Gail Hayward

The role of the anterior cingulate cortex in the counting Stroop task.

The role of the anterior cingulate in the counting Stroop task was examined using transcranial magnetic stimulation (TMS). TMS was given over sites targeting more dorsal and more ventral anterior cingulate cortex and a control area of parietal cortex whilst subjects reported the number of words presented on the screen using a key press. The Stroop interference effect was abolished by TMS over both anterior cingulate sites. These findings support functional neuroimaging research which suggests that cingulate cortex is central to the processes underlying the Stroop task.

Corticosteroids for pain relief in sore throat: systematic review and meta-analysis

Objective To evaluate whether systemic corticosteroids improve symptoms of sore throat in adults and children. Design Systematic review and meta-analysis. Data sources Cochrane Central, Medline, Embase, Database of Reviews of Effectiveness (DARE), NHS Health Economics Database, and bibliographies. Outcome measures Percentage of patients with complete resolution at 24 and 48 hours, mean time to onset of pain relief, mean time to complete resolution of symptoms, days missed from work or school, recurrence, and adverse events. Results We included eight trials, consisting of 743 patients in total (369 children, 374 adults). 348 (47%) had exudative sore throat, and 330 (44%) were positive for group A β-haemolytic streptococcus. In addition to antibiotics and analgesia, corticosteroids significantly increased the likelihood of complete resolution of pain at 24 hours (four trials) by more than three times (relative risk 3.2, 95% confidence interval 2.0 to 5.1), and at 48 hours (three trials) to a lesser extent (1.7, 1.3 to 2.1). Corticosteroids (six trials) reduced mean time to onset of pain relief by more than 6 hours (95% confidence interval 3.4 to 9.3, P<0.001), although significant heterogeneity was present. The mean time to complete resolution was inconsistent across trials and a pooled analysis was not undertaken. Reporting of other outcomes was limited. Conclusions Corticosteroids provide symptomatic relief of pain in sore throat, in addition to antibiotic therapy, mainly in participants with severe or exudative sore throat.

Selective processing of social threat cues following acute tryptophan depletion

The aim of the present study was to investigate the effects of low dose tryptophan depletion on recovered depressed patients both on and off antidepressant medication on an emotional Stroop task using social threat cues. Twenty-four healthy volunteers, 24 euthymic volunteers with a history of depression not currently on antidepressant medication and 24 euthymic volunteers with a history of depression and currently on antidepressant medication were randomly allocated to double-blind treatment with either a tryptophan depleting or a balanced mixture. All participants then completed subjective mood ratings and an emotional Stroop task using social threat cues. The recovered depressed group on medication demonstrated an increase in selective processing of social threat cues on the emotional Stroop task in the tryptophan depletion compared to the control condition. This was not the case for either healthy controls or the recovered depressed group not on medication. Although none of the patients showed a clinically significant relapse following tryptophan depletion, the medicated group showed a small but statistically significant increase in self-rated depression on the Profile of Mood States (POMS). Our data indicate that low-dose acute tryptophan depletion elicits both cognitive processing typical of the depressed state and subtle changes in subjective mood in the recovered depressed group on medication, but not in the recovered depressed group not on medication. This suggests that these two groups may differ in their underlying vulnerability to compromised serotonin function.

Intranasal Corticosteroids in Management of Acute Sinusitis: A Systematic Review and Meta-Analysis

PURPOSE Acute sinusitis is a common condition in ambulatory care, where it is frequently treated with antibiotics, despite little evidence of their benefit. Intranasal corticosteroids might relieve symptoms; however, evidence for this benefit is currently unclear. We performed a systematic review and meta-analysis of the effects of intranasal corticosteroids on the symptoms of acute sinusitis. METHODS We searched MEDLINE, EMBASE, the Cochrane Central register of Controlled Trials (CENTRAL), and Centre for Reviews and Dissemination databases until February 2011 for studies comparing intranasal corticosteroids with placebo in children or adults having clinical symptoms and signs of acute sinusitis or rhinosinusitis in ambulatory settings. We excluded chronic/allergic sinusitis. Two authors independently extracted data and assessed the studies’ methodologic quality. RESULTS We included 6 studies having a total of 2,495 patients. In 5 studies, antibiotics were prescribed in addition to corticosteroids or placebo. Intranasal corticosteroids resulted in a significant, small increase in resolution of or improvement in symptoms at days 14 to 21 (risk difference [RD] = 0.08; 95% CI, 0.03–0.13). Analysis of individual symptom scores revealed most consistently significant benefits for facial pain and congestion. Subgroup analysis by time of reported outcomes showed a significant beneficial effect at 21 days (RD = 0.11; 95% CI, 0.06–0.17), but not at 14 to 15 days (RD = 0.05; 95% CI, −0.01 to 0.11). Meta-regression analysis of trials using different doses of mometasone furoate showed a significant dose-response relationship (P=.02). CONCLUSIONS Intranasal corticosteroids offer a small therapeutic benefit in acute sinusitis, which may be greater with high doses and with courses of 21 days’ duration. Further trials are needed in antibiotic-naïve patients.

