Trainee's Preparedness for Paediatric Work.

Aim Compare the opinion of paediatric consultants to paediatric Senior House Officers (SHOs) with regards their perceived level of preparedness for starting work in paediatrics. Methods A 5-point Likert scale questionnaire was administered to paediatric consultants and SHOs investigating how well they considered the SHO was performing and how well prepared the SHO perceived themselves for work in clinical paediatrics, respectively. Questions related to procedures, clinical examination, teamwork, history taking and OPD related activity. Results 50 Consultants and 75 SHOs completed the questionnaire. Using a Mann-Whitney U test, both groups answered similarly to questions relating to clinical examination and history taking (p=0.51 and p=0.15). However, there were significant differences in their responses to questions relating to procedures, teamwork and OPD related activity (p<0.05). Conclusion There is a significant disparity between consultant opinion of ability and SHOs perception of preparedness for some of the same skills. More work, focusing on these specific aspects of undergraduate paediatric education needs to be carried out to improve graduate preparedness for this role.

Pedestrian deaths in children--potential for prevention.

The National Paediatric Mortality Database was reviewed for the six year period 1st January 2006 to 31st December 2011 and all pedestrian deaths extracted, after review of available data the deaths were categorized as either traffic or non-traffic related. There were 45 child pedestrian fatalities in the period examined. Traffic related deaths accounted for 26 (58%) vs. 19 (42%) non-traffic related. Analysis of the deaths showed there was a male preponderance 28 (62%), weekend trend 22 (49%) with an evening 16 (35%) and summer peak 20 (44%). The highest proportion of deaths occurred in the 1-4 year age group 24 (53%), with 13 (28%) due to low speed vehicle rollovers, mainly occurring in residential driveways 8 (61%). Child pedestrian fatalities are highly preventable through the modification of risk factors including behavioural, social and environmental. Preventative action needs to be addressed, particularly in relation to non-traffic related deaths i.e, low speed vehicle rollovers.

The assessment of general well-being using spontaneous burrowing behaviour in a short-term model of chemotherapy-induced mucositis in the rat.

Mucositis is a common and serious side-effect experienced by cancer patients during treatment with chemotherapeutic agents. Consequently, programmes of research focus on the elucidation of novel therapeutics for alleviation of mucositis symptoms, and these frequently use animal models. However, although these models are assumed to be painful and distressing to the animal, endpoints are difficult to determine. The aim of this study was to evaluate whether a change in burrowing behaviour could provide an indication of disease onset and potentially be applied as a humane endpoint. Baseline burrowing behaviour was measured in healthy animals on three occasions by determining the weight of gravel displaced from a hollow tube. Mucositis was then induced in the same animals by intraperitoneal injection of 5-fluorouracil (150 mg/kg) and burrowing behaviour recorded over three consecutive days. Standard measures of disease progression, including body weight loss and clinical score, were also made. The presence of mucositis was confirmed at necropsy by findings of decreased duodenal and colon lengths, and reduced liver, spleen and thymus weights in comparison with non-treated control animals. Histological score of the jejunum and ileum was also significantly increased. Mucositis onset coincided with a decrease in mean burrowing behaviour which was progressive, however this result did not achieve statistical significance (P = 0.66).We conclude that burrowing may be a useful indicator of inflammation in the mucositis model, although this requires further characterization. Pre-selection of animals into treatment groups based on their prior burrowing performance should be pursued in further studies.

Pertussis in young infants: clinical presentation, course and prevention.

Pertussis is a highly contagious disease caused by the Gram negative aerobic coccobacillus, Bordetella pertussis. It may present with severe symptoms and complications in infants and can pose a diagnostic challenge. This is a vaccine preventable illness covered by the Irish Childhood Immunisation Schedule. In 2011, a retrospective review was conducted of the records of infants, under six months, with a confirmed diagnosis of pertussis, presenting to Temple Street Children's University Hospital (TSCUH). A summery of notifications of pertussis nationally, from 2001 to 2012, was also examined as part of the study. This found that the rate of reported cases of pertussis has been increasing in Ireland. This national increase corresponds with a rising number of cases identified at TSCUH. Patients commonly presented severely ill with cyanosis and apnoea, on a background of prolonged cough. We found that pertussis was diagnosed rapidly in most cases however in all cases there was a delay to commencement of appropriate macrolide therapy.

Higher specialist training in paediatrics 2005-2010, the graduates' reflections.

