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Aims Wernicke–Korsakoff syndrome (WKS) is commonly associated with chronic alcohol misuse, a condition known to have multiple detrimental effects on thiamine metabolism. This study was conducted to identify genetic variants that may contribute to the development of WKS in individuals with alcohol dependence syndrome through alteration of thiamine transport into cells. Methods Exome sequencing data from a panel of genes related to alcohol metabolism and thiamine pathways were analysed in a discovery cohort of 29 individuals with WKS to identify possible genetic risk variants associated with its development. Variant frequencies in this discovery cohort were compared with European frequencies in the Genome Aggregation Database browser, and those present at significantly higher frequencies were genotyped in an additional cohort of 87 alcohol-dependent cases with WKS and 197 alcohol-dependent cognitively intact controls. Results Thirty non-synonymous variants were identified in the discovery cohort and, after filtering, 23 were taken forward and genotyped in the case–control cohort. Of these SLC19A1:rs1051266:G was nominally associated with WKS. SLC19A1 encodes the reduced folate carrier, a major transporter for physiological folate in plasma; rs1051266 is reported to impact folate transport. Thiamine pyrophosphate (TPP) efflux was significantly decreased in HEK293 cells, stably transfected with rs1051266:G, under thiamine deficient conditions when compared with the efflux from cells transfected with rs1051266:A (P = 5.7 × 10−11). Conclusion This study provides evidence for the role of genetic variation in the SLC19A1 gene, which may contribute to the development of WKS in vivo through modulation of TPP transport in cells.

Fun, as a game trait, is challenging to evaluate. Previous research explores game arc and game refinement to improve the quality of games. Fun, for some players, is having an even chance to win while executing their strategy. To explore this, we build boards for the game Ticket to Ride while optimizing for a given win rate between four AI agents. These agents execute popular strategies human players use: one-step thinking, long route exploitation, route focus, and destination hungry strategies. We create the underlying graph of a map by connecting several planar bipartite graphs. To build the map, we use a multiple phase design, with each phase implementing several simplified Monte Carlo Tree Search components. Within a phase, the components communicate with each other passively. The experiments show that the proposed approach results in improvements over randomly generated graphs and maps.

Minimum unit pricing (MUP) may reduce harmful drinking in the general population, but there is little evidence regarding its impact on marginalised groups. Our study is the first to explore the perceptions of MUP among stakeholders working with people experiencing homelessness following its introduction in Scotland in May 2018.Qualitative semi-structured interviews were conducted with 41 professional stakeholders from statutory and third sector organisations across Scotland. We explored their views on MUP and its impact on people experiencing homelessness, service provision and implications for policy. Data were analysed using thematic analysis.Participants suggested that the introduction of MUP in Scotland had negligible if any discernible impact on people experiencing homelessness and services that support them. Most service providers felt insufficiently informed about MUP prior to its implementation. Participants reported that where consequences for these populations were evident, they were primarily anticipated although some groups were negatively affected. People experiencing homelessness have complex needs in addition to alcohol addiction, and changes in the way services work need to be considered in future MUP-related discussions.This study suggests that despite initial concerns about potential unintended consequences of MUP, many of these did not materialise to the levels anticipated. As a population-level health policy, MUP is likely to have little beneficial impact on people experiencing homelessness without the provision of support to address their alcohol use and complex needs. The additional needs of certain groups (e.g., people with no recourse to public funds) need to be considered.

Introduction Genome-wide association studies (GWAS) of alcohol dependence syndrome (ADS) offer a platform to detect genetic risk loci. However, the majority of the ADS GWAS undertaken, to date, have utilized a case-control design and have failed to identify consistently replicable loci with the exception of protective variants within the alcohol metabolizing genes, notably ADH1B. have failed to identify consistently replicable loci. The ADS phenotype shows considerable variability and of the ADS phenotype means that the use of quantitative variables as a proxy for the severity of ADS has the potential to facilitate identification of risk loci by increasing statistical power. The current study aims to examine the influences of using binary and adjusted quantitative measures of ADS on GWAS outcomes and on calculated polygenic risk scores (PRS). Methods A GWAS was performed in 1251 healthy controls with no history of excess alcohol use and 739 patients with ADS classified using binary DMS-IV criteria. Additional two GWASs were undertaken using a quantitative score based on DSM-IV criteria, which were applied assuming both normal and non-normal distributions of the phenotypic variable. PRS analyses were performed utilizing the data from the binary and the quantitative trait analyses. Results No associations were identified at genome-wide significance in any of the individual GWAS; results were comparable in all three. The top associated single nucleotide polymorphism was located on the alcohol dehydrogenase gene cluster on chromosome 4, consistent with previous ADS GWAS. The quantitative trait analysis adjusted for the distribution of the criterion score and the associated PRS had the smallest standard errors and thus the greatest precision CONCLUSION: Further exploitation of the use of qualitative trait analysis in GWAS in ADS is warranted.

