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Except for psychosis, women's mental health problems across the reproductive lifespan are common. There are periods in a woman's life, associated with significant sex hormone fluctuations, that render her particularly susceptible to mood disturbance and mental health illnesses, including eating disorders. Whilst eating disorders are usually conceptualized as diseases afflicting adolescence and young adults, there is increasing evidence to suggest the landscape for eating disorders has considerably changed and includes a peak in midlife, correlating with the perimenopause. Inpatient admissions and outpatient clinic attendances have increased amongst older women. It is likely this increasing trend is the result of numerous biopsychosocial factors. A diagnosis of an eating disorder in midlife may be more common in those women simultaneously navigating the perimenopause than in midlife women who remain pre-menopausal owing to the significant ovarian hormonal fluctuations encountered in the perimenopause. Eating disorders are serious illnesses associated with significant morbidity and mortality, which are exacerbated when present at older ages. Research is beginning to recognize the importance of including this typically under-represented cohort of middle-aged women in empirical studies, which is critical to a complete etiological understanding. Recognizing and treating these varied presentations and establishing effective treatments for chronic, recurrent and new-onset eating disorders in midlife women is crucial., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

It is widely known that estrogen has a fundamental role to play in skeletal homeostasis. In the most reductionist sense, the action of estrogen can be surmised as anti-resorptive. Estrogen prevents the break-down of bone. It therefore follows that estrogen deficiency states, such as the menopause and functional hypothalamic amenorrhoea (FHA), are often characterised by increased bone remodelling and disrupted skeletal homeostasis. FHA is the cessation of menstruation secondary to abnormal signalling between the hypothalamus and pituitary gland due to deficient pulsatile secretion of Gonadotrophin Releasing Hormone (GnRH). Functional hypothalamic amenorrhoea is frequently a consequence of women suffering with eating disorders. The development of FHA secondary to eating disorders is an evolutionary adaptive response to chronic metabolic energy deficiency. Fundamentally, preservation of life is biologically prioritised over dispensable physiological process such as reproduction. Consequently, the hypothalamic-pituitary-ovarian (HPO) axis fails, which disrupts menstrual function and ovulation, culminating in a state of estrogen deficiency. One of the most important and long-lasting deleterious consequences of FHA is disrupted skeletal homeostasis and bone loss. Estrogen replacement, most commonly in the form of combined hormone replacement therapy (HRT) or the combined oral contraceptive pill (COCP), is advised for women with an early menopause to prevent bone loss. Arguably, estrogen replacement should also be utilised in the context of FHA. However, the optimum estrogen regime for women with FHA remains under-researched and so management is not evidence-based., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Ultrasound guided foam sclerotherapy (UGFS) is a flexible and highly utilised tool in the treatment of varicose veins (VVs), both as a primary treatment and as an adjunct to other treatments. Concern remains regarding the risk of neurological adverse events (AEs) such as migraine, visual disturbance and serious adverse events (SAEs) such as cerebrovascular accident that have been reported after UGFS treatments., Aim: To determine the incidence of neurological AEs and SAEs after UGFS., Methods: A prospective, multicentre, post-authorisation safety study across Europe (both private and government) was performed between January 2015-2020. Neurological adverse events after UGFS with Fibrovein® (Sodium Tetradecyl Sulfate) 1 and 3% physician generated foam., Results: 8056 patients underwent treatment. There were 46 AE (including 5 SAEs), 30 (65%) SAEs were in female patients. Mean age was 55 years with mean body mass index (BMI) of 27. Univariable logistic regression demonstrate that UGFS only treatment (i.e. no adjunctive treatment), liquid-to-gas ratio, gas type and total foam volume (1% sodium tetradecyl sulfate, STS) were significantly associated with the odds of experiencing the outcome. Multivariable logistic regression model exhibits that migraine and total foam volume (1% STS) maintained statistical significance thus associated with the odds of adverse events., Conclusions: This study demonstrates that UGFS with Fibrovein is safe with a very low incidence of neurological AEs and SAEs. Past history of migraine, use of physiological gas (O 2 /CO 2 ) and increasing volumes of 1% foam increase the risk of AEs.

