Attracting healthcare professionals to remote and rural medicine: learning from doctors in training in the north of Scotland.

BACKGROUND: Research exploring the experiences of trainee doctors in remote and rural locations is scarce. Our aim was to gain an understanding of the experiences and perceptions of Foundation Programme (FP) doctors training in placements in remote and rural areas of the north of Scotland. METHODS: FP doctors training in remote and rural areas in Scotland took part in a qualitative study (focus groups and individual interviews) exploring their training experiences and career plans. To make sense of a potential multitude of factors, we selected social cognitive careers theory (SCCT) to underpin data collection and analysis. RESULTS: A total of 20 trainees participated. Using data-driven analysis, three themes relevant to the SCCT emerged. These are the educational experience (e.g., opportunities to develop skills, greater responsibility), geographical isolation factors (e.g., the impact of staff shortages, poor accommodation, travel) and personal factors (e.g., social isolation, attitudes towards the experience). CONCLUSION: Many factors impact on trainees' experience of learning and living in remote and rural medicine (R&R) environments. These experiences can be very positive for some individuals but factors external to the educational environment influence the perception of the overall experience. SCCT helps clarify the interaction between individual and contextual factors in career decision making.

Beauveria bassiana (Ascomycota: Hypocreales) as a management agent for free-living Amblyomma americanum (Acari: Ixodidae) in Ohio.

Unfed adult Amblyomma americanum were exposed to the entomopathogenic fungus Beauveria bassiana and placed in the field. Ticks exposed to the fungus experienced higher mortality than those in the control group (P = 0.001). It is recommended that for inclusion in a tick management program, the fungus be applied in the late evening during the months March through June as this is when ticks are most active and conditions suitable for fungal activity occur.

Physiological effects upon Amblyomma americanum (Acari: Ixodidae) infected with Beauveria bassiana (Ascomycota: Hypocreales).

Unfed adult Amblyomma americanum were exposed to the entomopathogenic fungus Beauveria bassiana. Ticks exposed to the fungus exhibited reduced survival and increased water loss as indicated by change in weight. Treated ticks survived 7.2 ± 0.22 days (mean ± SE) and controls survived 17.9 ± 0.73 days (P = 0.01; df = 57). At death, ticks exposed to the fungus had lost 25.2 ± 0.84% of their starting weight; control ticks had lost 14.1 ± 0.85% of their starting weight (P = 0.01; df = 96). Water loss was highest immediately following inoculation, although losses continued to be higher than in uninoculated ticks. This suggests that fungal penetration causes sufficient cuticle damage to cause desiccation, although other water-loss avenues exist, including increased time of spiracular opening. Additionally this study did not eliminate the possibility of a negative impact on water vapor uptake. This is the first study to investigate the effect of an entomopathogenic fungus on the water balance of a tick.

Neem-tree (Azadirachta indica Juss.) extract as a feed additive against the American dog tick (Dermacentor variabilis) in sheep (Ovis aries).

Acaricides can be conveyed to ticks via the blood of their hosts. As fruit and kernel extracts from the Meliaceae family, and, in particular the tetranortriterpenoid azadirachtin (AZA) inhibits tick egg production and embryogenesis in the Ixodidae ticks, we investigated the effects of Neem Azal, an extract containing 43% AZA, given as a feed additive to lambs artificially infested with engorging adult Dermacentor vairiabilis ticks. After tick attachment, the lambs were allotted to three dietary treatments: AZA0 (control, n=10), AZA0.3 (n=5), and AZA0.6 (n=5), with feed containing 0%, 0.3%, and 0.6% AZA on DM basis, respectively. In half of the AZA0 lambs, ticks were sprayed on day 4 after attachment with an ethanol:water:soap emulsion containing 0.6% AZA (AZA0S). In spite of its very pungent odor, the neem extract was well accepted by all but one lamb. No differences were found between treatment groups in liver enzymes in blood, and there was no indication of toxicity. The plasma AZA concentrations after 7 and 14 days of feeding AZA were (4.81 and 4.35 microg/mL) for the AZA0.6 and (3.32 and 1.88 microg/mL) for the AZA0.3 treatments, respectively (P<0.0001). Treatments were not lethal to ticks, but tick weights at detachment were 0.64, 0.56, 0.48, and 0.37 g for ticks from the AZA0, AZA0.3, AZA0S, and AZA0.6 treatments (P<0.04), respectively, suggesting that blood AZA impaired blood-feeding. The highest mortality rate after detachment was for AZA0.6 (P<0.09). As AZA affects embryo development and ticks at the molting stages, we expect that following treatments of hosts for longer periods, one-host ticks will be more affected than the three-host tick D. variabilis.

