An audit of RCP guidelines on DMSA scanning after urinary tract infection.

AIM: To assess the outcome of imaging investigations carried out in children with urinary tract infection (UTI), to compare the investigations with national guidelines, and to assess the impact on management. METHODS: Retrospective review of inpatients and outpatients, aged 0-12 years, referred to the University Hospital of Wales Healthcare Trust between February 1997 and January 1998 with UTI. All children without bacterial evidence of UTI and children previously investigated for antenatal urological anomalies, major congenital anomalies, or UTI were excluded. RESULTS: A total of 164 children (51 boys, 113 girls) were included. Thirteen of 56 infants (23%) and 82/108 older children (76%) were diagnosed at home over one year. The prevalence of dilatation on ultrasound was 8%, renal scarring on dimercaptosuccinic acid (DMSA) scan was 11%, and vesicoureteric reflux (VUR) was 34% when investigations were carried out following guidelines published by the Royal College of Physicians. In children aged 1-6 years, the prevalence of scarring was 1/54 (2%) in those treated at home and 6/18 (33%) in inpatients. CONCLUSION: The low yield of positive results and lack of evidence of impact on management indicate that DMSA scanning, with all the implications of isotope exposure, intravenous injection, staff time, psychological trauma, and expense, could be omitted in children over 1 year with first simple UTI not sufficiently ill to be admitted to hospital. The low rate of detection of UTI in primary care in infants may represent under diagnosis.

Health promotion projects: skill and attitude learning for medical students.

OBJECTIVES: The aim of this health promotion project is to introduce students to appropriate skills and attitudes--as well as knowledge about health promotion strategies and methods. As part of this process, standardized procedures have been established to ensure that the projects are scientifically and ethically appropriate and adequately supervised. This project-centred course introduces the discipline of health promotion to third-year medical students at Monash University. It is aimed at introducing students to the range of health promotion concepts, providing them with experience of health promotion activities and involving them in consideration of the scientific, political and ethical issues arising from doctors' participation in health promotion. DESIGN: As the major learning and assessment component of the unit, students participate in self-selected project groups of three to five students. Each group develops a topic for a health promotion activity in the community, carries out that project and presents the results as a poster as well as a written report. SETTING: Monash University. SUBJECTS: Third-year medical students. RESULTS: Sixty per cent of each student's mark for the unit is based on the project. The posters produced by the project groups are placed on public display in a major teaching hospital for a week at the end of the unit. Public display of the posters helps each student to appreciate the variety of possible health promotion activities, and to appreciate health promotion as a scientific discipline. It also makes the project findings available to the public. CONCLUSIONS: Student evaluation of the project, and community response to the projects--especially the poster display-- indicate that the project is both a highly effective learning experience and a health-promoting activity in its own right.

Constipation and reversible urinary tract abnormalities.

Urinary tract anomalies were prospectively investigated with ultrasound in 29 children with functional constipation. These children were compared before and after treatment with 451 age matched healthy controls without constipation. The bladder residue and upper renal tract dilatation after micturition were significantly increased in the group with constipation and improved after treatment.

Diffuse nephrocalcinosis and idiopathic renal hypercalciuria.

A 12 year old boy presented with primary nocturnal enuresis. Investigation showed extensive bilateral nephrocalcinosis of no obvious or recognised cause. Persistent severe renal hypercalciuria was confirmed by an intravenous calcium infusion. Idiopathic hypercalciuria is not a common cause of nephrocalcinosis and has not previously been described in a child.

Variable expression of P fimbriae in Escherichia coli urinary tract infection.

Fresh urinary isolates were examined by immunofluorescence with polyclonal rabbit antibodies against type 1 and P fimbriae. This procedure showed P-fimbriate Escherichia coli in 22 of 24 samples from patients with asymptomatic bacteriuria, 24 of 26 samples from patients with cystitis, and 6 of 6 samples from patients with pyelonephritis. Type 1 fimbriae were expressed by less than 40% of isolates in all three groups. There was no relation between the presence of symptoms or the site of infection and fimbrial expression, of P or type 1, by bacteria adherent to freshly isolated uroepithelial cells.

A 6-year follow-up of the type A behaviour pattern in medical students.