Background: NICE Clinical Guidelines (CG) 168, published in July 2013, recommend specialist vascular referral for all leg ulcers, defined as a break in the skin below the knee that has not healed within two weeks., Aim: To examine the impact of CG168 on the primary care management of leg ulcers using The Health Improvement Network database., Methods: An eligible population of approximately two million adult patients was analysed over two 18-month periods before and after publication of CG168. Those with a new diagnosis of leg ulcers in each time period were analysed in terms of demographics, specialist referral and superficial venous ablation., Results: We identified 7532 and 7462 new diagnoses of leg ulcers in the pre- and post-CG168 cohorts, respectively. Patients with a new diagnosis of leg ulcers were elderly (median age: 77 years both cohorts) and less likely to be male (47% both cohorts). There were 2259 (30.0%) and 2329 (31.2%) vascular service referrals in the pre- and post-CG168 cohorts, respectively (hazard ratio, 1.05, 95% CI: 0.99, 1.11, p = 0.096). The median interval between general practitioner diagnosis and referral was 1.5 days in both cohorts. Patients from both cohorts who were referred for a new diagnosis of leg ulcers were equally likely to receive superficial venous ablation., Conclusions: Disappointingly, we have been unable to demonstrate that publication of NICE CG168 has been associated with a meaningful change in leg ulcer management in primary care in line with guideline recommendations.

Background Leg ulcers are a common cause of morbidity and disability and result in significant health and social care expenditure. The UK National Institute for Health and Care Excellence (NICE) Clinical Guideline (CG)168, published in July 2013, sought to improve care of patients with leg ulcers, recommending that patients with a break in the skin below the knee that had not healed within two weeks be referred to a specialist vascular service for diagnosis and management. Aim Determine the impact of CG168 on referrals to a leg ulcer service. Methods Patients referred with leg ulceration during an 18-month period prior to CG168 (January 2012-June 2013) and an 18-month period commencing six months after (January 2014-June 2015) publication of CG168 were compared. Results There was a two-fold increase in referrals (181 patients, 220 legs vs. 385 patients, 453 legs) but no change in mean age, gender or median-duration of ulcer at referral (16.6 vs. 16.2 weeks). Mean-time from referral to specialist appointment increased (4.8 vs. 6 weeks, p = 0.0001), as did legs with superficial venous insufficiency (SVI) (36% vs. 44%, p = 0.05). There was a trend towards more SVI endovenous interventions (32% vs. 39%, p = 0.271) with an increase in endothermal (2 vs. 32 legs, p = 0.001) but no change in sclerotherapy (24 vs. 51 legs) treatments. In both groups, 62% legs had compression. There was a reduction in legs treated conservatively with simple dressings (26% vs. 15%, p = 0.0006). Conclusions Since CG168, there has been a considerable increase in leg ulcer referrals. However, patients are still not referred until ulceration has been present for many months. Although many ulcers are multi-factorial and the mainstay of treatment remains compression, there has been an increase in SVI endovenous intervention. Further efforts are required to persuade community practitioners to refer patients earlier, to educate patients and encourage further investment in chronically underfunded leg ulcer services.

Background UK National Institute for Health and Care Excellence (NICE) clinical guidelines (CG) 168, published in July 2013, aimed to improve the management of lower limb venous disease by newly recommending interventional treatment for all people affected by symptomatic varicose veins (VV) and specialist vascular referral for all people suffering from a leg ulcer (LU) that had been present for ≥2 weeks. This study aims to determine if CG168 has increased access to vascular services, particularly for the socially deprived, who might be expected to have greater need for such services. Methods The study was performed in a highly multi-cultural, socio-economically diverse, mixed urban/suburban population of approximately 1.2 million people living in and around East Birmingham, UK. Index of multiple deprivation quintile (IMD-Q) was used as a measure of social deprivation to compare levels of social deprivation of people undergoing interventions for symptomatic VV or referred with an LU during 18-month periods before and after the publication of CG168. The referring general practitioner practices (GPPs) were also recorded. Results There was no change in overall IMD-Q distribution before and after CG168 in terms of VV interventions. However, there was a non-significant increase in proportions of people classified as IMD-Q5 (the most deprived quintile). After CG168, fewer IMD-Q5 people with LU were referred, with a shift in referrals towards those from less socially deprived areas. More GPP referred people with both VV and LU after CG168, and those that referred patients before and after CG168 tended to refer more after CG168. Conclusions CG168 has increased VV interventions as well as the number referred with LU. However, this improvement in access to treatment and referral may have disproportionately favoured the more socio-economic privileged. Professional and public education is required to ensure that the beneficial impact of the CG168 recommendations are maximised and that those with the greatest health needs have equal access to evidence-based management of their venous disease.