Flexible trainees in Scotland.

INTRODUCTION: Demand for flexible training is increasing. The contribution of such trainees to the trained medical workforce is not clear. METHODS: All full time and flexible trainees in Scotland were 'tracked' at the completion of training. RESULTS: 80% of flexible trainees took up a consultant post of which 93% were in Scotland. 82% of full time trainees took up a consultant post of which 80% were in Scotland. DISCUSSION: Flexible trainees become consultants at the same rate as their full time counterparts. They are commonly geographically tied and are therefore more likely to remain in Scotland and contribute to retention of doctors in this country.

Bovine hypodermosis: prevalence and economic significance in southern Punjab, Pakistan.

Prevalence and economic losses of warble fly infestation (WFI) in cattle and buffaloes were recorded in Dera Ghazi Khan and Rajan Pur districts of southern Punjab (Pakistan). A total of 18,000 cattle and 9000 buffaloes were examined in the field and slaughter house. Only one species of Hypoderma, i.e. Hypoderma lineatum was recorded from this area. The prevalence of WFI was higher in slaughter house versus field, cattle versus buffaloes, males versus females, and young versus old animals in both the districts. The highest month-wise prevalence was recorded in December and the lowest in July. Organ-wise prevalence of WFI was highest in oesophagus followed in order by rumen and spleen. The economic losses based on the value of warbled and warble-free hides were estimated as Rs. 22.8 million per annum (currency exchange rate is Rs. 57.5=US 1 dollar).

Using a 360 degrees diagnostic screening tool to provide an evidence trail of junior doctor performance throughout their first postgraduate year.

New medical graduates in the UK are known as Preregistration House Officers (PRHOs). At the end of this first postgraduate year, the Postgraduate Dean is responsible for allowing the PRHO to be fully registered with the General Medical Council. During the period 1999-2002 Professor Miriam Friedman Ben-David designed a more robust approach to appraisal and assessment of PRHOs, which provided educational feedback to all trainees, allowed any poor performers to be detected at an early stage, and provided 'hard' observable evidence for certification decisions. This paper describes the more recent development of her work resulting from further piloting of her system. The key tool, a 360 degrees diagnostic questionnaire, is designed to identify strengths and weaknesses in individual performance. It is presently being used as a screening tool to identify any trainees needing additional support and further assessment. The tool also forms part of an evidence trail for all PRHOs and helps inform formative assessment as well as contributing, along with other evidence, to full registration decisions. The evaluation of this tool, also described in this paper, shows the feasibility of implementing such a system on a wider scale and illustrates the successful balance made between robustness and feasibility.

Consultants in nhs scotland: a survey of work commitments, remuneration, job satisfaction and retirement plans.

BACKGROUND AND AIMS: UK consultants have reported working long hours, increased stress and reduced morale. This study set out to elicit consultants' views on flexible working and to gather data on consultants' workloads, remuneration, job satisfaction and retirement plans. As such it is the first comprehensive study of consultants in NHS Scotland. METHODS: The Information and Statistics Division of the Scottish Executive Health Dept provided a list of consultants working in NHS Scotland Focus groups and interviews informed the design of a postal self-completion, questionnaire. RESULTS: The response ratewas 61%. Almost two-thirds (65%) of respondents felt their workloads were unreasonable and unsustainable and 67% were unable to provide their desired standards of patient care. Two-thirds (67%) did not normally take meal breaks, 63% had insufficient time for outside interests, whilst 44% felt their health was being adversely affected Many (84%) believed that some of their work could be delegated to someone less qualified but 79% agreed that there were insufficient staff to make this possible. The average planned retirement age was 60 years, with 23% describing their plans as definite and 70% as quite or very likely. When asked what might induce them to postpone retirement, 50% cited reduced workload/work intensity. CONCLUSIONS: In 2003, a majority of consultants in the UK voted in favour of the new consultant contract. This will improve consultant pay and introduce a standard 40-hour working week, including worked on-call. This should address tow of the main areas of consultant dissatisfaction in NHS Scotland. However, staff shortages will require to be addressed if the contract is to be successfully implemented.

The Grampian Senior House Officer scheme in medicine -- the early years and now.

A rotational scheme for Senior House Officers in medicine is described. Although it was introduced more than 30 years ago its effectiveness is such that it has remained the basis of training. Details of the original scheme are given together with the underpinning principles. The modifications leading to the current scheme are noted.

Effects of mailed dissemination of the Royal College of Radiologists' guidelines on general practitioner referrals for radiography: a time series analysis.

