Undergraduate education about cancer.

The quality, quantity and balance of undergraduate cancer teaching in Australian Medical Schools were investigated by a survey, using a self-administered questionnaire, of recent graduates from all Australian medical schools. Stratified random cluster sampling was used and a response rate of 84% (389 respondents) was achieved. The results revealed substantial differences in knowledge, experience in, and rating of teaching between the medical, surgical, radiotherapeutic and palliative components of cancer management. The proportions of graduates who had never attended radiotherapy and palliative care clinics or units (42.3% and 49.9%, respectively) were more than double the proportion who had never attended medical and surgical cancer clinics or units (17.5% and 10.9%, respectively). More than twice as many graduates rated their instruction in the palliative management of cancer as poor or very poor (29.4%) compared with those rating their instruction as poor or very poor in both cancer prevention (8.4%) and treatment for cure (14.6%). The respondents displayed a considerable lack of knowledge about radiotherapy treatment options, and reported a lack of perceived competence in doing cervical smears. Their answers to questions about 5-year survival of selected cancers, about the existence of screening tests validly shown to reduce mortality, and the ages at which breast and cervical cancers are likely to develop all revealed worrying levels of incorrect knowledge. There was some important disturbing variation in levels of knowledge, experience and rating of cancer instruction between states and between universities.

Variability in the interpretation of dimercaptosuccinic acid scintigraphy after urinary tract infection in children.

UNLABELLED: Technetium-99m-dimercaptosuccinic acid (DMSA) scintigraphy is a frequently used diagnostic test in pediatric practice to assess the presence and severity of renal damage. Most commonly it is performed after urinary tract infection. The aim of this study was to investigate the variability in the interpretation of DMSA scans by pediatric nuclear medicine physicians in this clinical setting. METHODS: We selected all 441 scans from children with first-time urinary tract infection who presented between 1993 and 1995 to a pediatric casualty department and who are participants in a prospective cohort study. Two hundred and ninety-four scans were performed at a median time of 7 days after diagnosis, and 147 scans were from children who were free from further infection over a 1-yr follow-up period. Two experienced nuclear medicine physicians independently interpreted the 441 scans according to whether renal damage was present or absent and using the modified 4-level grading system for DMSA abnormality of Goldraich. Apart from being informed that urinary tract infection was the indication for DMSA scintigraphy, no other clinical information was given to the nuclear medicine physicians. The indices of variability used were the percentage of agreement and the kappa statistic. For the grading scale used, both measures were weighted with integers representing the number of categories from perfect agreement. Disagreement was analyzed for children, kidneys and kidney zones. RESULTS: There was agreement in 86% (kappa = 69%) for the normal-abnormal DMSA scan dichotomy, and the weighted agreement was 94% (weighted kappa = 82%) for the grading of abnormality. Disagreement of DMSA scan interpretation of > or =2 grades was present in three cases (0.7%). The same high level of agreement was present for patient, kidney and kidney zone comparisons. Agreement was not influenced by age or timing of scintigraphy after urinary tract infection. CONCLUSION: Two experienced nuclear medicine physicians showed good agreement in the interpretation of DMSA scintigraphy in children after urinary tract infection and using the grading system of Goldraich.

Estimation of test error rates, disease prevalence and relative risk from misclassified data: a review.

We review methods for the analysis of categorical clinical and epidemiological data, in which the observations are subject to misclassification. Under certain conditions, it is possible to estimate error parameters such as sensitivity, specificity, relative risk, or predictive value, even though no definitive classification (gold standard) is available. The parameter estimates are obtained by modelling the data, using maximum likelihood, with or without some constraints. The models recognize that the true classification of an individual is unknown, and so are sometimes referred to as "latent class" models. The latent class approach provides a unified framework for various methods found in a dispersed literature, characterising each by the number of populations or subgroups in the data, and the number of observations made on each individual; the statistical degrees of freedom are implied by the sampling design. Data sets with less than three replicate observations per individual necessarily require constraints for parameter estimation to be possible. Data sets with three or more replicates lead directly to estimates of the misclassification rates, subject to some simple assumptions. Some more complex problems are also discussed, including data where the response variable has more than two levels, sequential and irregular designs and the effects of assumption violations.