Introduction Lower limb venous disease affects up to one half, and obesity up to one quarter, of the adult population. Many people are therefore affected by, and present to health services for the treatment of both conditions. This article reviews the available evidence of pathophysiological and clinical relationship between obesity and varicose veins, chronic venous insufficiency and ulceration and deep vein thrombosis. Methods A literature search of PubMed and Cochrane libraries was performed in accordance with PRISMA statement from 1946 to 2015, with further article identification from following cited references for articles examining the relationship between obesity and venous disease. Search terms included obesity, overweight, thrombosis, varicose veins, CEAP, chronic venous insufficiency, treatment, endovenous, endothermal, sclerotherapy, bariatric surgery and deep vein thrombosis. Results The proportion of the population suffering from lower limb venous disease and obesity is increasing. Obesity is an important risk factor for all types of lower limb venous disease, and obese patients with lower limb venous disease are more likely to be symptomatic as a result of their lower limb venous disease. The clinical diagnosis, investigation, imaging and treatment of lower limb venous disease in obese people present a number of challenges. The evidence base underpinning medical, surgical and endovenous management of lower limb venous disease in obese people is limited and such treatment may be associated with worse outcomes and increased risks when compared to patients with a normal body mass index. Conclusion Lower limb venous disease and obesity are both increasingly common. As such, phlebologists will be treating ever greater numbers of obese patients with lower limb venous disease, and clinicians in many other specialties are going to be treating a wide range of obesity-related health problems in people with or at risk of lower limb venous disease. Unfortunately, obese people have been specifically excluded from many, if not most, of the pivotal studies. As such, many basic questions remain unanswered and there is an urgent need for research in this challenging and increasingly prevalent patient group.

Objective: Although varicose veins are a common cause of morbidity, the UK National Health Service and private medical insurers have previously sought to ration their treatment in a non-evidence based manner in order to limit health-care expenditure and reimbursement. In July 2013, the UK National Institute for Health and Care Excellence published new national Clinical Guidelines (CG168) to promote evidence-based commissioning and management of varicose veins. The aim of this study was to evaluate the impact of CG168 on the referral and management of varicose veins at the Heart of England NHS Foundation Trust, Birmingham, UK., Methods: Interrogation of a prospectively gathered database, provided by the Heart of England NHS Foundation Trust Performance Unit, of patients undergoing interventions for varicose veins since 1 January 2012. Patients treated before (group 1) and after (group 2) publication of CG168 were compared., Results: There were 253 patients, 286 legs (48% male, mean (range) age 54 (20-91) years) treated in group 1, and 417 patients, 452 legs, (46% male, mean (range) age 54 (14-90) years) treated in group 2, an increase of 65%. CG168 was associated with a significant reduction in the use of surgery (131 patients (52%) group 1 vs. 127 patients (30%) group 2, p = 0.0003, χ(2)), no change in endothermal ablation (30 patients (12%) group 1 vs. 45 patients (11%) group 2), a significant increase in ultrasound-guided foam sclerotherapy (92 patients (36%) group 1 and 245 patients (59%) group 2, p = 0.0001, χ(2)) and an increase in treatment for C2/3 disease (53% group 1 and 65.2% group 2, p = 0.0022, χ(2))., Conclusions: Publication of National Institute for Health and Care Excellence CG168 has been associated with a significant increase (65%) in the number of patients treated, referral at an earlier (CEAP C) stage and increased use of endovenous treatment. CG 168 has been highly effective in improving access to, and quality of care, for varicose veins at Heart of England NHS Foundation Trust., (© The Author(s) 2015.)