AIM: To evaluate the effect of postal dissemination of the third edition of the Royal College of Radiologists' (RCR) guidelines on general practitioner referrals for radiography. MATERIALS AND METHODS: An interrupted time series using monthly data for 34 months before and 14 months after dissemination of the guidelines was employed. Data were abstracted for the period April 1994 to March 1998 from the computerized administrative systems of open access radiological services provided by two teaching hospitals in one region of Scotland. The time series results are contrasted with those obtained by using a simple before and after design. RESULTS: A total of 117 747 imaging requests from general practice were received in the two departments. There were no significant effects of disseminating the guidelines on the total number of requests, or on requests for individual examinations. If a simple before and after study had been used, then we would have erroneously concluded that significant changes had occurred in referral practice for 11 of the 18 procedures concerned. CONCLUSION: Mailing of copies of the RCR guidelines had a small effect on general practitioners' use of X-ray investigations of uncertain clinical significance. Additional dissemination and implementation strategies appear necessary to promote the use of guidelines.

Ixodid ticks feeding on humans in South Africa: with notes on preferred hosts, geographic distribution, seasonal occurrence and transmission of pathogens.

This paper records the identities of 558 ixodid ticks feeding on 194 humans in South Africa. These ticks belonged to 20 species in six genera and those most frequently encountered were AmblYomma hebraeum, Haemaphysalis leachi, Hyalomma marginatum rufipes, Hyalomma truncatum, Rhipicephalus appendiculatus, Rhipicephalus gertrudae and Rhipicephalus simus. With the exception of the larvae of R. appendiculatus, the incidents of these ticks feeding on humans correlated well with their seasonal occurrences on preferred hosts. Ticks were also collected at monthly intervals, for 14 consecutive months, from the clothing of a game-guard providing protection for field-workers engaged in the collection, by means of flannel strips, of free-living ticks from the vegetation of four localities in the southern region of the Kruger National Park. In addition, with the exception of 3 months when the particular worker was absent, ticks that fed on one of the field-workers were collected over the same 14-month period. A total of 54,429 free-living ticks belonging to 14 species and six genera were collected from the vegetation at the four localities during this time and 3751 ticks belonging to 11 species and six genera from the clothing of the game-guard. The larvae of A. hebraeum and Boophilus decoloratus were the most numerous of the immature ticks, and H. leachi and R. simus of the adults on both the vegetation and the guard's clothing. Ticks fed on the field-worker on six occasions and 14 were collected, all of which were A. hebraeum larvae.

What is achieved by mammographic surveillance after breast conservation treatment for breast cancer?

BACKGROUND: After breast conservation surgery for breast cancer, patients are followed up by regular clinical examination and mammography, at intervals which vary according to local practice. However, the optimum interval remains unclear with current guidelines suggesting mammography should be carried out every 1 to 2 years. This study has investigated this aspect and, in particular, whether mammography or clinical examination or both allowed an early detection of recurrence of the disease in the conserved breast. METHODS: A total of 695 patients who had undergone breast conservation surgery were identified from a database of prospectively recorded data during the period 1990 to 1995. Clinical examination and annual mammography were performed in accordance with local protocol. The results of clinical examination, mammography, and local recurrence rates were evaluated. RESULTS: A total of 2,181 mammograms were undertaken in the 695 patients studied. Local recurrence of disease in the conserved breast occurred in 21 patients (3%), at a mean follow-up of 3.5 years. The first identification of tumor recurrence was by clinical examination in 11 patients with local recurrence, and by the surveillance mammography in the other 10 patients with local recurrence. Overall, mammography detected the local recurrence in 13 of 20 (65%) patients who underwent this examination. In the other patients, the recurrence was detected on clinical examination only. In addition, in 52 patients, mammography was falsely positive, giving a false positive rate of 2.3%. Contralateral cancers in the opposite breast were detected in 2 patients. CONCLUSIONS: The detection of local disease after breast conservation surgery requires both clinical examination and mammography. In the context of our follow-up policy, in 52% of patients with local recurrence, this was first identified by clinical examination. Disease recurrence was identified in the other 48% of patients by mammographic surveillance. Overall, mammography will identify or confirm local recurrence in two thirds of women. However, in a small number of cases (2.3% in our series) mammography will give false positive results. New imaging modalities to assist in the diagnosis of local recurrence of disease after breast conservation surgery are required.

Ixodes rubicundus nymphs are short-day diapause-induced ticks with thermolabile sensitivity and desiccation resistance.