Surveillance in developed countries with particular reference to child growth.

Surveillance of biological function rather than of disease events is a possible method of detecting early changes in population health. The reasons for and methods of a pilot surveillance scheme of the growth of schoolchildren in Britain are discussed. The study, started in 1972, supports the feasibility of surveillance using simple growth measurements and information provided by parents on self-administered questionnaires. Other possible applications of this type of surveillance include growth and nutrition at other stages of life as related to nutrition intervention programmes, and respiratory function as related to environmental changes or the introduction of new substances such as 'safer' cigarettes.

Risk factors for maternal mortality in five Kampala hospitals, 1980-1986.

A case-control study assessing risk factors for maternal mortality was carried out in five Kampala hospitals covering a period of seven years (1 January 1980 to 31 December 1986). The major predictors of maternal mortality were the general condition on admission, the mode of delivery and the Apgar score of the newborn. These predictors indicate that women at high risk were those admitted to hospital for delivery in a poor state of health. We believe that the risk of maternal mortality can be reduced through appropriate action by health workers and that there is a need for a more complete view of risk factors for both maternal and perinatal mortality to be obtained through population-based studies rather than only those women who deliver in hospital.

PIP: Researchers matched each 444 maternal death cases from 4 private hospitals and 1 government national referral hospital in Kampala, Uganda with women who survived pregnancy and delivered in the same ward from 1980-1986 to identify risk factors for maternal mortality. The nonabortion maternal mortality rate for Kampala for this time period stood at 2.65/1000 deliveries. The abortion related mortality rate was 3.58/1000 abortions. The multiple conditional regression model revealed that the highest risk factor for maternal mortality was an Apgar score of 0 (odds ratio=304.31). The poor condition of the mother upon admission posed the 2nd highest risk (OR=100.18). The 3rd highest risk included caesarean or laparotomy (OR=21.46). Apgar scores between 1-6 posed the 4th highest risk (OR=19.91). Further, as the distance from where the mother lived to the hospital increased so did the risk of maternal mortality (p=.0001). Moreover, the more often a mother attended an antenatal clinic the less likely she would die (p=.02). In addition, a significant positive association existed between blood loss and maternal mortality (p=.0001). Physician assisted deliveries presented 15 times the risk of maternal mortality than midwife assisted deliveries. The researchers recommended that governmental vehicles (e.g., military and police) transport pregnant women to a hospital in cases of emergency. They also suggested staff meetings to review maternal deaths and to identify preventive steps, oral and media campaigns about pregnancy related dangers, and training of traditional birth attendants in septic delivery methods and identifying risk factors.

Risk of asbestosis in crocidolite and amosite mines in South Africa.

X-rays of all while and mixed-race men employed in crocidolite and amosite mines and mills were read independently by three experienced readers according to the ILO U/C classification. Abnormality was regarded as present if reported by two or more readers. Parenchymal abnormality, defined as the presence of small irregular opacities of profusion 1/0 or greater, was found in 7.3% of the workers. Pleural thickening was found in 4.5% of the workers, costophrenic angle obliteration in 3.2%, and pleural calcification in 1.7%. The prevalences of both pleural and parenchymal abnormality were strongly related to the duration of exposure to asbestos at work. The overall prevalence of abnormality increase from 4.0% in men with exposure for 1 year or less to 47.9% in men with more than 15 years of exposure. After taking into account the effects of age and duration of asbestos exposure, the prevalence of pleural abnormality was not predicted by fiber concentration. However, white men working with amosite tended to develop a higher prevalence of pleural abnormality than did those working with crocidolite. Compared to whites, men of mixed race, who only work with crocidolite, had a high prevalence of pleural abnormality in each exposure duration category. In contrast to pleural abnormality, the prevalence of parenchymal abnormality, after taking into account the effects of age and duration of exposure, was significantly predicted by fiber concentration but not by race or asbestos type. Our results suggest that parenchymal abnormality in workers in South African asbestos mines could be largely prevented by reducing exposure to fibers visible under the light microscope. However, this may not be the case for pleural abnormality.