Quality improvement approaches drawn from industry can go beyond traditional concepts of value and deliver improvements in healthcare services, argue Iain Smith and colleagues

The COVID-19 pandemic has infected tens of millions of people worldwide causing many deaths. Healthcare systems have been stretched caring for the most seriously ill and lockdown measures to interrupt COVID-19 transmission have had adverse economic and societal impacts. Large-scale population vaccination is seen as the solution.In the UK, a network of sites to deploy vaccines comprised National Health Service hospitals, primary care and new mass vaccination centres. Due to the pace at which mass vaccination centres were established and the scale of vaccine deployment, some sites experienced problems with queues and waiting times. To address this, one site used the Lean systematic improvement approach to make rapid operational improvements to reduce process times and improve flow.The case example identifies obstacles to flow experienced by a mass vaccination centre and how they were addressed using Lean concepts and techniques. Process cycle times were used as a proxy metric for efficiency and flow. Based on daily demand volume and open hours, takt time was calculated to give a process completion rate to achieve flow through the vaccination centre.The mass vaccination centre achieved its aim of reducing process times and improving flow. Administrative and clinical cycle times were reduced sufficiently to increase throughput and the number of queues and queueing time were reduced improving client experience.The design and operational management of vaccination centre processes contribute to client experience, efficiency and throughput. Lean provides a systematic approach that can improve operational processes and facilitate client flow through mass vaccination centres.

Introduction Foundation doctors often say they feel intimidated by the idea of ‘leadership’ and have received little teaching on the subject. We planned to address this using peer to peer teaching. This method has been shown previously to be a valuable learning experience for the participants and the facilitators. Method We surveyed the Foundation doctors asking them how much leadership teaching they had previous had and to rank their confidence in their leadership abilities, how keen they were to develop and improve their leadership skills and whether leadership teaching is important and relevant for them as Foundation doctors. We arranged a peer led leadership teaching session for foundation doctors which consisted of several short workshops. These were ‘difficult conversations’, ‘followership’, ‘resilience and how to develop in your team’ and a ‘senior doctors experience’. We then assessed whether it was an effective way to improve understanding and engagement in leadership by repeating the survey asking the same three questions. The Results were analysed using a two tailed paired T-test (n= 23, p Results Feedback from the facilitators and participants was positive. The mean rating by the participants was 4.4/5. Most trainees had received very little or no formal leadership teaching prior to the session (median = 0). The teaching session showed an improvement in all 3 areas assessed, notably in the confidence of participants in their leadership ability, increasing from 3.3/5 to 3.5/5 (p Conclusion Our research illustrates the lack of formal leadership teaching for foundation doctors. This project demonstrates that peer to peer teaching is an effective way to help build confidence and understanding both for those who receive the session and those who organise it. We hope that our leadership teaching model will be replicated across other foundation schools in the UK.

The Alcohol Withdrawal Syndrome (AWS), which may occur with or without delirium, is a frequent consequence of sudden alcohol cessation in patients with moderate to severe Alcohol Dependence Syndrome (ADS). Withdrawal as a result of habituation to alcohol is part of the definition of the Alcohol Dependence Syndrome (ICD10). Since the recognition of Delirium Tremens, in the early nineteenth century, the management of the syndrome, an acute medical emergency, has proven controversial. The barbiturates , chlormethiazole and recently the safer benzodiazepines transformed the management of these conditions. The benzodiazepines , particularly diazepam and chlordiazepoxide, are now the most used first line agents in the treatment of AWS. In addition, a number of other agents , including baclofen, a GABA-B receptor agonist, have the potential to suppress the alcohol withdrawal syndrome. In this review we review the potential use of baclofen in its role to treat AWS. We summarise initial case reports as well as more recent randomized trials of AWS treatment with baclofen. We conclude that currently there is not enough evidence to support the use of baclofen as a first line treatment for AWS. More research will be needed to determine where baclofen might have a role in second-line management of the Alcohol Withdrawal Syndrome on its own or in combination with benzodiazepines or other agents.