The Karoo Paralysis tick, Ixodes rubicundus Neumann (Acari: Ixodidae), is a semi-voltine ixodid that survives stressful environmental conditions using morphogenetic diapause (eggs and engorged nymphs) and desiccation resistance. Both photoperiod and temperature influence diapause induction in the engorged nymph. Ixodes rubicundus nymphs are typical long-day photoperiodic organisms. The critical photoperiod is approximately 13.5 h light, 10.5 h dark, and they display a thermolabile response. The period between detachment and apolysis in engorged nymphs is modified by photoperiod; however, apolysis to ecdysis is not affected by photoperiod. Thus, initiation of development, but not the actual process is controlled by photoperiod. Most engorged nymphs delayed metamorphosis when exposed to short-day regimen (LD 12 : 12 h) after feeding. Nymphs exposed to pre- and post-feeding long-day regimen (LD 14 : 10 h) developed. Times for 50% of nymphs to apolyse when exposed to photoperiods of LD 14 : 10 h, 13.5 : 10.5 h, 13 : 11 h and 12 : 12 h were 28, 36, 40 and 58 days, respectively. Times for 50% of engorged nymphs to ecdyse ranged from 38 to 40 days after apolysis. Nymphs were sensitive to photoperiodic exposures before, during and after feeding. Nymphs exposed to long day (LD 14 :10 h) before and during feeding, moulted at 20 degrees C; however, most exposed to 10 degrees C followed by 20 degrees C (post-feeding) went into diapause. Both short- (10 : 14 h) and long- (14 : 10 h) day exposed engorged nymphs survived 45 days at 0% r.h. (n = 73), but diapause-destined ticks kept at 13 degrees C lost the least mass (29.5+/-9.5%, SD), while nondiapause ticks at 23 degrees C lost the most (48.7+/-8.2%, SD). Termination of diapause and transition to development probably coincides with a definite increase of water vapour uptake by engorged nymphs. Comparatively, I. rubicundus engorged nymphs are more desiccation tolerant than a North-American counterpart, Amblyomma cajennense (Fabricius) (Acari: Ixodidae), which is also semi-arid- to xeric-adapted. Diapause conveys important survival attributes that enable engorged I. rubicundus nymphs to inhabit a semi-arid environment with great temperature extremes, and to synchronize their activity periods with seasons and host utilization patterns.

Effect of audit and feedback, and reminder messages on primary-care radiology referrals: a randomised trial.

BACKGROUND: Radiological tests are often used by general practitioners (GPs). These tests can be overused and contribute little to clinical management. We aimed to assess two methods of reducing GP requests for radiological tests in accordance with the UK Royal College of Radiologists' guidelines on lumbar spine and knee radiographs. METHODS: We assessed audit and feedback, and educational reminder messages in six radiology departments and 244 general practices that they served. The study was a before-and-after, pragmatic, cluster randomised controlled trial with a 232 factorial design. A random subset of GP patients' records were examined for concordance with the guidelines. The main outcome measure was number of radiograph requests per 1000 patients per year. Analysis was by intention to treat. FINDINGS: The effect of educational reminder messages (ie, the change in request rate after intervention) was an absolute change of -1.53 (95% CI -2.5 to -0.57) for lumbar spine and of -1.61 (-2.6 to -0.62) for knee radiographs, both relative reductions of about 20%. The effect of audit and feedback was an absolute change of -0.07 (-1.3 to 0.9) for lumbar spine of 0.04 (-0.95 to 1.03) for knee radiograph requests, both relative reductions of about 1%. Concordance between groups did not differ significantly. INTERPRETATION: 6-monthly feedback of audit data is ineffective but the routine attachment of educational reminder messages to radiographs is effective and does not affect quality of referrals. Any department of radiology that handles referrals from primary care could deliver this intervention to good effect.

Assessment of maxillary sinus volume for the sinus lift operation by three-dimensional magnetic resonance imaging.

OBJECTIVES: To calculate sinus and bone graft volumes and vertical bone heights from sequential magnetic resonance imaging (MRI) examinations in patients undergoing a sinus lift operation. METHODS: MRI scans were obtained pre-operatively and at 10 days and 10 weeks post-operatively, using a 0.95 tesla MRI scanner and a three-dimensional (3D) magnetisation prepared, rapid acquisition gradient-echo (MP-RAGE) sequence. RESULTS: Estimates of the bone graft volumes required for a desired vertical bone height were made from the pre-operative MRI scan. Measurements of the graft volumes and bone heights actually achieved were made from the post-operative scans. The MRI appearance of the graft changed between the 10 day and 10 week scans. CONCLUSIONS: We have proposed a technique which has the potential to give the surgeon an estimate of the optimum volume of graft for the sinus lift operation from the pre-operative MRI scan alone and demonstrated its application in a single patient. Changes in the sequential MRI appearance of the graft are consistent with replacement of fluid by a matrix of trabecular bone.