The influence of availability of free school milk on the height of children in England and Scotland.

The effect is investigated of availability of free school milk on height gain in one year of six- and seven-year-old primary schoolchildren in England and Scotland, using data collected annually from 1972 to 1976. The height gain of children for whom milk was available for the whole year of observation was compared with that of children who had no milk. Out of 16 sex-country-year-specific analyses for children from manual social classes only, 13 showed no significant evidence of greater height gain in children who had milk. Comparison of children from Social Classes IV and V (semi-skilled and unskilled) showed no greater increase in height for those who had milk, nor was there a difference in height gain between manual social class children according to the number of glasses of milk they drank a day at home or at school. We concluded that, given the standard of living at the time of the survey, the drinking of free school milk did not increase the growth rate of six- and seven-year-old children.

The effect of removal of profile requesting on chemical pathology requesting patterns.

We investigated the effect on pathology requesting behaviour in a metropolitan teaching hospital, following the proscription by the Health Insurance Commission of the MBA (multiple biochemical analysis) request. Our laboratory had provided a 20 test profile in response to a request for MBA until February 1991, when the MBA request was no longer accepted. During the period February to June 1991, requesting clinicians had to comply with the new requesting requirements, although they continued to receive the results of the 20 test profile because of limitations imposed by our laboratory instrumentation. After June 1991, with the installation of a new analyzer that allowed discretionary requesting, results were provided only for those tests requested. We studied requesting patterns in the 3 time periods: i.e. (1) before the MBA request was withdrawn, and after the MBA request was withdrawn, (2) firstly while results for the 20 test profile were still provided and (3) secondly when the results were provided only for the tests requested. For each of the 3 periods the average number of requests per day for MBA, group and individual tests was calculated. The effect of removal of the MBA request on the Medicare Benefits payable was estimated. We found compliance by the requesting clinicians with the new requirements and a reduction in the number of tests requested. There was a reduction from 20 to 12 in the average number of tests per request. This was associated with a 2.2% reduction in the Medicare Benefits payable.

Telling people about screening programmes and screening test results: how can we do it better?

To make an informed choice about whether to be screened, people need information that allows them to weigh up the benefits and harms of screening. To understand their screening test results they require even more information. Yet currently, people attending a screening programme or considering a screening test may only be told that the test can detect disease or risk factors for disease, and that early intervention improves outcomes. When given their test results, people are generally only told the test was abnormal ("positive") or normal ("negative"). We believe that information given before and after the screening test can, and should, be improved. This will probably require information that includes both the benefits and harms of screening and is probabilistic. Indeed, we believe the traditional dichotomisation of screening test results into positive and negative is problematic, and could be replaced by standard use of risks or probabilistic data before and after screening. The relevant risk data could be explained in a range of ways, for example, quantitatively, qualitatively, and/or by "anchoring" to everyday experiences. In this paper we explore why dichotomisation of screening test results is problematic and look at the adverse consequences of presenting test results in terms of true and false, positive and negative. We present some ideas on alternative ways of providing information on screening programmes and screening test results. Our aim is to stimulate debate about these issues and to provide some starting points which could be further developed and evaluated in a wide range of screening programmes.

A new, clinically-based algorithm for the diagnosis of HIV in African tuberculosis patients: cross-sectional analysis from Mzuzu, Malawi.

We aimed to create an improved, clinically-based algorithm for the diagnosis of HIV in tuberculosis (TB) patients. Cross-sectional analysis was performed on data from adult TB patients consecutively diagnosed at a Malawian district level hospital. Of 225 patients, 187 with valid HIV results were included in the study. Sixty-seven per cent were HIV seropositive. Urban address, history of skin rash and sexually transmitted diseases (STDs) and, on examination, oral candidiasis and lymphadenopathy, were associated with HIV co-infection. Using these clinical characteristics, a case definition for HIV was constructed. The Mzuzu clinical case definition was highly sensitive (86%). The area under the receiver operating characteristic (ROC) curve was 0.81, significantly larger than existing World Health Organization (WHO) clinical case definitions. The Mzuzu definition is proposed for further evaluation in settings where HIV serological testing is not readily available.

