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Previous research has established that patients with irritable bowel syndrome (IBS) frequently have comorbid psychiatric disorders. This study sought to establish if the timing of the onset of psychiatric disorders indicated that IBS was more likely to be caused by or more likely to cause psychological difficulties. Participants were 188 treatment-seeking IBS patients who were assessed for psychiatric diagnoses using a semistructured clinical interview. Timing of the onset of any lifetime psychiatric disorders was noted in an attempt to determine if psychiatric disorders were more likely to precede or follow the onset of IBS symptoms. Those participants that met criteria for an Axis I disorder sometime during their life were significantly more likely to develop an Axis I disorder before the onset of IBS symptoms. Anxiety disorders were the most likely disorder to develop before IBS. These results support the theory that psychiatric symptoms, especially anxiety, play a role in the development of IBS. [ABSTRACT FROM AUTHOR]

Abstract Background Evidence for an association between exposure during pregnancy to trihalomethanes (THMs) in drinking water and impaired fetal growth is still inconsistent and inconclusive, in particular, for various exposure routes. We examined the relationship of individual exposures to THMs in drinking water on low birth weight (LBW), small for gestational age (SGA), and birth weight (BW) in singleton births. Methods We conducted a cohort study of 4,161 pregnant women in Kaunas (Lithuania), using individual information on drinking water, ingestion, showering and bathing, and uptake factors of THMs in blood, to estimate an internal dose of THM. We used regression analysis to evaluate the relationship between internal THM dose and birth outcomes, adjusting for family status, education, smoking, alcohol consumption, body mass index, blood pressure, ethnic group, previous preterm, infant gender, and birth year. Results The estimated internal dose of THMs ranged from 0.0025 to 2.40 mg/d. We found dose-response relationships for the entire pregnancy and trimester-specific THM and chloroform internal dose and risk for LBW and a reduction in BW. The adjusted odds ratio for third tertile vs. first tertile chloroform internal dose of entire pregnancy was 2.17, 95% CI 1.19-3.98 for LBW; the OR per every 0.1 μg/d increase in chloroform internal dose was 1.10, 95% CI 1.01-1.19. Chloroform internal dose was associated with a slightly increased risk of SGA (OR 1.19, 95% CI 0.87-1.63 and OR 1.22, 95% CI 0.89-1.68, respectively, for second and third tertile of third trimester); the risk increased by 4% per every 0.1 μg/d increase in chloroform internal dose (OR 1.04, 95% CI 1.00-1.09). Conclusions THM internal dose in pregnancy varies substantially across individuals, and depends on both water THM levels and water use habits. Increased internal dose may affect fetal growth.

