risk for cancer of the oesophagus (OR 1.47, 95% CI 0.98-2.21). Regular aspirin use was not associated with risk of UADT cancer overall but was associated with a reduced risk for cancer of oesophagus (OR 0.51, 95% CI 0.28-0.96), hypopharynx (OR 0.53, 95% CI 0.28-1.02) and larynx (OR 0.74, 95% CI 0.54-1.01)., Conclusions: A history of some infections appears to be a marker for decreased risk of UADT cancer. The role of medical history and medication use varied by UADT subsites with aspirin use associated with a decreased risk of oesophageal cancer and suggestive of a decreased risk of hypopharyngeal and laryngeal cancers.

The 3-yearly World Congress of Epidemiology is the premier, international, scientific conference organised under the auspices of the International Epidemiological Association (in open competition). This paper explores the justification for seeking to host the Congress and reflects on the structures and processes adopted in making the XIXth Congress in Scotland happen. Preparing the bid was invaluable for forming collaborations, generating scientific ideas, and garnering opinion. After the bid was accepted, we formed a local organising committee, named the Management Executive Committee to signal its decision making authority; and scientific, fundraising, marketing, international and social subcommittees. There was uncertainty about critical matters such as delegate numbers, costs and the total budget. Early decisions had to be made on, for example, the fee and fundraising target (£250,000), despite financial risks. Development of the scientific programme was a critical step that underpinned fundraising and marketing and permitted involvement of the international committee. Overall the 2011 WCE succeeded. The key ingredients to success were: a large collaboration of institutions and individuals; early pledges of financial support mostly from the UK; the valuable and relevant experience of the professional conference organisers; unstinting support and advice from IEA; and the effectiveness of the committee structure. The educational and professional development benefits of this WCE will reach a worldwide community and not just delegates, because of video, PowerPoint and textual accounts being open access on the Internet. This reach is unprecedented for IEA's World Congresses. We anticipate that the Congress will translate into better public health practice, better future Congresses, advances in epidemiology and improved population health., (Copyright © 2012 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.)

Objective: The aim was to examine the relationship between gestational age and birthweight and adult chronic widespread pain (CWP)., Design and Participants: A prospective cohort study of 18,558 participants recorded birthweight and gestation at birth., Exposure: Participants were categorised by gestation (fullterm ≥37 weeks; preterm <37 week) and birthweight (full birthweight (FBW) ≥2.5 kg; low birthweight (LBW) 1.5-2.5 kg; and very low birthweight (VLBW) <1.5 kg)., Outcome: The presence or absence of CWP was measured by self-completed questionnaire in 8572 participants at age 45 yrs. Risk ratios were calculated using Poisson regression. Adjustment was made for potential confounding factors., Results: Premature birth was associated with a 26% increase in the risk of CWP compared to fullterm birth, although this was not statistically significant (risk ratio 1.26, 95% confidence interval 0.95-1.67). This increased risk was robust to adjustment for sex, social class at birth and age 42 yrs, or birthweight, but was completely attenuated when adjusted for childhood behavioural problems and adult psychiatric disorder. LBW was not associated with an increased risk of CWP (RR 1.01, 95%CI 0.78-1.32). VLBW was associated with a non-significant increased risk (RR 1.48, 0.42-5.22) although there was insufficient study power to examine this relationship in the context of other factors., Conclusions: Premature birth and VLBW are associated with increased risk of adult CWP although these effects are modest, and not statistically significant. Although not conclusive in itself, this study lends support to the theory that adult chronic pain may have its origins - at least in part - in very early life., (© 2011 European Federation of International Association for the Study of Pain Chapters.)