A randomized trial of penicillin and streptomycin in the prevention of post-partum infection in Uganda.

We report findings of a randomized trial of penicillin and streptomycin to prevent post-partum infection conducted on 737 women who delivered consecutively at Kawempe Maternity Centre (KMC) in Kampala from 1st October, 1989 to 31st May, 1990. The objectives were: (i) to identify clinical post-partum infection using at least two of its symptoms and signs (fever, lower abdominal pain, lower abdominal tenderness, vaginal discharge); (ii) to identify the causes of post-partum infection using laboratory methods; and (iii) evaluate the effectiveness of prophylactic fortified procaine penicillin (PPF) and streptomycin on post-partum infection. Clinical infection occurred in 36.4% of the group not given antibiotics, 23.3% in the PPF group and 20.3% in the streptomycin group. Laboratory-confirmed infection occurred in 15.5% of the group not given antibiotics, 9.2% in the PPF group and 8.4% in the streptomycin group. However, severe laboratory-confirmed infection (severe clinical infection plus positive laboratory findings) occurred in 4.9% of the group not given antibiotics, 6.1% in the PPF group and 6.6% in the streptomycin group. In general, the organisms isolated included enterobacteria (35.9%), yeast and protozoa (31.6%), staphylococci (23.9%), streptococci (69%) and Neisseria (1.7%). The advantage of PPF and streptomycin was evident in most subgroups defined by clinical characteristics or laboratory findings. In view of the findings in this study, we believe that prophylactic antibiotics given in labor may have a role to play at reducing the incidence of post-partum infection. However, as the cost of antibiotics in developing countries is significant, the development of resistant organisms due to indiscriminate antibiotic use is also a concern and health resources are best used when targeted at specific populations, we feel that antibiotic prophylaxis should not be used routinely and that a more realistic view can be obtained by studying high-risk groups of women with more severe infection.

Incidence and causes of maternal mortality in five Kampala hospitals, 1980-1986.

This report presents results of a descriptive study to estimate the mortality rate, identify the type and the causes of maternal deaths. The study was conducted in 1987 in Kampala hospitals for a period covering seven years from 1st January 1980 to 31st December, 1986. The non abortion maternal mortality rate (NAMMR) was 2.65 per 1000 deliveries while the abortion related maternal mortality rate (ARMMR) was 3.58 per 1000 abortions. There was a statistically significant increase in NAMMR while the increase in ARMMR was almost significant over the seven year period. Of all maternal deaths, 80 per cent were non abortion while 20 per cent were abortion related. The commonest immediate causes of death, in order of importance, were sepsis, haemorrhage, ruptured uterus, anaesthesia and anaemia. The commonest patient management factors which contributed to death, in order of importance, were lack of blood for transfusion, lack of drugs and intravenous fluids, theatre problems and doctor related factors. We feel that a lot happens to the pregnant mother before she finally reaches a health unit for delivery and that there is a great need to improve on the community's gynaecological and obstetrical services as well as ambulance and emergency services. We also feel that maternal mortality in developing countries could be reduced if the health workers were imaginative in respect to each patient, tried not to operate as though they were working in a developed country, and created relevant solutions for the local problems.(ABSTRACT TRUNCATED AT 250 WORDS)