The performance of a pilot-scale horizontal sedimentation tank was characterised utilising computational fluid dynamics (CFD) and a bespoke ultrasonic backscatter array, for both spherical glass and flocculated calcite separation. The CFD simulation was developed in OpenFOAM, using algebraic slip and hindered settling models, in order to solve the transport of multiple particle size classes, enabled through a population balance approach. Simulations of concentration compared closely to samples for the glass dispersions, but under-predicted concentration with flocculated calcite (likely due to complexities from modelling floc break-up in the mixer). In comparison, the acoustic array measured the calcite concentration with a high degree of resolution, where in particular, evidence suspension mobilisation near the outlet was observed, due to recirculation. Overall, we demonstrate the performance and current limitations of large-scale CFD for complex floc systems, as well as the use of ultrasonics to significantly aid process understanding, through online monitoring of solid-liquid separations.

The National Health Service (NHS) in England has a capital budget of approximately £4bn per year to spend on the construction and refurbishment of new and existing buildings. The majority of capital costs are committed by early stage design decisions, which have a large impact on operations, costs and performance. It is necessary to incorporate a sociotechnical approach to design as healthcare is a service environment in which patients are part of the system. The design of facilities determines the allocation of space and the interacting flows including: patients, clinicians, visitors, medication, supplies, equipment, and information. The design requires many trade-offs and has a major impact on the patient experience and the quality and efficiency of care. This paper evaluates the application of the Lean 3P (production, preparation, process) participative design method as part of a pilot project to design a new endoscopy unit at Gateshead Health NHS Foundation Trust. The research, which was funded by the Health Foundation, used participant observation, and an analysis of the layout drawings and the 7 flows of medicine to appraise 3P. The existing and proposed designs were compared. The results show that 3P is an effective tool that can develop designs that meet the requirements of multiple stakeholders. A framework was developed that positions 3P within the overall design process. The seven flows of medicine classification was extended to include subcategories and to identify interrelationships between the flows. This will help inform the design of healthcare facilities.

A healthy 55-year-old man without known medical problems presented for a routine physical examination and was found to have an abnormal ECG. He denied chest pain, dyspnea, palpitations, dizziness, or syncopal episodes. He also denied orthopnea, paroxysmal nocturnal dyspnea, and lower-extremity edema. His exercise capacity had been excellent. He was a lifelong nonsmoker and never had lung problems.

Since the publication of Bram Stoker’s novel Dracula in 1897, the character of Count Dracula has proven to be eminently adaptable, appearing in various guises in over 300 feature films – from FW Murnau’s Nosferatu (1922) through to Dario Argento’s Dracula 3D (2012). As with other iconic characters such as Sherlock Holmes and Batman, Dracula has been freed from his roots in a source text and entered what Will Brooker describes as ‘the realm of the icon’. Yet, while there has been a considerable amount of scholarship on the canonical adaptations of Dracula produced in Hollywood, the UK and Germany, very little has been written on the numerous adaptations of the Count Dracula character that have appeared in other film industries. This chapter considers examples of transnational film remakes, including the 1953 Turkish film Drakula İstanbul'da (Dracula in Istanbul), the 1957 Mexican film El Vampiro (The Vampire), and the 1967 Pakistani film Zinda Laash (The Living Corpse). Paying close attention to the variety of ways in which the character is utilised across different cultural contexts, this chapter interrogates the complex issues that this raises in relation to the dynamic interplay of global and local within international popular cinema.