Aims: To investigate the effects of human gut micro-organisms on cytokine production by human intestinal cell lines., Methods and Results: Quantitative real-time PCR assays were developed to measure the production of pro-inflammatory (IL-1α, IL-6, IL-18 and TNFα) and anti-inflammatory (TGF-β1, TGF-β2, TGF-β3, IL-4 and IL-10) cytokines in HT-29 and Caco-2 cell lines. They were co-cultured with a range of mucosal bacteria isolated from ulcerative colitis patients, together with lactobacilli and bifidobacteria obtained from healthy people. HT-29 cells were also co-cultured with Campylobacter jejuni, enterotoxigenic Escherichia coli (ETEC), enteropathogenic E. coli and Salmonella typhimurium. The majority of commensal bacteria tested suppressed the expression of anti-inflammatory cytokine mRNA, increased IL-18, reduced IL-1α, and with the exception of nonpathogenic E. coli, reduced TNF-α. All overtly pathogenic species increased both pro-inflammatory and anti-inflammatory cytokine mRNA., Conclusion:   Commensal and pathogenic species induced fundamentally different cytokine responses in human intestinal epithelial cell lines., Significance and Impact of the Study: Interactions between commensal bacteria tested in this study and the innate immune system were shown to be anti-inflammatory in nature, in contrast to the pathogenic organisms investigated. These data contribute towards our understanding of how potential probiotic species can be used to suppress the pro-inflammatory response in inflammatory bowel disease., (© 2010 The Authors. Journal of Applied Microbiology © 2010 The Society for Applied Microbiology.)

Although mounting evidence suggests exposure to estrogenic contaminants increases vitellogenin production in molluscs, demonstration of dose-response relationships and knowledge of the temporal nature of the vitellogenin response with continual exposure is currently lacking for biomarker utility. To address this knowledge gap, adult Sydney rock oysters, Saccostrea glomerata, were exposed to a range of environmentally relevant concentrations of 17α-ethynylestradiol (EE2) (0, 6.25, 12.5, 25 or 50 ng/l) in seawater under laboratory conditions. Vitellogenin induction and gonadal development was assessed following 4, 21 and 49 days exposure to EE2. Vitellogenin was found to increase in a dose dependent manner with EE2 exposure for females (4 and 49 days) and males (4 and 21 days). Histological examination of gonads revealed a number of individuals exhibited intersex (ovotestis) in 50 ng/l EE2 (after 21 days) and in 6.25 and 12.5 ng/l EE2 (after 49 days). Furthermore, a significant shift towards females was observed following 49 days exposure at 50 ng/l EE2 suggesting estrogenic exposure is capable of facilitating a progression for protandric males from male-intersex-female gametal status. Increases in female vitellogenin (4 days) were predictive of later increases in female developmental stages at 21 days and increases in oocyte area following 49 days. Male vitellogenin (4 days) was predictive of decreased male percentages and lower male developmental stages at 49 days. Vitellogenin in S. glomerata is a predictive biomarker of estrogenic exposure and effect if sampled soon after exposure and at the commencement of a gonadal development cycle.

Background: Crohn's disease is an inflammatory illness in which the immune response against gut microorganisms is believed to drive an abnormal immune response. Consequently, modification of mucosal bacterial communities, and the immune effects they elicit, might be used to modify the disease state., Aim: To investigate the effects of synbiotic consumption on disease processes in patients with Crohn's disease., Methods: A randomized, double-blind placebo-controlled trial was conducted involving 35 patients with active Crohn's disease, using a synbiotic comprising Bifidobacterium longum and Synergy 1. Clinical status was scored and rectal biopsies were collected at the start, and at 3- and 6-month intervals. Transcription levels of immune markers and mucosal bacterial 16S rRNA gene copy numbers were quantified using real-time PCR., Results: Significant improvements in clinical outcomes occurred with synbiotic consumption, with reductions in both Crohn's disease activity indices (P = 0.020) and histological scores (P = 0.018). The synbiotic had little effect on mucosal IL-18, INF-gamma and IL-1beta; however, significant reductions occurred in TNF-alpha expression in synbiotic patients at 3 months (P = 0.041), although not at 6 months. Mucosal bifidobacteria proliferated in synbiotic patients., Conclusion: Synbiotic consumption was effective in improving clinical symptoms in patients with active Crohn's disease., (2010 Blackwell Publishing Ltd.)