Parasitic mites of honey bees: life history, implications, and impact.

The hive of the honey bee is a suitable habitat for diverse mites (Acari), including nonparasitic, omnivorous, and pollen-feeding species, and parasites. The biology and damage of the three main pest species Acarapis woodi, Varroa jacobsoni, and Tropilaelaps clareae is reviewed, along with detection and control methods. The hypothesis that Acarapis woodi is a recently evolved species is rejected. Mite-associated bee pathologies (mostly viral) also cause increasing losses to apiaries. Future studies on bee mites are beset by three main problems: (a) The recent discovery of several new honey bee species and new bee-parasitizing mite species (along with the probability that several species are masquerading under the name Varroa jacobsoni) may bring about new bee-mite associations and increase damage to beekeeping; (b) methods for studying bee pathologies caused by viruses are still largely lacking; (c) few bee- and consumer-friendly methods for controlling bee mites in large apiaries are available.

The accuracy of "one-stop" diagnosis for 1,110 patients presenting to a symptomatic breast clinic.

UNLABELLED: To minimise delay in diagnosis and reduce patient anxiety, triple assessment with immediate reporting has been used in our symptomatic breast clinic since 1991. This article examines the accuracy of the diagnostic modalities used and the efficacy of the "one-stop" diagnostic policy. The data on 1,110 new patients presenting to the symptomatic breast clinic between January and July 1993, were analysed and subsequent three year follow-up and outcome established. Fine needle aspiration cytology (FNAC) gave the highest predictive value (97.3%) with a sensitivity of 93.5% and a specificity of 98.1%. Ultrasonography provided a 97.0% prediction with a sensitivity of 88.9% and a specificity of 97.4%, whereas mammography had a prediction of 96.4% with sensitivity of 93.2% and a specificity of 96.7%. When the mammogram or ultrasound scan were reported as unequivocally benign (M1), there were no missed cancers. The false positive and false negative rates for FNAC were 0% and 1.4%, respectively. Following assessment, a diagnosis was made in 96% of patients. Sixty-two percent of the patients were discharged at the first clinic visit. Four breast malignancies were subsequently diagnosed in the discharged group; two with new microcalcifications due to ductal carcinoma in situ, one with invasive disease in a different quadrant of the breast from that originally investigated, and in one patient the cancer was missed. CONCLUSION: A "one-stop" symptomatic breast clinic provides an accurate and effective means of establishing a correct diagnosis.

DISCERN: an instrument for judging the quality of written consumer health information on treatment choices.

OBJECTIVE: To develop a short instrument, called DISCERN, which will enable patients and information providers to judge the quality of written information about treatment choices. DISCERN will also facilitate the production of new, high quality, evidence-based consumer health information. DESIGN: An expert panel, representing a range of expertise in consumer health information, generated criteria from a random sample of information for three medical conditions with varying degrees of evidence: myocardial infarction, endometriosis, and chronic fatigue syndrome. A graft instrument, based on this analysis, was tested by the panel on a random sample of new material for the same three conditions. The panel re-drafted the instrument to take account of the results of the test. The DISCERN instrument was finally tested by a national sample of 15 information providers and 13 self help group members on a random sample of leaflets from 19 major national self help organisations. Participants also completed an 8 item questionnaire concerning the face and content validity of the instrument. RESULTS: Chance corrected agreement (weighted kappa) for the overall quality rating was kappa = 0.53 (95% CI kappa = 0.48 to kappa = 0.59) among the expert panel, kappa = 0.40 (95% CI kappa = 0.36 to kappa = 0.43) among information providers, and kappa = 0.23 (95% CI kappa = 0.19 to kappa = 0.27) among self help group members. Higher agreement levels were associated with experience of using the instrument and with professional knowledge of consumer health information. Levels of agreement varied across individual items on the instrument, reflecting the need for subjectivity in rating certain criteria. The trends in levels of agreement were similar among all groups. The final instrument consisted of 15 questions plus an overall quality rating. Responses to the questionnaire after the final testing revealed the instrument to have good face and content validity and to be generally applicable. CONCLUSIONS: DISCERN is a reliable and valid instrument for judging the quality of written consumer health information. While some subjectivity is required for rating certain criteria, the findings demonstrate that the instrument can be applied by experienced users and providers of health information to discriminate between publications of high and low quality. The instrument will also be of benefit to patients, though its use will be improved by training.