SummaryThe relationship between alcohol use and cognitive impairment has been notoriously difficult to disentangle. We present what is known about cognitive impairment associated with alcohol use/misuse, covering the spectrum from mild and subtle cognitive change through to severe alcohol-related brain damage, including Wernicke-Korsakoff syndrome. We highlight aids to the diagnosis and management of these conditions, and emphasise the benefits of prompt treatment on outcome. We also review progress in understanding their neurobiology. Suggestions for possible service configuration based on both our clinical practice and national guidelines are given.Learning Objectives•Gain an understanding of the spectrum of clinical presentations found in alcohol-related brain damage.•Understand that the aetiology of these conditions is complex and not solely due to the neurotoxic effects of alcohol.•Be better able to plan for the rehabilitation of individuals with established alcohol-related brain damage in your local service area.

Certain single nucleotide polymorphisms (SNPs) in genes encoding alcohol dehydrogenase (ADH) enzymes confer a significant protective effect against alcohol dependence syndrome (ADS) in East Asian populations. Recently, attention has focused on the role of these SNPs in determining ADS risk in European populations. To further elucidate these associations, SNPs of interest in ADH1B, ADH1C and the ADH1B/1C intergenic region were genotyped in a British and Irish population (ADS cases n = 1076: controls n = 1027) to assess their relative contribution to ADS risk. A highly significant, protective association was observed between the minor allele of rs1229984 in ADH1B and ADS risk [allelic P = 8.4 × 10(-6) , odds ratio (OR) = 0.26, 95 percent confidence interval, 0.14, 0.49]. Significant associations were also observed between ADS risk and the ADH1B/1C intergenic variant, rs1789891 [allelic P = 7.2 × 10(-5) , OR = 1.4 (1.2, 1.6)] and three non-synonymous SNPs rs698, rs1693482 and rs283413 in ADH1C. However, these associations were not completely independent; thus, while the ADH1B rs1229984 minor allele association was independent of those of the intergenic variant rs1789891 and the three ADH1C variants, the three ADH1C variants were not individually independent. In conclusion, the rare ADH1B rs1229984 mutation provides significant protection against ADS in this British and Irish population; other variants in the ADH gene cluster also alter ADS risk, although the strong linkage disequilibrium between SNPs at this location precluded clear identification of the variant(s) driving the associations.

The last half century has seen significant changes to Maternity services in England. Though rates of maternal and infant mortality have fallen to very low levels, this has been achieved largely through hospital admission. It has been argued that maternity services may have become over-medicalised and service users have expressed a preference for more personalised care. NHS England's national strategy sets out a vision for a modern maternity service that continues to deliver safe care whilst also adopting the principles of personalisation. Therefore, there is a need to develop maternity services that balance safety with personal choice. To address this challenge, a maternity unit in North East England considered improving their service through refurbishment or building new facilities. Using a design process known as the production preparation process (or 3P), the Lean principles of understanding user value, mapping value-streams, creating flow, developing pull processes and continuous improvement were applied to the design of a new maternity department. Multiple stakeholders were engaged in the design through participation in a time-out (3P) workshop in which an innovative pathway and facility for maternity services were co-designed. The team created a hybrid model that they described as "wrap around care" in which the Lean concept of pull was applied to create a service and facility design in which expectant mothers were put at the centre of care with clinicians, skills, equipment and supplies drawn towards them in line with acuity changes as needed. Applying the Lean principles using the 3P method helped stakeholders to create an innovative design in line with the aspirations and objectives of the National Maternity Review. The case provides a practical example of stakeholders applying the Lean principles to maternity services and demonstrates the potential applicability of the Lean 3P approach to design healthcare services in line with policy requirements.

This chapter investigates the cultural politics of transnational borrowings through an analysis of the ‘Masala Western’ — a cycle of Indian films that began in the early 1970s which borrowed and recombined tropes from American Westerns, Italian Westerns, Japanese sword films, and the South Asian ‘dacoit’ (bandit) films, among other inflences. While the genre is more often referred to as the ‘Curry Western’, Masala — the South Asian term for spice mix — more clearly evokes the cultural mixing and blending at the heart of this phenomenon. The chapter will examine the Masala Western utilising a memetic model of cultural hybridization.