Bioactivity-guided fractionation of an ethanolic extract of the rhizome of Pleuranthodium racemigerum, a tropical Zingiberaceae species from Northeastern Australia, resulted in the isolation and structural elucidation of 1-(4''-methoxyphenyl)-7-(4'-hydroxyphenyl)-(E)-hept-2-ene (1), a new diarylheptanoid related to curcumin. Compound 1 was a fairly potent inhibitor of prostaglandin E(2) production in 3T3 murine fibroblasts (IC(50) approximately 34 microM) and also displayed moderate cytotoxicity against this cell line (IC(50) = 52.8 microM). The compound also demonstrated cytotoxic activity against the P388D1 murine lymphoblast cell line (IC(50) = 117.0 microM) and four human cell lines: Caco-2 colonic adenocarcinoma (IC(50) = 44.8 microM), PC3 prostate adenocarcinoma (IC(50) = 23.6 microM), HepG2 hepatocyte carcinoma (IC(50) = 40.6 microM), and MCF7 mammary adenocarcinoma (IC(50) = 56.9 microM). The cytotoxicity of compound 1 closely resembled that of curcumin, in terms of both IC(50) values and dose-response curves.

Purpose: To systematically evaluate the diagnostic benefits and inter- and intraobserver reliability of an incremental computed tomographic (CT) protocol in the confirmation of clinically suspected stroke, with combined imaging and clinical data as the reference standard., Materials and Methods: Institutional review board approval was obtained, and participants gave informed consent. A total of 191 patients (mean age, 67 years +/- 16 [standard deviation]; 105 men) with strokelike symptoms of no more than 3 hours duration were recruited. Blinded review was performed by four readers with limited stroke imaging experience. Diagnostic confidence was recorded on a five-point scale. Logistic regression analysis was used to calculate the difference between the real and observed diagnoses, adjusting for confidence. Predictive effects of observed diagnostic performance and confidence score were quantified with the entropy r(2) value. Sensitivity, specificity, and confidence intervals were calculated while accounting for multiple reader assessments. Receiver operating characteristic (ROC) analyses, including area under the ROC curve, were conducted for three modalities in combination with confidence score. Inter- and intraobserver agreement was established with the Cohen kappa statistic., Results: The final diagnosis was infarct in 64% of the patients, transient ischemic attack in 18%, and stroke mimic in 17%. Large-vessel occlusion occurred in 70% of the patients with an infarct. Sensitivity for stroke determination with noncontrast CT, CT angiography, and CT perfusion increased by 12.4% over that with noncontrast CT and CT angiography and by 18.2% over that with only noncontrast CT for a confidence level of 4 or higher. The incremental protocol was more likely to enable confirmation of clinical stroke diagnosis (odds ratio, 13.3) than was noncontrast CT and CT angiography (odds ratio, 6.4) or noncontrast CT alone (odds ratio, 3.3), The area under the ROC curve was 0.67 for the combination of noncontrast CT and confidence score, 0.72 for the combination of CT angiography and confidence score, and 0.81 for the combination of CT perfusion and confidence score. Inter- and intraobserver agreement increased with progressive sequence use., Conclusion: An incremental stroke protocol that includes CT perfusion increases diagnostic performance for stroke diagnosis and inter- and intraobserver agreement., (RSNA, 2010)