Evidence for non-communicable diseases: analysis of Cochrane reviews and randomised trials by World Bank classification

Introduction Prevalence of non-communicable diseases (NCDs) is increasing globally, with the greatest projected increases in low-income and middle-income countries. We sought to quantify the proportion of Cochrane evidence relating to NCDs derived from such countries. Methods We searched the Cochrane database of systematic reviews for reviews relating to NCDs highlighted in the WHO NCD action plan (cardiovascular, cancers, diabetes and chronic respiratory diseases). We excluded reviews at the protocol stage and those that were repeated or had been withdrawn. For each review, two independent researchers extracted data relating to the country of the corresponding author and the number of trials and participants from countries, using the World Bank classification of gross national income per capita. Results 797 reviews were analysed, with a reported total number of 12 340 trials and 10 937 306 participants. Of the corresponding authors 90% were from high-income countries (41% from the UK). Of the 746 reviews in which at least one trial had met the inclusion criteria, only 55% provided a summary of the country of included trials. Analysis of the 633 reviews in which country of trials could be established revealed that almost 90% of trials and over 80% of participants were from high-income countries. 438 (5%) trials including 1 145 013 (11.7%) participants were undertaken in low-middle income countries. We found that only 13 (0.15%) trials with 982 (0.01%) participants were undertaken in low-income countries. Other than the five Cochrane NCD corresponding authors from South Africa, only one other corresponding author was from Africa (Gambia). Discussion The overwhelming body of evidence for NCDs pertains to high-income countries, with only a small number of review authors based in low-income settings. As a consequence, there is an urgent need for research infrastructure and funding for the undertaking of high-quality trials in this area.

Security and skills: the two key issues in health worker migration

Background Migration of health workers from Africa continues to undermine the universal provision of quality health care. South Africa is an epicentre for migration – it exports more health workers to high-income countries than any other African country and imports health workers from its lower-income neighbours to fill the gap. Although an inter-governmental agreement in 2003 reduced the very high numbers migrating from South Africa to the United Kingdom, migration continues to other high-income English-speaking countries and few workers seem to return although the financial incentive to work abroad has lessened. A deeper understanding of reasons for migration from South Africa and post-migration experiences is therefore needed to underpin policy which is developed in order to improve retention within source countries and encourage return. Methods Semi-structured interviews were conducted with 16 South African doctors and nurses who had migrated to the United Kingdom. Interviews explored factors influencing the decision to migrate and post-migration experiences. Results Salary, career progression, and poor working conditions were not major push factors for migration. Many health workers reported that they had previously overcome these issues within the South African healthcare system by migrating to the private sector. Overwhelmingly, the major push factors were insecurity, high levels of crime, and racial tension. Although the wish to work and train in what was perceived to be a first-class care system was a pull factor to migrate to the United Kingdom, many were disappointed by the experience. Instead of obtaining new skills, many (particularly nurses) felt they had become ‘de-skilled’. Many also felt that working conditions and opportunities for them in the UK National Health Service (NHS) compared unfavourably with the private sector in South Africa. Conclusions Migration from South Africa seems unlikely to diminish until the major concerns over security, crime, and racial tensions are resolved. However, good working conditions in the private sector in South Africa provide an occupational incentive to return if security did improve. Potential migrants should be made more aware of the risks of losing skills while working abroad that might prejudice return. In addition, re-skilling initiatives should be encouraged.

Effect of Oral Dexamethasone Without Immediate Antibiotics vs Placebo on Acute Sore Throat in Adults: A Randomized Clinical Trial