This article was migrated. The article was not marked as recommended. Background: The need for medical students to engage with patients with addictive problems is projected to increase in coming years. There will also be a concomitant greater emphasis on community-based learning. The present study assessed the impact of a community based teaching initiative, the Student Selected Component (SSC) Lay and Professional Perspectives on the Addictions, on students' attitudes to these groups. Summary of Work: The SSC is assessed by a final student report which includes a self-reflective section. The free text data from this section of 28 qualitative reports over 7 years was analysed using content analysis. Summary of Results: Students were clear they believed the experience of the SSC had increased their understanding of both the psychological and social complexity related to the addictions and the role of medicine within this. Conclusions: We discovered that the SSC Lay and Professional Perspectives on the Addictions not only gave students first-hand experience of those suffering from and treating addictive problems, but also had a positive effect on their attitude towards this group.

The measurement of the concentration of solid particles in suspension without physical sampling is a necessary tool for the nuclear industry involved with cleanup of a significant quantity of legacy waste in the form of sludge. This paper presents the work of a project to develop acoustic instrumentation for the in-situ characterization of such sludge. The measurement principle and signal processing employed is presented along with the design of a custom acoustic instrument for deployment in nuclear and industrial environments. The paper presents experimental results demonstrating the ability of the technique for the online measurement of mass concentration in a suspension of glass power in water.

A healthy 55-year-old man without known medical problems presented for a routine physical examination and was found to have an abnormal ECG. He denied chest pain, dyspnea, palpitations, dizziness, or syncopal episodes. He also denied orthopnea, paroxysmal nocturnal dyspnea, and lower-extremity edema. His exercise capacity had been excellent. He was a lifelong nonsmoker and never had lung problems.

This chapter explores links between psychostimulants and creativity in the arts. These links are set in the context of an overview of the association between mind-altering drugs in general and specific branches of the arts, particularly literature. The economic impact of the psychostimulants both historically and in today's world has been substantial and this is mirrored in the culture of the countries involved with the trade in these special commodities. As with other families of addictive drugs, the psychostimulants are sought out more frequently than is the norm by creative individuals who then may represent the drugs in their art or associate the drugs with their creativity. The creative process is outlined and it is noted that if a drug helps at all with creativity then the specific properties of the drug may link it to a particular stage of the creative process. Stimulants are particularly associated with the evaluation and elaboration stage of the creative process and in particular nicotine and caffeine have been used in this way by writers when putting words on paper. The ability of psychostimulants to boost convergent thinking is the main mechanism at work but this is at a cost as divergent thinking is diminished. The other findings of note in this review are that particular venues based around the consumption of a psychostimulants can act as a creative hub-café culture in Paris and Vienna and early modern Europe-and that particular drugs can come to define an artistic grouping as with the Beats and the group around Warhol who had a preference for amphetamine.

This chapter explores links between psychostimulants and creativity in the arts. These links are set in the context of an overview of the association between mind-altering drugs in general and specific branches of the arts, particularly literature. The economic impact of the psychostimulants both historically and in today's world has been substantial and this is mirrored in the culture of the countries involved with the trade in these special commodities. As with other families of addictive drugs, the psychostimulants are sought out more frequently than is the norm by creative individuals who then may represent the drugs in their art or associate the drugs with their creativity. The creative process is outlined and it is noted that if a drug helps at all with creativity then the specific properties of the drug may link it to a particular stage of the creative process. Stimulants are particularly associated with the evaluation and elaboration stage of the creative process and in particular nicotine and caffeine have been used in this way by writers when putting words on paper. The ability of psychostimulants to boost convergent thinking is the main mechanism at work but this is at a cost as divergent thinking is diminished. The other findings of note in this review are that particular venues based around the consumption of a psychostimulants can act as a creative hub-cafe culture in Paris and Vienna and early modern Europe-and that particular drugs can come to define an artistic grouping as with the Beats and the group around Warhol who had a preference for amphetamine.

On 25 December 2008, Geetha Arts India released Ghajini, a Hindi language remake of a Tamil film of the same name from 2005. Directed by A.R. Murugadoss, the film closely replicates much of the plot from the earlier film and is representative of a broader trend within the Hindi language industry for producing remakes of South Indian cinema. What is especially significant with Ghajini, however, is that the Tamil film was itself an unacknowledged remake of the American independent film Memento (2000). Borrowing many of the narrative elements from director Christopher Nolan’s film, yet adapting them to fit with the dominant narrative structure of commercial Indian cinema, the case study of the Hindi Ghajini presented in this chapter offers a privileged insight into the adaptation of narrative forms across different national and institutional contexts.