The aim of this study was to explore associations between social mobility and tumours of the upper aero-digestive tract (UADT), focussing on life-course transitions in social prestige (SP) based on occupational history. 1,796 cases diagnosed between 1993 and 2005 in ten European countries were compared with 1585 controls. SP was classified by the Standard International Occupational Prestige Scale (SIOPS) based on job histories. SIOPS was categorised in high (H), medium (M) and low (L). Time weighted average achieved and transitions between SP with nine trajectories: H --> H, H --> M, H --> L, M --> H, M --> M, M --> L, L --> H, L --> M and L --> L were analysed. Odds ratios (ORs) and 95%-confidence intervals [95%-CIs] were estimated with logistic regression models including age, consumption of fruits/vegetables, study centre, smoking and alcohol consumption. The adjusted OR for the lowest versus the highest of three categories (time weighted average of SP) was 1.28 [1.04-1.56]. The distance of SP widened between cases and controls during working life. The downward trajectory H --> L gave an OR of 1.71 [0.75-3.87] as compared to H --> H. Subjects with M --> M and L --> L trajectories ORs were also elevated relative to subjects with H --> H trajectories. The association between SP and UADT is not fully explained by confounding factors. Downward social trajectory during the life course may be an independent risk factor for UADT cancers.

Introduction: In the European Union, there are 180,000 new cases of upper aerodigestive tract (UADT) cancer cases per year--more than half of whom will die of the disease. Socioeconomic inequalities in UADT cancer incidence are recognised across Europe. We aimed to assess the components of socioeconomic risk both independently and through their influence on the known behavioural risk factors of smoking, alcohol consumption and diet., Patients and Methods: A multicentre case-control study with 2198 cases of UADT cancer and 2141 controls from hospital and population sources was undertaken involving 14 centres from 10 countries. Personal interviews collected information on demographics, lifetime occupation history, smoking, alcohol consumption and diet. Socioeconomic status was measured by education, occupational social class and unemployment. Odds ratios (ORs) and 95% confidence intervals (CIs) were computed using unconditional logistic regression., Results: When controlling for age, sex and centre significantly increased risks for UADT cancer were observed for those with low versus high educational attainment OR=1.98 (95% CI 1.67, 2.36). Similarly, for occupational socioeconomic indicators--comparing the lowest versus highest International Socio-Economic Index (ISEI) quartile for the longest occupation gave OR=1.60 (1.28, 2.00); and for unemployment OR=1.64 (1.24, 2.17). Statistical significance remained for low education when adjusting for smoking, alcohol and diet behaviours OR=1.29 (1.06, 1.57) in the multivariate analysis. Inequalities were observed only among men but not among women and were greater among those in the British Isles and Eastern European countries than in Southern and Central/Northern European countries. Associations were broadly consistent for subsite and source of controls (hospital and community)., Conclusion: Socioeconomic inequalities for UADT cancers are only observed among men and are not totally explained by smoking, alcohol drinking and diet., (Copyright (c) 2009 Elsevier Ltd. All rights reserved.)

Objective: This study aims to determine to what extent the reporting of pain in adulthood varies by adult socioeconomic status, whether there are additional long-term effects of socioeconomic status in childhood and whether any such relationships are mediated through adult psychological ill health., Methods: A prospective cohort study (the 1958 British Birth Cohort Study) was conducted. Participants were recruited, at birth, in 1958 and were followed-up throughout childhood and adulthood, most recently at 45 years when information was collected on regional and widespread pain, and various potential mediating factors., Results: The prevalence of shoulder, forearm, low back, knee and chronic widespread pain at 45 years generally increased with lower adult social class. Persons in the lowest social class (compared to the highest) experienced nearly a threefold increase in the risk of chronic widespread pain: relative risk: 2.9 (95% CI 1.8 to 4.6). The strength of association varied between 1.5 and 2.0 for regional pains. Childhood social class also demonstrated a relationship with most regional pains and chronic widespread pain. With the exception of forearm pain, the magnitude of effect of childhood social status on reporting of pain in adulthood was less than that of adult social status. On multivariable analysis these relationships were partly explained by poor adult mental health, psychological distress, adverse life events and lifestyle factors., Conclusions: These results emphasise the importance and potential impact of measures to reduce social adversity, which will have the effect of improving musculoskeletal health in adult life and other major causes of morbidity.