Objective: The last 10 years have seen the introduction into everyday clinical practice of a wide range of novel non-surgical treatments for varicose veins. In July 2013, the UK National Institute for Health and Care Excellence recommended the following treatment hierarchy for varicose veins: endothermal ablation, ultrasound-guided foam sclerotherapy, surgery and compression hosiery. The aim of this paper is to review the randomised controlled trials that have compared endothermal ablation and ultrasound-guided foam sclerotherapy to determine if the level 1 evidence base still supports an "endothermal ablation first" strategy for the treatment of varicose veins., Methods: A PubMed and OVID literature search (until 31 January 2015) was performed and randomised controlled trials comparing endothermal ablation and ultrasound-guided foam sclerotherapy were obtained., Results: Although anatomical success appeared higher with endothermal ablation than ultrasound-guided foam sclerotherapy, clinical success and patient-reported outcomes measures were similar. Morbidity and complication rates were very low and not significantly different between endothermal ablation and ultrasound-guided foam sclerotherapy. Ultrasound-guided foam sclerotherapy was consistently less expensive that endothermal ablation., Conclusions: All endovenous modalities appear to be successful and have a role in modern day practice. Although further work is required to optimise ultrasound-guided foam sclerotherapy technique to maximise anatomical success and minimise retreatment, the present level 1 evidence base shows there is no significant difference in clinical important outcomes between ultrasound-guided foam sclerotherapy and endothermal ablation. As ultrasound-guided foam sclerotherapy is less expensive, it is likely to be a more cost-effective option in most patients in most healthcare settings. Strict adherence to the treatment hierarchy recommended by National Institute for Health and Care Excellence seems unjustified., (© The Author(s) 2015.)

Aerosol-assisted chemical vapour deposition of substituted polyoxometalates H 4 [PMo 11 VO 40 ], H 7 [PMo 8 V 4 O 40 ], [nBu 4 N] 4 [PVW 11 O 40 ] and [nBu 4 N] 5 [PV 2 W 10 O 40 ] resulted in the formation of vanadium-doped metal oxide thin films. Depositions were carried out at 550 °C in methanol or acetonitrile for the POMs that contained molybdenum or tungsten, respectively. The as-deposited films were X-ray amorphous and relatively non-adherent. However, on annealing in air at 600 °C, decolourised translucent films that were more mechanically robust were obtained. Films deposited from H 4 [PMo 11 VO 40 ] and H 7 [PMo 8 V 4 O 40 ] consisted of V-doped MoO 3 in the orthorhombic phase and films from [nBu 4 N] 4 [PVW 11 O 40 ] and [nBu 4 N] 5 [PV 2 W 10 O 40 ] comprised of monoclinic V-doped WO 3 . All films were fully characterised by using X-ray photoelectron spectroscopy, energy-dispersive X-ray diffraction, scanning electron microscopy and UV/Vis spectroscopy., (© 2016 WILEY-VCH Verlag GmbH & Co. KGaA, Weinheim.)

Introduction: Herniation following Pfannenstiel incision is rare. Closure of the incision in four layers including the rectii abdominis, is done uncommonly. The authors report five cases of interstitial herniae between the rectus muscles and the anterior rectus sheath, incarcerating omentum and bowel. Four patients underwent repair, two as an emergency. One patient was managed conservatively., Method: Subsequently all consultant and specialist registrars in obstetrics and gynaecology in the Wessex region were sent questionnaires on their methods of closure of Pfannenstiel incisions and rates of associated herniae. Fifty-three of 74 surgeons responded and only three (5.6 %) routinely closed the abdominal recti. The surveyed surgeons felt post-Pfannenstiel incisional hernia rates were low (0-1 %) though the rate was unknown to 33 % of surgeons., Conclusion: Complex incisional interstitial herniae of this type have not previously been described. Closure of the rectii abdominis (as originally described by Pfannenstiel in 1900) could minimise the incidence of incisional herniae.

Thin films of ceria (CeO(2)) have many applications, and their synthesis by liquid-injection MOCVD (metal-organic chemical vapor deposition) or ALD (atomic layer deposition) requires volatile precursor compounds. Here we report the synthesis of a series of homoleptic and heteroleptic Ce(IV) complexes with donor-functionalized alkoxide ligands mmp (1-methoxy-2-methylpropan-2-olate), dmap (1-(dimethylamino)propan-2-olate), and dmop (2-(4,4-dimethyl-4,5-dihydrooxazol-2-yl)propan-2-olate) and their potential as precursors for MOCVD and ALD of CeO(2). New complexes were synthesized by alcohol exchange reactions with [Ce(OBu(t))(4)]. [Ce(mmp)(4)] and [Ce(dmap)(4)] were both found to be excellent precursors for liquid-injection MOCVD of CeO(2), depositing high purity thin films with very low carbon contamination, and both have a large temperature window for diffusion controlled growth (350-600 °C for [Ce(mmp)(4)]; 300-600 °C for [Ce(dmap)(4)]). [Ce(mmp)(4)] is also an excellent precursor for liquid-injection ALD of CeO(2) using H(2)O as oxygen source and demonstrates self-limiting growth from 150 to 350 °C. [Ce(dmap)(4)] has lower thermal stability than [Ce(mmp)(4)] and does not show self-limiting growth in ALD. Heteroleptic complexes show a tendency to undergo ligand redistribution reactions to form mixtures in solution and are unsuitable as precursors for liquid-injection CVD.