Aims: Stress echocardiography is widely used to assess patients with chest pain. The clinical value of a positive or negative test result to inform on likely longer-term outcomes when applied in real world practice across a healthcare system has not been previously reported., Methods and Results: 5503 patients recruited across 32 UK NHS hospitals between 2018 and 2022, participating in the EVAREST/BSE-NSTEP prospective cohort study, with data on medical outcomes up to 2023 available from NHS England were included in analysis. Stress echocardiography results were related to outcomes, including death, procedures, hospital admissions and relevant cardiovascular diagnoses, based on Kaplan-Meier analysis and Cox proportional hazard ratios. Median follow-up was 829 days (IQR 224-1434). A positive stress echocardiogram was associated with a greater risk of myocardial infarction (HR 2.71, 95% CI 1.73-4.24, P<0.001), and a composite endpoint of cardiac-related mortality and myocardial infarction (HR 2.03, 95% CI 1.41-2.93, P<0.001). Hazard ratios increased with ischaemic burden. A negative stress echocardiogram identified an event-free 'warranty period' of at least five years in patients with no prior history of coronary artery disease, and four years for those with disease., Conclusions: In real-world practice, the degree of myocardial ischaemia recorded by clinicians at stress echocardiography correctly categorises risk of future events over the next five years. Reporting a stress echocardiogram as negative correctly identifies patients with no greater than a background risk of cardiovascular events over a similar time period., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Background: Hypertensive pregnancy disorders are associated with adverse cardiac remodeling, which can fail to reverse in the postpartum period in some women. The Physician-Optimized Postpartum Hypertension Treatment trial demonstrated that improved blood pressure control while the cardiovascular system recovers postpartum associates with persistently reduced blood pressure. We now report the effect on cardiac remodeling., Methods: In this prospective, randomized, open-label, blinded end point trial, in a single UK hospital, 220 women were randomly assigned 1:1 to self-monitoring with research physician-optimized antihypertensive titration or usual postnatal care from a primary care physician and midwife. Participants were 18 years of age or older, with preeclampsia or gestational hypertension, requiring antihypertensives on hospital discharge postnatally. Prespecified secondary cardiac imaging outcomes were recorded by echocardiography around delivery, and again at blood pressure primary outcome assessment, around 9 months postpartum, when cardiovascular magnetic resonance was also performed., Results: A total of 187 women (101 intervention; 86 usual care) underwent echocardiography at baseline and follow-up, at a mean 258±14.6 days postpartum, of which 174 (93 intervention; 81 usual care) also had cardiovascular magnetic resonance at follow-up. Relative wall thickness by echocardiography was 0.06 (95% CI, 0.07-0.05; P <0.001) lower in the intervention group between baseline and follow-up, and cardiovascular magnetic resonance at follow-up demonstrated a lower left ventricular mass (-6.37 g/m 2 ; 95% CI, -7.99 to -4.74; P <0.001), end-diastolic volume (-3.87 mL/m 2 ; 95% CI, -6.77 to -0.98; P =0.009), and end-systolic volume (-3.25 mL/m 2 ; 95% CI, 4.87 to -1.63; P <0.001) and higher left and right ventricular ejection fraction by 2.6% (95% CI, 1.3-3.9; P <0.001) and 2.8% (95% CI, 1.4-4.1; P <0.001), respectively. Echocardiography-assessed left ventricular diastolic function demonstrated a mean difference in average E/E' of 0.52 (95% CI, -0.97 to -0.07; P =0.024) and a reduction in left atrial volumes of -4.33 mL/m 2 (95% CI, -5.52 to -3.21; P <0.001) between baseline and follow-up when adjusted for baseline differences in measures., Conclusions: Short-term postnatal optimization of blood pressure control after hypertensive pregnancy, through self-monitoring and physician-guided antihypertensive titration, associates with long-term changes in cardiovascular structure and function, in a pattern associated with more favorable cardiovascular outcomes., Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT04273854., Competing Interests: Disclosures L.M. and P.L. are supported by the National Institute for Health and Care Research Oxford Biomedical Research Centre. L.M. is a part-time employee of EMIS Group plc. P.L. is a founder and shareholder of a health care imaging company and a named inventor on patents related to cardiovascular imaging. R.M. has received blood pressure monitors for research from Omron and has worked with Omron and Sensyne on telemonitoring interventions for which licensing and consultancy fees have been paid to the University of Oxford. C.R. has received consultancy fees from Sensyne Health for work on telemonitoring products. J.K. is an executive committee member of the British Society of Cardiac Imaging and Cardiac Computed Tomography. The other authors report no conflicts.

Background: Stress echocardiography (SE) is one of the most commonly used diagnostic imaging tests for coronary artery disease (CAD) but requires clinicians to visually assess scans to identify patients who may benefit from invasive investigation and treatment. EchoGo Pro provides an automated interpretation of SE based on artificial intelligence (AI) image analysis. In reader studies, use of EchoGo Pro when making clinical decisions improves diagnostic accuracy and confidence. Prospective evaluation in real world practice is now important to understand the impact of EchoGo Pro on the patient pathway and outcome., Methods: PROTEUS is a randomized, multicenter, 2-armed, noninferiority study aiming to recruit 2,500 participants from National Health Service (NHS) hospitals in the UK referred to SE clinics for investigation of suspected CAD. All participants will undergo a stress echocardiogram protocol as per local hospital policy. Participants will be randomized 1:1 to a control group, representing current practice, or an intervention group, in which clinicians will receive an AI image analysis report (EchoGo Pro, Ultromics Ltd, Oxford, UK) to use during image interpretation, indicating the likelihood of severe CAD. The primary outcome will be appropriateness of clinician decision to refer for coronary angiography. Secondary outcomes will assess other health impacts including appropriate use of other clinical management approaches, impact on variability in decision making, patient and clinician qualitative experience and a health economic analysis., Discussion: This will be the first study to assess the impact of introducing an AI medical diagnostic aid into the standard care pathway of patients with suspected CAD being investigated with SE., Trial Registration: Clinicaltrials.gov registration number NCT05028179, registered on 31 August 2021; ISRCTN: ISRCTN15113915; IRAS ref: 293515; REC ref: 21/NW/0199., Competing Interests: Declaration of Competing Interest GW, RS, WH, TD, ES, MB, OH, LT, JL, RU are all employees of Ultromics Ltd GW, RS, WH, BT, JL hold share options for Ultromics Ltd PL and RU are founders and shareholders of Ultromics Ltd and have patents in the field of AI and imaging. SEP provides consultancy to Circle Cardiovascular Imaging, Inc, Calgary, Alberta, Canada. All other authors declare that they have no competing interests., (Copyright © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: Stress echocardiography is widely used to detect coronary artery disease, but little evidence on downstream hospital costs in real-world practice is available. We examined how stress echocardiography accuracy and downstream hospital costs vary across NHS hospitals and identified key factors that affect costs to help inform future clinical planning and guidelines., Methods: Data on 7636 patients recruited from 31 NHS hospitals within the UK between 2014 and 2020 as part of EVAREST/BSE-NSTEP clinical study, were used. Data included all diagnostic tests, procedures, and hospital admissions for 12 months after a stress echocardiogram and were costed using the NHS national unit costs. A decision tree was built to illustrate the clinical pathway and estimate average downstream hospital costs. Multi-level regression analysis was performed to identify variation in accuracy and costs at both patient, procedural, and hospital level. Linear regression and extrapolation were used to estimate annual hospital cost-savings associated with increasing predictive accuracy at hospital and national level., Results: Stress echocardiography accuracy varied with patient, hospital and operator characteristics. Hypertension, presence of wall motion abnormalities and higher number of hospital cardiology outpatient attendances annually reduced accuracy, adjusted odds ratio of 0.78 (95% CI 0.65 to 0.93), 0.27 (95% CI 0.15 to 0.48), 0.99 (95% CI 0.98 to 0.99) respectively, whereas a prior myocardial infarction, angiotensin receptor blocker medication, and greater operator experience increased accuracy, adjusted odds ratio of 1.77 (95% CI 1.34 to 2.33), 1.64 (95% CI 1.22 to 2.22), and 1.06 (95% CI 1.02 to 1.09) respectively. Average downstream costs were £646 per patient (SD 1796) with significant variation across hospitals. The average downstream costs between the 31 hospitals varied from £384-1730 per patient. False positive and false negative tests were associated with average downstream costs of £1446 (SD £601) and £4192 (SD 3332) respectively, driven by increased non-elective hospital admissions, adjusted odds ratio 2.48 (95% CI 1.08 to 5.66), 21.06 (95% CI 10.41 to 42.59) respectively. We estimated that an increase in accuracy by 1 percentage point could save the NHS in the UK £3.2 million annually., Conclusion: This study provides real-world evidence of downstream costs associated with stress echocardiography practice in the UK and estimates how improvements in accuracy could impact healthcare expenditure in the NHS. A real-world downstream costing approach could be adopted more widely in evaluation of imaging tests and interventions to reflect actual value for money and support realistic planning., (© 2023. The Author(s).)