Objectives: To establish whether review articles provide consistent conclusions on associations between workplace psychosocial factors and musculoskeletal pain and, if differences exist, to explore whether this is related to the methods used., Methods: Reviews, reported up to February 2007, that included consideration of workplace psychosocial factors and upper limb, back or knee pain were identified through searches of multiple databases. The specific work-related psychosocial factors considered were job demands, support, job autonomy and job satisfaction. The conclusions of each review on one or more of the psychosocial/musculoskeletal pain associations were extracted., Results: 15 review articles were identified that considered one or more of the regional pain syndromes included in the study. For back pain, the most consistent conclusions (four reviews positive out of six) were with high job demands and low job satisfaction. The studies of upper limb pain were exclusively related to shoulder and/or neck pain, and the most consistent positive conclusions were with high and low job demands (four reviews positive out of six and two reviews positive out of three, respectively). For knee pain, only a single review was identified. For individual reviews of back and upper limb pain, there were marked differences in the number of associations concluded to be positive between reviews., Conclusions: The reasons for reviews coming to different conclusions included that they were often evaluating different bodies of evidence (according to their search criteria, the year when the review was conducted, the role that quality assessment played in whether studies contributed to evidence, and the combination of risk factors addressed in individual studies), but more important was whether the review specified explicit criteria for making conclusions on strength of evidence. These conclusions emphasise the importance of developing standardised methods for conducting such evaluations of existing evidence and the importance of new longitudinal studies for clarifying the temporal relationship between psychosocial factors and musculoskeletal pain in the workplace.

Background: Identified aetiological factors for chronic widespread pain (CWP) are largely related to emotional and behavioural factors, but current management leads to modest improvement in symptoms. Vitamin D deficiency has been suggested as a new modifiable risk factor for CWP., Objective: To examine the association between vitamin D status (measured by 25-hydroxyvitamin D (25(OH)D)) and CWP in a nationwide population sample of white British adults, accounting for potential mediating and confounding lifestyle factors., Methods: 9377 participants born 1 week in March 1958, in England, Scotland or Wales and completing a biomedical assessment at age 45; 6824 eligible participants had data on 25(OH)D and completed pain manikins., Results: Prevalence of CWP varied by 25(OH)D concentration in women but not in men, with the lowest prevalence observed for women with 75-99 nmol/l (14.4% for <25 nmol/l, 14.8% for 25-49 nmol/l, 11.6% for 50-74 nmo/l, 8.2% for 75-99 nmol/l and 9.8% for participants with > or =100 nmol/l). There was an interaction between 25(OH)D concentration and gender in relation to CWP (interaction, p = 0.006), which was not fully explained by differences in lifestyle or social factors (adjusted interaction, p = 0.03). For women, the association between 25(OH)D concentration and CWP persisted after full adjustment (odds ratio (OR) for <75 nmol/l vs 75-99 nmol/l 1.57, 95% CI 1.09 to 2.26), while no evidence for an association was apparent in men (OR = 1.03, 95% CI 0.75 to 1.43)., Conclusion: Current vitamin D status was associated with CWP in women but not in men. Follow-up studies are needed to evaluate whether higher vitamin D intake might have beneficial effects on the risk of CWP.