Amiodarone pulmonary toxicity represents the most serious adverse reaction from amiodarone use. It remains underdiagnosed and can have a variable presentation. The elderly population is at increased risk for amiodarone pulmonary toxicity. Thus, clinicians should prescribe the lowest dosage possible in the elderly and have a low threshold to discontinue the amiodarone for anyone with unexplained fatigue, dyspnea, cough, or weight loss. We present the case of an 89-year-old female who presented with a several month history of fatigue and recent development of dyspnea on exertion and a dry cough. She had been taking amiodarone for 1 year secondary to atrial fibrillation. Chest x-ray and chest CT revealed multilobar airway opacities. An infectious work-up was negative and a transbronchial biopsy revealed prominent intra-alveolar foamy macrophages, consistent with amiodarone pulmonary toxicity. Despite the prompt discontinuation of her amiodarone and a trial of intravenous steroids, the patient succumbed to respiratory failure. The risk factors, clinical presentation, diagnosis, treatment, and prevention of amiodarone pulmonary toxicity are discussed.

In the face of rising oil, natural gas, and coal prices, how can the global economy continue to grow with record high commodity prices as we butt up against supply constraints? There are only two possible solutions: increase supply or reduce demand. This piece will highlight various ways we believe our current energy supply can be augmented through alternative and renewable energy sources. We will also consider ways in which the growth rate in energy demand can be mitigated by adopting more conservation-minded initiatives, especially in the U.S.

Musculoskeletal injuries secondary to seizures are well documented and have a variable incidence. Meperidine (Demerol [Abbott, Abbott Park, IL]) has been used for many years in the postoperative setting for pain control; however, in high doses, it has been associated with seizure. We report the case of patient who experienced a tonic-clonic seizure 5 days after hip revision surgery, resulting in dissociation of the socket from the acetabulum with an associated acetabular fracture. In this patient, meperidine administered for patient-controlled analgesia within recommended range caused the seizure.

For many people, integrity and self-respect are basic values. They are absolute needs open to no negotiation. Beyond material goods lies an inner sense of what is good. Beyond calculation lies judgment. Indeed, is this not the essence of responsible management? To judge the difference between short-term calculable gains and deeply rooted core values?

This article attempts to give a flavour of the influence that psychoactive substances have had on many authors and the literary process. It explores the idea of the narrative as it is applied to addictive disorders and gives a range of examples of writing about different substances that might enhance the reader's knowledge of current drug culture. The portrayal in literature of doctors with addictions is presented as a warning against the development of such problems in psychiatrists. The authors hope to have demonstrated that literature can be a valuable tool in understanding the experience of drug and alcohol use and addiction.

Certain single nucleotide polymorphisms (SNPs) in genes encoding alcohol dehydrogenase (ADH) enzymes confer a significant protective effect against alcohol dependence syndrome (ADS) in East Asian populations. Recently, attention has focused on the role of these SNPs in determining ADS risk in European populations. To further elucidate these associations, SNPs of interest in ADH1B, ADH1C and the ADH1B/1C intergenic region were genotyped in a British and Irish population (ADS cases n = 1076: controls n = 1027) to assess their relative contribution to ADS risk. A highly significant, protective association was observed between the minor allele of rs1229984 in ADH1B and ADS risk [allelic P = 8.4 × 10(-6) , odds ratio (OR) = 0.26, 95 percent confidence interval, 0.14, 0.49]. Significant associations were also observed between ADS risk and the ADH1B/1C intergenic variant, rs1789891 [allelic P = 7.2 × 10(-5) , OR = 1.4 (1.2, 1.6)] and three non-synonymous SNPs rs698, rs1693482 and rs283413 in ADH1C. However, these associations were not completely independent; thus, while the ADH1B rs1229984 minor allele association was independent of those of the intergenic variant rs1789891 and the three ADH1C variants, the three ADH1C variants were not individually independent. In conclusion, the rare ADH1B rs1229984 mutation provides significant protection against ADS in this British and Irish population; other variants in the ADH gene cluster also alter ADS risk, although the strong linkage disequilibrium between SNPs at this location precluded clear identification of the variant(s) driving the associations.