This study of paediatric trainees, who were awarded their CSCST from 2005 to 2010, evaluated their training experience and assessed whether the curriculum goals were achieved. From an incomplete database 23 (57.7%) graduates based in Ireland and 3 (19%) based abroad responded. Twenty one (81%) of respondents were currently working in Ireland as consultants, 20 (80%) had a post membership qualification and 23 (92%) had travelled abroad for fellowships. Positive experiences included clinical training (44%), positive role models (44%), quality of the training days (52%).Negative experiences included lack of protected time for research (52%), excessive clinical service (28%), and poor monitoring of trainers (20%). Mean Likert scores for curriculum competencies were clinical care 4.9, clinical knowledge 5, application of evidence 3.7, academic supervisor skills3.3, knowledge of public health 3.2, health economics 2.2, and healthcare systems modification 2.3. The curriculum deficiencies can be addressed through the diploma in Leadership and Quality in Healthcare which has been developed by the Health Service Executive and the College of Physicians but an adequate database of graduates needs to be maintained.

A multi-centre retrospective cohort study comparing the efficacy, safety and cost-effectiveness of hysterectomy and uterine artery embolisation for the treatment of symptomatic uterine fibroids. The HOPEFUL study.

OBJECTIVES: To examine and compare the medium-term results of hysterectomy and uterine artery embolisation (UAE) as a treatment for symptomatic uterine fibroids with regard to safety, efficacy, special issues in the UAE group, cost-effectiveness, and women's own perspectives on the treatments. DESIGN: Data were collected locally from patients' hospital records and also from patients themselves by postal questionnaire. Questionnaire data included free-text comments and this qualitative material was analysed using constant comparison. A two-stage probabilistic decision model was designed to estimate UK NHS costs and health outcomes in terms of quality-adjusted life-years (QALYs). SETTING: Eighteen NHS hospital trusts, 17 in England and one in Scotland. PARTICIPANTS: Eligible women (972 UAE, 762 hysterectomies) who had received treatment specifically for symptomatic fibroids were identified. INTERVENTIONS: The UAE patients were treated by experienced interventional radiologists and all received their index UAE prior to the end of 2002, ensuring a minimum 2-year follow-up. The average length of follow-up was 8.6 years for the hysterectomy cohort and 4.6 years for the UAE cohort. MAIN OUTCOME MEASURES: Primary outcome measures were complication rates to assess the comparative safety of the two interventions. Secondary outcome measures related to treatment efficacy including resolution of symptoms and patient-reported satisfaction with treatment. Further efficacy outcome measures obtained in the UAE group included fibroid/uterine size shrinkage and further treatments required for unresolved fibroid symptoms. Data were also gathered on pregnancies post-UAE. RESULTS: Data were available for 1108 women (649 UAE and 459 hysterectomy). Fewer complications were experienced by women in the UAE cohort compared to the hysterectomy cohort: hysterectomy n = 120 (26.1%), UAE n = 114 (17.6%), adjusted odds ratio 0.48 [95% confidence interval (CI) 0.26 to 0.89]. When only the severe/major complications were considered, this odds ratio was reduced to 0.25 (95% CI 0.13 to 0.48). Expected general side-effects of UAE occurred in 32.7% of the UAE cohort, of which 8.9% also experienced complications. Obesity and medical co-morbidity predisposed women to complications, whereas prophylactic antibiotics appeared to protect against both complications and the expected side-effects of UAE. More women in the hysterectomy cohort reported relief from fibroid symptoms (89% versus 80% UAE, p less than 0.0001) and feeling better (81% versus 74% UAE, p less than 0.0001), but only 70% (compared with 86% UAE, p = 0.007) would recommend their treatment to a friend. In the UAE cohort, 18.3% of the women went on to receive one or more further fibroid treatments including hysterectomy (11.2%). After adjusting for differential time of follow-up, the UAE women had up to a 23% (95% CI 19 to 27%) likelihood of requiring further treatment. The free-text data indicated that many women, in both cohorts, felt that their treatment had been a complete success. In the UAE cohort there were several areas where expectations were apparently high and outcome had not fulfilled their expectations. Disappointment was expressed mainly about continuation or return of symptoms or failure to become pregnant. Many continued to have remaining questions about their treatment. The economic analysis indicated that UAE is less expensive than hysterectomy even after further treatments for unresolved or recurrent symptoms are taken into account, with little difference in QALYs between the two treatments. Younger women are exposed to the risk of recurrent fibroids and subsequent additional procedures over a longer period and consequently UAE may no longer be cost-effective. CONCLUSIONS: The study results suggest that both UAE and hysterectomy are safe. No unexpected problems were detected following UAE after a long follow-up period (average 5 years). Complications are less common for UAE than hysterectomy. The cost-effectiveness analysis favours embolisation even after taking account of complications, expected side-effects associated with the procedure and subsequent re-treatments for women with a preference for uterus preservation. It is important to improve the management of expectations following UAE, particularly regarding fertility. The data suggested that fertility and miscarriage rate are consistent with those of age-matched women with fibroids. UAE is an effective treatment for some women with fibroids and our trial supports the National Institute for Health and Clinical Excellence guidance that it should be made available as one of the options for treatment, with a possible reduction in the need for hysterectomy as the first-line treatment. Further research is needed into which women will be treated most successfully by UAE, the best method of achieving effective embolisation, advice for women who desire future fertility, the role of prophylactic antibiotics in UAE, and the effects of HRT use after UAE on recurrence of fibroid symptoms.