Appendicectomy is one of the commoner operations with a lifetime risk as high as 12% or 23% in males or females, respectively. Since the 1940s intra-operative intra-peritoneal swabs have commonly been taken from the appendix site, the spectrum of infecting organisms and their antibiotic sensitivity may be gauged from the culture results. This approach remains common but in recent years, studies have claimed that intra-peritoneal swabs are unnecessary; however, they relied upon retrospective patient groups predating wider use of laparoscopic appendicectomy, increasing numbers of immunocompromised people at risk of appendicitis and the clinical/medicolegal significance of increasing risk of antibiotic-associated Clostridium difficile colitis. Therefore, a key-word literature research was done to identify relevant publications from 1930 to June 2009. Newer features relating to intra-peritoneal swabs in appendicectomy have been discussed against this background information for periabdominal appendicectomy with or without appendicular perforation, laparoscopic appendicectomy and appendicectomy in the growing numbers of immunocompromised patients. All studies questioning the use of intra-peritoneal swabs were open, non-randomised, and retrospective with incompletely matched control groups, non-standardised swab collection techniques, and consequently lacked power to inform surgical practice. They concluded that an appropriately powered randomised, blinded, prospective, controlled clinical trial is needed to test for absolute efficacy in the use of peritoneal swabs in patient management. Until controlled trial data becomes available, it may be wise to continue peritoneal swabs at least in high-risk patients to decrease clinical and medicolegal risk., (Copyright © 2010 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.)

Thin films of tungsten carbonitride have been formed on glass by low-pressure chemical vapour deposition (LP)CVD at 550 degrees C from four closely related precursors: [W(mu-N(t)Bu)(N(t)Bu)Cl(2)(H(2)N(t)Bu)](2), [W(N(t)Bu)(2)Cl(2)(TMEDA)] (TMEDA = N,N,N',N'-tetramethylethylenediamine), [W(N(t)Bu)(2)Cl(2)(py)(2)] (py = pyridine) and [W(N(t)Bu)(2)Cl(N{SiMe(3)}(2))]. The grey mirror-like films were grown with a nitrogen or ammonia bleed gas. In all cases the chlorine content of the deposited films was less than 1 at% and the oxygen content of the films was lower for those grown using ammonia. Surprisingly, the use of ammonia did not significantly change the carbon content of the resulting films. Despite the coordination environment around the metal being essentially the same and the materials having a comparable volatility, some differences in film quality were observed. The films were uniform, adhesive, abrasion resistant, conformal and hard, being resistant to scratching with a steel scalpel. X-Ray powder diffraction patterns of all the films showed the formation of beta-WN(x)C(y). As a comparison the aerosol-assisted chemical vapour deposition (AA)CVD of [W(mu-N(t)Bu)(N(t)Bu)Cl(2)(H(2)N(t)Bu)](2) was investigated and amorphous tungsten carbonitride films were deposited.

The reaction of Me3In and ROH (R = CH2CH2NMe2, CH(CH3)CH2NMe2, C(CH3)2CH2OMe, CH2CH2OMe) in toluene under aerosol assisted chemical vapor deposition (AACVD) conditions leads to the production of indium oxide thin films on glass. The indium oxide films were deposited at 550 degrees C and analyzed by scanning electron microscopy (SEM), X-ray powder diffraction, wavelength dispersive analysis of X-rays (WDX), X-ray photoelectron spectroscopy (XPS), and Raman spectroscopy. This CVD technique offers a rapid, convenient route to In2O3, which presumably involves the in situ formation of dimethylindium alkoxides, of the type [Me2InOR]2. In order to identify compounds present in the aerosol mist, the solution-phase reaction between Me3In and ROH (R = CH2CH2NMe2, C(CH3)2CH2OMe, CH(CH3)CH2NMe2, CH(CH2NMe2)2) at room temperature in toluene was carried out. Dimeric indium alkoxides, of the type [Me2In(OR)]2, were isolated, and their structures were determined by X-ray crystallography.