N‑nitrosodimethylamine (NDMA) was detected in the source water of some Chinese drinking water treatment plants (DWTPs), which decreased in concentration along the treatment train. Volatilization, photolysis, and/or biodegradation were suspected of being capable of attenuating NDMA. In this study, the contribution of these mechanisms to NDMA removal was investigated by a field study in a conventional DWTP with aerated bio-pretreatment, as well as in laboratory-based experiments. The effluent of each unit process (i.e., aerated bio-pretreatment tank, horizontal sedimentation tank, sand filter) of this DWTP was sampled in the winter and summer, and the concentration of NDMA, its formation potential, and other water quality parameters were measured. NDMA removal by volatilization and biodegradation was simulated in batch experiments, and that by photolysis was calculated with parameters reported in the literature. The sampling results indicated that the aerated biofilm reactor of this DWTP removed 48% of the NDMA in August and 22% in December. According to modeling results, it could be well explained by photolysis (NDMA removal of 51% in summer and 25% in winter) and biotreatment (NDMA removal of 0.2-12% in summer and 0.1-6.1% in winter), with little contribution from aeration (NDMA removal of 0.8%). The sampling results indicated that the sedimentation tank removed 19% of NDMA in August and 9.2% in December. According to modeling results, it could be well explained by photolysis (NDMA removal of 16% in August and 9.4% in December), but little by volatilization. Thus, photolysis was shown to be the most important process for NDMA removal in this DWTP. Further investigation is needed to better understand NDMA removal during biotreatment., (Copyright © 2019 Elsevier B.V. All rights reserved.)

In order to better understand the occurrence of disinfection byproducts (DBPs) in tap water and their real impacts on consumers, this study made a one-year long survey of the temporal variations of a series of DBPs before and after a point-of-use (POU) treatment facility installed in a building serving for ∼300 people. Water samples were collected every week at a fixed location and time for 1 year, and frequent samplings were carried out every 6 h a day for 1 month at selected seasons, which ultimately amounted to 322 samples. The results show that the concentrations of DBPs were higher in the summer than other seasons, with the lowest DBP levels being observed in spring. Within one week, higher levels of haloacetic acids (HAAs) were identified on weekdays than those on weekends. Diurnally, trihalomethanes, HAAs, and haloacetaldehydes were found to be higher at noon but lower in the evening. Consistent with other studies, the variations of most DBPs were somewhat positively related to the changes of temperature and organic matter, but negatively related to the quantity of free chlorine. With the use of a POU facility, which equips with two activated carbon cartridges and a boiler in sequence, most of DBPs were dramatically reduced, leading to 62-100% lower cytotoxicity for the measured DBPs. The study hence provides a real-water evidence about the DBP occurrences in a typical distribution system endpoint and the efficiency of a typical POU on mitigating DBP risks., (Copyright © 2019 Elsevier Ltd. All rights reserved.)