The aim of the study was to compare self reported "ecstasy" use with the results of the analysis of hair harvested from the same users. Subjects were recruited by multisite chain-referral sampling within the 1994-95 "dance scene" in Glasgow. One hundred subjects donated hair after completing a lengthy interviewer-administered questionnaire. Overall gross concordance between self reported "ecstasy" use and discovery of MDMA (or related compounds) in analysed hair did not surpass 59%, and no relationship had a Cohen's kappa of more than 0.08. Within the positive concordant dataset (n = 52), scatter was considerable, with no correlation being significant, and none more strongly positive than -0.0518. The results presented here indicate that, as far as MDMA is concerned, if judged by self-report, hair does not reach a level of apparent accuracy that would permit its use as a general population estimator. However, hair testing is probably more reliable than self-report, and its accuracy could be verified independently if large-scale inter- and intra-laboratory comparative research is conducted.

“Contrary to popular belief, partial recovery from Korsakoff's Psychosis is the rule and 21% recover more or less completely. However the extent to which the patient will recover cannot be predicted with confidence during the acute stages of the illness. Failure to appreciate these facts about the natural history of the mental illness may result in the premature confinement of the patient to a mental hospital” (Victoret al, 1971).

This paper reports on a study of the local policies and specific rationing strategies for in vitro fertilisation (IVF) adopted by Health Authorities in England and Wales. All Health Authorities in England and Wales were asked for this information and a representative sample then took part in a follow-up interview. A majority of Health Authorities had adopted formal eligibility criteria in order to fund access to IVF treatment. These criteria were both overt and covert and ranged from the clinical to the social. They included infertility, age limits, number of children, status of the couple and sexual orientation. Social criteria tended to exclude from public funding individuals who were not in a stable heterosexual relationship. We found a multiplicity of approaches which were not necessarily consistent with each other nor based on the purported goal of promoting clinical and cost effectiveness. Some policies were discriminatory against certain categories of women. Further, there appeared to be a discrepancy between some Health Authorities' exclusion policies and the 1990 legislative framework on access to IVF treatment in the UK.

Objective: To investigate the role of sleeping arrangements as risk factors for the sudden infant death syndrome after a national risk reduction campaign. Design: Two year population based case-control study. Parental interviews were conducted for each infant who died and for four controls matched for age and date of interview. Setting: Three regions in England with a total population of 17 million people. Subjects: 195 babies who died and 780 matched controls. Results: Prone and side sleeping positions both carried increased risks of death compared with supine when adjusted for maternal age, parity, gestation, birth weight, exposure to smoke, and other relevant factors in the sleeping environment (multivariate odds ratio = 9.00 (95% confidence interval 2.84 to 28.47) and 1.84 (1.02 to 3.31), respectively). The higher incidence of side rather than prone sleeping led to a higher population attributable risk (side 18.4%, prone 14.2%). More of the infants who died were found with bed covers over their heads (21.58; 6.21 to 74.99). The use of a dummy had an apparent protective effect (0.38; 0.21 to 0.70). Bed sharing for the whole night was a significant risk factor for infants whose mothers smoked (9.25; 2.31 to 34.02). No protective effect of breast feeding could be identified on multivariate analysis. Conclusions: This study confirms the importance of certain risk factors for the sudden infant death syndrome and identifies others—for example, covers over the head, side sleeping position—which may be amenable to change by educating and informing parents and health care professionals. Key messages This large case-control study is the first after the national campaign to reduce the risk of the syndrome The risk of sudden infant death is increased by prone or side sleeping position; loose bedding (particularly duvets), which can slip over the baby9s head; and bed sharing by mothers who smoke The risk may be reduced by supine sleeping position; placing the baby with feet at the foot of the cot (“feet to foot”); ensuring that bedding is securely tucked in; and avoiding the use of duvets