PIP: Maternal mortality is examined from June 1980 to December 1986 at Mulago, Nsambyo, Old Kampala, Rubaga, and Mengo Hospitals in Kampala, Uganda. Clinical or immediate causes, direct and indirect, were recorded from case summary forms based on ICD9 definitions of obstetric complications. The nonabortion maternal mortality rate (NAMMR) was 2.65/1000 deliveries (580 deaths); the abortion-related maternal mortality rate (ARMMR) was 3.58/1000 abortions. The hospital maternal mortality rate was 2.0/1000 deliveries. 75% of maternal deaths of women of 28 weeks' gestation or more had delivered outside the hospital. NAMMR doubled between 1980-86, a statistically significant increase. ARMMR increases were almost significant. 75% were direct obstetric and 21% were indirect obstetric causes. 38% had clinical anemia, 29% had some sepsis, 18% had substantial bleeding, and 14% had obstructed labor. Other contributing conditions were pneumonia, ruptured uterus, laparotomy, evacuations and curettage, malaria, preeclampsia, sickle cell anemia, pulmonary embolism, malnutrition, tetanus, meningitis, prolonged labor, and hepatitis. At admission, 48% were in poor condition, 30% in good condition, and 22% in fair condition. 27% had sickle cell anemia, high blood pressure, multiple pregnancy, or malaria at admission. 64% were admitted within 24 hours after delivery, 67% 1-7 days after delivery, and 92% 7-42 days after delivery. Those in good condition were all admitted 7 days postdelivery. 41% of deaths were due to lack of drugs, 7% lack of fluids, 20% with theater problems, 14% with doctor-related factors, and 3% with midwife-related factors. Better information is needed on mortality before delivery, mortality in hospitals vs. outside, and mortality from abortion, and ectopic and hydatidiform molar pregnancies. An explanation given for the increase in maternal mortality is the decline in economic conditions. Abortion complications may be due to the concealment practiced. Causes are consistent with trends from the 1950s, 1960s, and 1970s in Uganda and developing countries in general. Availability and accessibility of gynecological and obstetric services needs great improvement. Training traditional birth attendants and obtaining rural ambulance services are also needed. Health workers lack creativity and imagination for developing country conditions; scarce resources are not the only problem.

Predicting intention to use condoms in homosexual men: an application and extension of the theory of reasoned action.

PIP: A questionnaire based upon the Theory of Reasoned Action was developed and tested to identify predictors of intention to use condoms. Behavioral intentions, attitudes and subjective normative beliefs, behavioral norms, and age of HIV-positive status were included on the questionnaire. Internal consistency of the four components was high, with Cronbach's alpha coefficients of 0.76-0.87. Qualitative data were collected over 2 months from 194 homosexual men who participated in Sydney's homosexual community. Participants aged 17-64 years of mean age 29.5 attended individual interviews or small focus groups to discuss their views concerning condom use. 15% reported having tested HIV-positive, 59% tested negative, and 26% reported not knowing their HIV serostatus. According to logistic modeling, the significant predictors of intentions to use a condom were attitudes and behavioral norms, while HIV antibody positive status and age directly influence behavioral intentions to use a condom. About 50% of men over age 25 years intended to use a condom, irrespective of HIV status. Overall, 59% of men aged 25 years and younger intended to use a condom; 22% of HIV-positive men and 63% of HIV-negative men.^ieng

An evidence based approach to individualising treatment.

To which groups of patients can the results of clinical trials be applied? This question is often inappropriately answered by reference to the trial entry criteria. Instead, the benefit and harm (adverse events, discomfort of treatment, etc) of treatment could be assessed separately for individual patients. Patients at greatest risk of a disease will have the greatest net benefit as benefit to patients usually increases with risk while harm remains comparatively fixed. To assess net benefit, the relative risks should come from (a meta-analysis of) randomised trials; the risk in individual patients should come from multivariate risk equations derived from cohort studies. However, before making firm conclusions, the assumptions of fixed adverse effects and constant reduction in relative risk need to be checked.

[Reporting studies of diagnostic accuracy according to a standard method; the Standards for Reporting of Diagnostic Accuracy (STARD)]. / Verslaglegging van diagnostisch evaluatieonderzoek volgens een standaardmethode; de 'standards for reporting of diagnostic accuracy' (STARD).