Individuals with "insecure" adult attachment styles have been shown to experience more pain than people with secure attachment, though results of previous studies have been inconsistent. We performed a cross-sectional study on a large population-based sample to investigate whether, compared to pain free individuals, subjects with chronic widespread pain were more likely to report insecure adult attachment style. Subjects in a population-based cross-sectional study completed a self-rated assessment of adult attachment style. Attachment style was categorised as secure (i.e., normal attachment style); or preoccupied, dismissing or fearful (insecure attachment styles). Subjects completed a pain questionnaire from which three groups were identified: pain free; chronic widespread pain; and other pain. Subjects rated their pain intensity and pain-related disability on an 11 point Likert scale. Subjects (2509) returned a completed questionnaire (median age 49.9 years (IQR 41.2-50.0); 59.2% female). Subjects with CWP were more likely to report a preoccupied (RRR 2.6; 95%CI 1.8-3.7), dismissing (RRR 1.9; 95%CI 1.2-3.1) or fearful attachment style (RRR 1.4; 95%CI 1.1-1.8) than those free of pain. Among CWP subjects, insecure attachment style was associated with number of pain sites (Dismissing: RRR 2.8; 95%CI 1.2-2.3, Preoccupied: RRR=1.8, 95%CI 0.98-3.5) and degree of pain-related disability (Preoccupied: RRR=2.1, 95%CI 1.0-4.1), but not pain intensity. These findings suggest that treatment strategies based on knowledge of attachment style, possibly using support and education, may alleviate distress and disability in people at risk of, or affected by, chronic widespread pain.

Objectives: To determine whether among middle-aged and elderly men there is evidence of international differences in the prevalence of chronic widespread pain (CWP) and whether any such differences could be explained by psychological, psychosocial factors or differences in physical health status., Methods: The European Male Ageing Study (EMAS) sampled from population registers in cities (centres) of eight European countries. Each centre recruited an age-stratified sample of men aged 40-79 years. Information on pain was collected by questionnaire and subjects were classified according to whether they satisfied the American College of Rheumatology definition of CWP. Information was collected on social status, mental health, recent life events and co-morbidities., Results: Across all centres 3963 subjects completed a study questionnaire, with participation rates ranging from 24% in Hungary to 72% in Estonia. There were significant differences in prevalence: between 5% and 7% in centres in Italy, England, Belgium and Sweden, 9-15% in centres in Spain, Poland and Hungary and 15% in Estonia. There were strong relationships between poor mental health, adverse recent life events, co-morbidities and CWP. Adjustment for these factors explained between half and all of the excess risk in the eastern European centres: the excess risk in Poland was explained (odds ratio (OR) 1.1, 95% CI 0.9 to 1.2) but there remained excess risk in Hungary (OR 1.6, 95% CI 1.4 to 1.8) and Estonia (OR 2.6, 95% CI 2.2 to 2.9)., Conclusions: This study is the first directly to compare the occurrence of CWP internationally. There is an excess prevalence in countries of eastern Europe and this excess is associated with adverse psychosocial factors as well as poorer psychological and physical health.

To assess the relationships among pressure ulcer prevalence, body mass index (BMI), and weight, this report analyzed the US data from the 2006 and 2007 International Pressure Ulcer Prevalence Surveys. Findings indicated an overall reduction in pressure ulcer prevalence from 2004 and 2005 to 2006 and 2007; there was a higher prevalence of pressure ulcers in patients with low BMI and patients with both low and high weights. One in 10 patients were extremely obese.

Introduction: We compared depression, social stress and treatment in people of Pakistani origin and white Europeans living in an UK city., Method: In a population-based two-phase sample of 1,856 adults we interviewed 651 (77%) of eligible participants, using the schedule for clinical assessment in neuropsychiatry and life events and difficulties schedule. We identified 216 people with depressive and 208 with subthreshold disorder; after 6-months we re-interviewed 398 (94% response)., Results: Depressive disorder was more common in Pakistani women only (31.1% [24.1-38.0] vs.19.3% [14.1-24.5]) and persisted more often in Pakistanis over 50 years of age (90 vs.66%, P = 0.023). New episodes of depressive disorder occurred in 17% of participants who had subthreshold disorder at baseline in each ethnic group. Persistent depression in the Pakistani group was associated with continuing problems of disabling physical illness and close relationships. Treatment was limited and not associated with persistent depression., Conclusions: Persistent depressive disorder in older people of Pakistani origin is associated with potentially remediable factors.