Recommendations for reporting economic evaluations of haemophilia prophylaxis: a nominal groups consensus statement on behalf of the Economics Expert Working Group of The International Prophylaxis Study Group.

BACKGROUND: The need for clearly reported studies evaluating the cost of prophylaxis and its overall outcomes has been recommended from previous literature. OBJECTIVES: To establish minimal ''core standards'' that can be followed when conducting and reporting economic evaluations of hemophilia prophylaxis. METHODS: Ten members of the IPSG Economic Analysis Working Group participated in a consensus process using the Nominal Groups Technique (NGT). The following topics relating to the economic analysis of prophylaxis studies were addressed; Whose perspective should be taken? Which is the best methodological approach? Is micro- or macro-costing the best costing strategy? What information must be presented about costs and outcomes in order to facilitate local and international interpretation? RESULTS: The group suggests studies on the economic impact of prophylaxis should be viewed from a societal perspective and be reported using a Cost Utility Analysis (CUA) (with consideration of also reporting Cost Benefit Analysis [CBA]). All costs that exceed $500 should be used to measure the costs of prophylaxis (macro strategy) including items such as clotting factor costs, hospitalizations, surgical procedures, productivity loss and number of days lost from school or work. Generic and disease specific quality of lífe and utility measures should be used to report the outcomes of the study. CONCLUSIONS: The IPSG has suggested minimal core standards to be applied to the reporting of economic evaluations of hemophilia prophylaxis. Standardized reporting will facilitate the comparison of studies and will allow for more rational policy decisions and treatment choices.

Uterine artery embolisation or hysterectomy for the treatment of symptomatic uterine fibroids: a cost-utility analysis of the HOPEFUL study.

OBJECTIVES: To evaluate the relative cost-effectiveness of uterine artery embolisation (UAE) and hysterectomy in women with symptomatic uterine fibroids from the perspective of the UK NHS. DESIGN: Cost-utility analysis. SETTING: Eighteen UK NHS hospital trusts. POPULATION OR SAMPLE Women who underwent UAE (n= 649; average follow up of 8.6 years) or hysterectomy (n= 459; average follow up of 4.6 years) for the treatments of symptomatic fibroids. METHODS: A probabilistic decision model was carried out based on data from a large comparative cohort and the literature. The two interventions were evaluated over the time horizon from the initial procedure to menopause. Extensive sensitivity analysis was carried out to test model assumptions and parameter uncertainties. MAIN OUTCOME MEASURES: Costs of procedures and complications and quality of life expressed as quality-adjusted life years (QALYs). RESULTS: Overall, UAE was associated with lower mean cost (2536 pounds sterling versus 3282 pounds sterling) and a small reduction in quality of life (8.203 versus 8.241 QALYs) when compared with hysterectomy. However, when the quality of life associated with the conservation of the uterus was incorporated in the model, UAE was shown to be the dominant strategy--lower costs and greater QALYs. CONCLUSIONS: UAE is a less expensive option to the health service compared with hysterectomy, even when the costs of repeat procedures and associated complications are factored in. The quality of life implications in the short term are also predicted to favour UAE; however, this advantage may be eroded over time as women undergo additional procedures to deal with recurrent fibroids. Given the hysterectomy is the current standard treatment for symptomatic fibroids, offering women UAE as an alternative treatment for fibroids is likely to be highly cost-effective for those women who prefer uterus-conserving treatment.

Assessment of cell cycle state may facilitate the histopathological diagnosis of malignant mesothelioma.

AIMS: The differentiation of benign pleural conditions from malignant mesothelioma may be difficult, especially with a small biopsy. We have tested the hypothesis that assessment of the cell cycle status is of value in the histopathological diagnosis of such biopsies, by comparing 33 malignant mesotheliomas with 36 cases of reactive mesothelial hyperplasia and reactive pleural fibrosis. METHODS AND RESULTS: Biopsies were investigated for proliferative status by immunostaining for a novel antibody, MCM2, all of which showed nuclear expression of MCM2 at higher frequency than Ki67 (P < 0.0001). Counts in areas of maximum tumour staining showed significantly higher labelling indices (LIMax) in epithelioid and sarcomatoid mesotheliomas compared with reactive mesothelial hyperplasia and reactive pleural fibrosis (P < 0.0001 for both). Average counts (LIAve) revealed a significant increase in epithelioid mesothelioma compared with reactive mesothelial hyperplasia (P < 0.0001). CONCLUSION: We consider MCM2 to be a useful adjunct in the differential diagnosis of malignant mesothelioma.