The objective of the 'Standards for Reporting of Diagnostic Accuracy' (STARD) initiative is to improve the reporting of studies of diagnostic accuracy, so as to allow readers to assess the potential for bias in a study and to evaluate the generalibility of its results. The group searched the literature to identify publications on the appropriate conduct and reporting of diagnostic studies. This was used to draw up a list of potential items. During a consensus meeting, a group of researchers, medical journal editors, and members of professional organisations reduced this list to a usable checklist. Wherever possible, evidence from the literature was used to justify the decisions made. The search for published guidelines about diagnostic research yielded 33 previously published checklists, from which a list of 75 potential items was extracted. At the consensus meeting, participants shortened the list to a 25-item checklist. A generic flow diagram was drawn up to provide guidance on the method for including patients, the order in which tests were to be conducted and the number of patients to undergo the test being evaluated, the reference standard, or both. A scientific publication can only be assessed when the reporting is both correct and complete. Use of the checklist and flow diagram will improve the quality of reports produced, to the advantage of clinicians, researchers, reviewers, journal editors and other interested parties.

Childhood mortality rates, infant feeding and use of health services in rural Transkei.

Childhood mortality rates in rural Transkei were calculated using data obtained from a sample survey of about 5 000 women who were questioned about the outcome of their pregnancies. There was almost a 1 in 5 risk of children dying before the age of 5 years. The greatest risk was in the 1st year; the infant mortality rate was 130/1 000. About 75% of infant deaths occurred in the postneonatal period. We suggest that many postneonatal deaths are probably caused by diarrhoea and could be prevented by community-based oral rehydration programmes. About 75% of the children were breast-fed beyond the age of 1 year; however, 66% of them were also given other milk before they were 4 months old. Over 80% of women attended an antenatal clinic at least once, although only about 33% of the babies were delivered by the health services. Health services had been attended by 85% of children over 3 months old. The survey methods used were found suitable for ascertaining childhood mortality rates in rural areas of southern Africa. They should be applied more extensively to provide information for planning health services.

The management of pulmonary tuberculosis in the border sub-region, 1983.

In order to study the management of pulmonary tuberculosis among black and coloured adults in the Border region of South Africa in 1983, a historical inception cohort representative of tuberculosis hospitals and local authority health services was followed up over 15 months to assess how efficiently the national responsibility is discharged in a region. About 75% of patients were sputum-positive, and 81% were judged to have had active pulmonary tuberculosis. The mean service delay after radiography was about 1 1/2 weeks. About 26% of patients were treated with a rifampicin regimen, 50% were frequent attenders and 41% completed treatment, although about 21% were still being treated after 15 months. There was a deficiency of laboratory information for diagnosis and monitoring of response to treatment. Periodic cohort evaluation and improvement of diagnostic efficiency, of peripheral use of laboratories, and of spending on community service infrastructure are essential for closing the gap between policies and implementation.

Lung function and respiratory symptoms in silicotic and nonsilicotic gold miners.

In a cross-sectional sample of 1,973 white gold miners 45 to 54 years of age, symptoms of chronic bronchitis were equally common in men with radiologically diagnosed silicosis and those without silicosis; however, more silicotic miners complained of missing work during the previous 3 years because of chest illness. Whereas mean forced vital capacity did not differ between the 2 groups, both the 1-sec forced expiratory volume and the mean forced expiratory flow during the middle half of the forced vital capacity were significantly lower in those with silicosis. This difference was almost entirely accounted for by their higher exposure to dust in the mines. Men with silicosis, therefore, have the same or only slightly more airway obstruction than men without silicosis who have had similar total exposure to dust.

Exposure-response relationship for a dichotomized response when the continuous underlying variable is not measured.

Radiological assessment of pneumoconiosis is an example of a dichotomized variable, namely one that is analysed as a binary response but in fact has an underlying continuum, which in this case is not measurable. Estimates of exposure-response relationships vary greatly for different observers of a dichotomized response variable because of random error of measurement and differences in the threshold implicitly chosen by each observer for categorizing cases. We present a method of using the biserial correlation coefficient and normal distribution theory to estimate exposure-response relationships at any required threshold for each observer. Exposure-response relationships can also be corrected for random observational error using the reliability coefficient, calculated as the tetrachoric correlation between repeat observations by readers.