Objective: To investigate the effects of exposure to tobacco smoke and of parental consumption of alcohol and illegal drugs as risk factors for the sudden infant death syndrome after a national risk reduction campaign which included advice on prenatal and postnatal avoidance of tobacco smoke. Design: Two year population based case-control study. Parental interviews were conducted for each infant who died and four controls matched for age and date of interview. Setting: Three regions in England with a total population of 17 million people. Subjects: 195 babies who died and 780 matched controls. Results: More index than control mothers (62.6% v 25.1%) smoked during pregnancy (multivariate odds ratio = 2.10; 95% confidence interval 1.24 to 3.54). Paternal smoking had an additional independent effect when other factors were controlled for (2.50; 1.48 to 4.22). The risk of death rose with increasing postnatal exposure to tobacco smoke, which had an additive effect among those also exposed to maternal smoking during pregnancy (2.93; 1.56 to 5.48). The population attributable risk was over 61%, which implies that the numbers of deaths from the syndrome could be reduced by almost two third if parents did not smoke. Alcohol use was higher among index than control mothers but was strongly correlated with smoking and on multivariate analysis was not found to have any additional independent effect. Illegal drug use was more common among the index parents, and paternal use of illegal drugs remained significant in the multivariate model (4.68; 1.56 to 14.05). Conclusions: This study confirms the increased risk of the sudden infant death syndrome associated with maternal smoking during pregnancy and shows evidence that household exposure to tobacco smoke has an independent additive effect. Parental drug misuse has an additional small but significant effect. Key messages Exposure of babies to tobacco smoke from other members of the household before or after birth increases the risk of death: the greater the exposure the higher the risk Over 60% of such deaths may be attributable to the effects of exposure to tobacco smoke before and after birth

In the UK, bowel cancer is the second largest cancer killer. Diagnosing people earlier can save lives but demand for endoscopies is increasing and this can put pressure on waiting times.To address this challenge, an endoscopy unit in North East England decided to improve their facilities to increase capacity and create environments that improve the experience of users. This presented a significant opportunity for step change improvement but also a problem in terms of creating designs that meet user requirements whilst addressing structural or space constraints.The Lean design process known as ‘3P’ (standing for the production preparation process) was utilised as a participative design strategy to engage stakeholders in the design of the new department. This involved a time-out workshop (or 3P event) in which Lean and participative design tools were utilised to create an innovative design based on ‘point of delivery’ (POD) principles. The team created a design that demonstrated an increase in treatment room capacity by 25% and bed capacity by 70% whilst reducing travel distance for patients by 25.8% and staff by 27.1%. This was achieved with an increase in available space of only 13%.The Lean 3P method provided a structured approach for corporate and clinical staff to work together with patient representatives as cross-functional teams. This participative approach facilitated communication and learning between stakeholders about care processes and personal preferences. Lean 3P therefore appears to be a promising approach to improving the healthcare facilities design process to meet user requirements.

Facial trauma is associated with male gender, low socioeconomic status, alcohol misuse, and violence. Brief intervention (BI) for alcohol is effective at reducing consumption in patients presenting with facial trauma. Single-session control of violence for angry impulsive drinkers (SS-COVAID) is a new intervention that attempts to address alcohol-related violence. This study assessed the effect of SS-COVAID and BI on drinking and aggression in facial trauma patients. Male facial trauma patients who sustained their injuries as a result of interpersonal violence while drinking and who had Alcohol Use Disorders Identification Test (AUDIT) scores of ≥8 were randomized to either BI or SS-COVAID. Patients were followed up at six and 12 months, and drinking and aggression outcomes were analyzed. One hundred ninety-nine patients entered the trial, and 187 were included in the analysis. Of these, 165 (89%) considered themselves to be victims, 92 (51%) had sustained a previous alcohol-related injury, and 28 (15%) had previous convictions for violence. Both interventions resulted in a significant decrease in negative drinking outcomes over 12 months of follow-up (p < 0.001). Neither intervention had a significant effect on aggression scores, nor was there a significant difference between interventions in terms of either outcome. Both SS-COVAID and BI had a significant effect on drinking variables in this patient cohort. No effect on aggression was seen despite the fact that SS-COVAID specifically addresses the relationship between alcohol and violence. One reason for this may be that the facial trauma patients in this study considered themselves to be victims rather than aggressors. Another possibility is that, while BI may successfully address lifestyle factors such as hazardous or harmful drinking, it may not be effective in modifying personality traits such as aggression.