A brain dead donor model of porcine orthotopic cardiac transplantation for assessment of cardiac allograft preservation.

BACKGROUND: We aimed to develop a large animal model of orthotopic cardiac transplantation, incorporating donor brain death, to assess new methods of preservation of the donor heart. METHODS: Brain death was achieved in the donor pig by inflation of a 20 cc subdural balloon 1 h prior to harvest. The donor heart was stored for 6 h with conventional hypothermic ischaemic preservation. It was then transplanted orthotopically into the recipient pig using the Lower and Shumway technique. One hour after reperfusion, the transplanted heart was weaned from cardiopulmonary bypass with dobutamine support. Dobutamine support was continued for up to 4 h, if required. After 6 h of physiological and biochemical evaluation, the recipient was euthanased and the heart excised for histological assessment. RESULTS: All pigs experienced the classical haemodynamic changes associated with brain death. This resulted in the release of Troponin I, consistent with myocardial injury. The donor operation was successfully completed in 11 out of 13 pigs. Six out of 11 transplanted hearts were successfully weaned from cardiopulmonary bypass, but required ongoing dobutamine support. CONCLUSIONS: This porcine model of orthotopic cardiac transplantation is a relevant and practical large animal model for the assessment of new methods of preservation of the donor heart.

Inequalities in mortality and illness in Trent NHS Region.

BACKGROUND: The Department of Health is encouraging health authorities to improve health status by tackling health inequalities. We defined ward level spatial health variations in Trent National Health Service Region, England, investigated urban and rural inequalities, and examined the relationship with deprivation, to identify the extent of small area health inequalities and to establish whether a quantifiable difference exists between urban and rural health as affected by deprivation. METHOD: A small area ecological study design was adopted and ward level (n=591) standardized ratios were calculated (population aged <75, n=3,900,000) for specific causes of death and limiting long-term illness. A classification was devised to assess ward health inequalities according to an urban-rural dimension. Deprivation was measured using the Townsend Index and the relationship with mortality and illness was analysed using Pearson product moment correlation. RESULTS: Wide variations in mortality and illness were evident at ward level, being widest for accident mortality (standardized mortality range 0-508). Stroke mortality accounted for the largest proportion of wards with standardized mortality ratios over 125 (36.2 per cent). Relative deprivation correlated strongly with limiting long-term illness (r=0.82) and all-cause mortality (r=0.68) across Trent, and in both urban and rural environments. CONCLUSION: The study set health inequalities within a regional context for Trent as an initiative to coincide with the Government's proposed health strategy for the next few years. Wide health inequalities were evident in Trent and the association between deprivation and health was of a similar magnitude in urban and rural wards. This small area approach allows health authorities access to ward level information in order to inform key debate on tackling health inequalities and distributing resources in relation to need.

The impact of socioeconomic status on health functioning as assessed by the SF-36 questionnaire: the Whitehall II Study.

OBJECTIVES: This study measured the association between socioeconomic status and the eight scale scores of the Medical Outcomes Study short form 36 (SF-36) general health survey in the Whitehall II study of British civil servants. It also assessed, for the physical functioning scale, whether this association was independent of disease. METHODS: A questionnaire containing the SF-36 was administered at the third phase of the study to 5766 men and 2589 women aged 39 through 63 years. Socioeconomic status was measured by means of six levels of employment grades. RESULTS: There were significant improvements with age in general mental health, role-emotional, vitality, and social functioning scale scores. In men, all the scales except vitality showed significant age-adjusted gradients across the employment grades (lower grades, worse health). Among women, a similar relationship was found for the physical functioning, pain, and social functioning scales. For physical functioning, the effect of grade was found in those with and without disease. CONCLUSIONS: Low socioeconomic status was associated with poor health functioning, and the effect sizes were comparable to those for some clinical conditions. For physical functioning, this association may act both via and independently of disease.

The medical costs attributable to meat consumption.

OBJECTIVE: To estimate the medical costs that are attributable to the health effects of meat consumption. METHODS: The prevalence of hypertension, heart disease, cancer, diabetes, gallstones, obesity, and foodborne illness among omnivores and vegetarians are compared in studies that have controlled for other lifestyle factors, and the corresponding attributable medical costs are calculated in 1992 dollars. RESULTS: Direct health care costs attributable to meat consumption are estimated to be +2.8-8.5 billion for hypertension, +9.5 billion for heart disease, +0-16.5 billion for cancer, +14.0-17.1 billion for diabetes, +0.2-2.4 billion for gallbladder disease, +1.9 billion for obesity-related musculoskeletal disorders, and +0.2-5.5 billion for foodborne illness. The total direct medical costs attributable to meat consumption for 1992 are estimated at +28.6-61.4 billion. CONCLUSION: Health care costs attributable to meat consumption are quantifiable and substantial.