Importance Acute sore throat poses a significant burden on primary care and is a source of inappropriate antibiotic prescribing. Corticosteroids could be an alternative symptomatic treatment. Objective To assess the clinical effectiveness of oral corticosteroids for acute sore throat in the absence of antibiotics. Design, Setting, and Participants Double-blind, placebo-controlled randomized trial (April 2013-February 2015; 28-day follow-up completed April 2015) conducted in 42 family practices in South and West England, enrolled 576 adults recruited on the day of presentation to primary care with acute sore throat not requiring immediate antibiotic therapy. Interventions Single oral dose of 10 mg of dexamethasone (n = 293) or identical placebo (n = 283). Main Outcomes and Measures Primary: proportion of participants experiencing complete resolution of symptoms at 24 hours. Secondary: complete resolution at 48 hours, duration of moderately bad symptoms (based on a Likert scale, 0, normal; 6, as bad as it could be), visual analog symptom scales (0-100 mm; 0, no symptom to 100, worst imaginable), health care attendance, days missed from work or education, consumption of delayed antibiotics or other medications, adverse events. Results Among 565 eligible participants who were randomized (median age, 34 years [interquartile range, 26.0-45.5 year]; 75.2% women; 100% completed the intervention), 288 received dexamethasone; 277, placebo. At 24 hours, 65 participants (22.6%) in the dexamethasone group and 49 (17.7%) in the placebo group achieved complete resolution of symptoms, for a risk difference of 4.7% (95% CI, −1.8% to 11.2%) and a relative risk of 1.28 (95% CI; 0.92 to 1.78; P = .14). At 24 hours, participants receiving dexamethasone were not more likely than those receiving placebo to have complete symptom resolution. At 48 hours, 102 participants (35.4%) in the dexamethasone group vs 75 (27.1%) in the placebo group achieved complete resolution of symptoms, for a risk difference of 8.7% (95% CI, 1.2% to 16.2%) and a relative risk of 1.31 (95% CI, 1.02 to 1.68; P = .03). This difference also was observed in participants not offered delayed antibiotic prescription, for a risk difference of 10.3% (95% CI, 0.6% to 20.1%) and a relative risk of 1.37 (95% CI, 1.01 to 1.87; P = .046). There were no significant differences in any other secondary outcomes. Conclusions and Relevance Among adults presenting to primary care with acute sore throat, a single dose of oral dexamethasone compared with placebo did not increase the proportion of patients with resolution of symptoms at 24 hours. However, there was a significant difference at 48 hours. Trial Registration isrctn.org Identifier: ISRCTN17435450

Increase in antibiotic prescriptions in out-of-hours primary care in contrast to in-hours primary care prescriptions: service evaluation in a population of 600 000 patients

OBJECTIVES The objective of this study was to describe the frequency and nature of antibiotic prescriptions issued by a primary care out-of-hours (OOH) service and compare time trends in prescriptions between OOH and in-hours primary care. METHODS We performed a retrospective audit of 496 931 patient contacts with the Oxfordshire OOH primary care service. Comparison of time trends in antibiotic prescriptions from OOH primary care and in-hours primary care for the same population was made using multiple linear regression models fitted to the monthly data for OOH prescriptions, OOH contacts and in-hours prescriptions between September 2010 and August 2014. RESULTS Compared with the overall population contacting the OOH service, younger age, female sex and patients who were less deprived were independently correlated with an increased chance of a contact resulting in prescription of antibiotics. The majority of antibiotics were prescribed to patients contacting the service at weekends. Despite a reduction in patient contacts with the OOH service [an estimated decrease of 486.5 monthly contacts each year (95% CI -676.3 to -296.8), 5.0% of the average monthly contacts], antibiotic prescriptions from this service rose during the study period [increase of 37.1 monthly prescriptions each year (95% CI 10.6-63.7), 2.5% of the average monthly prescriptions]. A matching increase was not seen for in-hours antibiotic prescriptions; the difference between the year trends was significant (Z test, P = 0.002). CONCLUSIONS We have demonstrated trends in prescribing that could represent a partial displacement of antibiotic prescribing from in-hours to OOH primary care. The possibility that the trends we describe are evident nationally should be explored.

What factors influence prognosis in children with acute cough and respiratory tract infection in primary care

Cough is the commonest reason for preschool children to see a general practitioner,1 with primary care costs conservatively estimated at £31 million (€38.4 million;

‘You can't stay away from your family’: a qualitative study of the ongoing ties and future plans of South African health workers in the United Kingdom

50.3 million) a year for this age group alone.2 Acute cough has been shown to last longer than two weeks in a quarter of preschool children, and up to 12% of children could have deterioration in their condition necessitating reconsultation or complications, including pneumonia.3 Primary care clinicians attempt to balance the need to reduce unnecessary antibiotic prescriptions with the prevention of complications from respiratory tract infections. However, recent guidance from the National Institute for Health and Clinical Excellence4 acknowledged that a key driver for increased antibiotic prescriptions is clinical uncertainty in identifying those children most likely to develop complications or who need hospital care for respiratory infections—that is, those at risk of poorer prognosis. This uncertainty is evident from the wide variation in prescribing rates between individual clinicians, general practices, and countries.5 6 7 We researched this question using a literature review (box). #### Search strategy for literature review > respiratory tract infection [MeSH Terms] OR respiratory infection* OR rti OR lrti OR urti OR lri OR uri OR chest infection* OR cough OR dyspnoea OR congestion OR (lung consolidation) OR (lobar pneumonia) OR (difficult breath*) OR respiration disorder* > > AND > > child* OR schoolchild* OR preschool* OR pediatric* OR paediatric* OR parent OR parents OR parental OR mother OR father OR mom OR dad OR mum OR caregiver OR guardian OR …