A sample of 104 medical students was tested for the Type A behaviour pattern, using the Jenkins Activity Survey (Form N fully weighted and Form C Glass Student scores) at four points over a 6-year period during the medical course. Fully weighted Type A scores showed a significant increase over the first 3 years of the course, followed by a drop--to approximately second-year levels--by the end of the 6-year period. A similar but non-significant pattern was observed for the Glass scores. It was suggested that the decrease in the scores was related to lesser usefulness of the Type A pattern during the clinical years of the medical course. A significant difference was found for the final written examination, with those who scored above the median on the Glass Student Type A scale doing better than low scorers. This result was not replicated for the fully weighted Type A scores. It may be that there is some specific usefulness of Type A responding for performance on written examinations, although no equivalent performance difference was found for the final clinical examination.

Type A, test performance and salivary cortisol.

Forty first year medical students, previously screened for the presence or absence of the Type A behavior pattern, collected saliva samples for four days leading up to the first major examination of their medical school course. It was observed that the day of the examination produced substantially different patterns of salivary cortisol concentrations for Type A and non-A subjects, depending on their level of performance. The Type A subjects who scored above the median on the examination showed higher concentrations of salivary cortisol than Type A subjects who scored below the median. The reverse of this pattern was found for non-A subjects. Visual analog scale ratings of subjective stress showed no behavior pattern effects and a very low correlation with the salivary cortisol concentrations. The results support the view that the occurrence of physiological arousal associated with the Type A behaviour pattern is intermittent and dependent on situational factors such as expectation of success and actual success. This is consistent with conceptualizing the Type A pattern as a strategy for resource allocation which may be elective, rather then the behavioural manifestation of an automatic physical response to stress.

The thrill of victory: blood-pressure variability and the type A behavior pattern.

Winning and losing were predicted to be more significant in determining cardiovascular responses for Type A's than for Type B's. Twenty-four healthy, preclinical medical students (12 Type A and 12 Type B) were randomly assigned to be winners or losers at a competitive reaction-time task. Type A winners were different from all other subjects in maintaining initially high systolic blood-pressure levels. Rather than showing a pattern consistent with unusual stress, the Type A losers appeared to slow down in their reaction time and lose interest in the competition. It is suggested that the continued stimulation that Type A's get from successfully competing for rewards may be more important in cardiovascular terms than the stress of losing--at least for males. It is also suggested that activation of the Type A behavior pattern may be more elective than it is usually considered to be.

Languages spoken by medical students.

A self-reported survey of 878 medical students in Monash University (excluding students sponsored by overseas governments) showed that 21.4% had a fluent command of a language other than English, and 62.2% had a basic usable knowledge of another language. Only 28.5% of the students reported having neither a fluent nor a usable command of another language. These results suggest a rich resource of skills in community languages other than English among people who will be entering the medical workforce. Positive recommendations are made to develop and use this resource effectively.

Countries of origin and languages of Australian medical students.

Monash University medical students were surveyed to determine whether they represented the cultural diversity of their community. A total of 878 students completed self reports which showed they originated from forty countries and spoke forty-one languages. The medical school academic intake procedure had selected students from many ethnic groups reflecting the cultural diversity of the community. All had passed the Higher School Certificate English Examination or equivalent to enter the course. A total of 21% reported fluency in a language other than English, and 62% reported having a usable other language in which they were not fluent. The number of fluent languages spoken was constant over the medical course while the number of languages in which students were not fluent decreased significantly. Findings refuted the stereotype that Australian medical students were all monolingual Anglo-Saxons. Training in use of interpreters, and positive discrimination for medical school entry were considered.

A four-year follow-up of schoolgirls with untreated covert bacteriuria: bacteriological aspects.

In 75 schoolgirls aged 5-11 with untreated covert coliform bacteriuria who were followed up to 4 years, infection cleared in 16 (21%), cleared and recurred in 37 (50%) and persisted in 22 (29%). Clearance of bacteriuria was significantly (P less than .05) more frequent in girls with normal radiological findings than in those with abnormal findings. In 31 (59%) of the 53 girls in whom bacteriuria cleared spontaneously, the urine became sterile within the first year after the discovery of the bacteriuria. Spontaneous clearance of bacteriuria was preceded by an increase of the sensitivity of the urinary pathogens to the cidal effect of human serum. Seven (10%) of the 75 untreated bacteriuric girls had shown progression of kidney damage (progression of scarring in 4 and failure of kidney growth in 3). In all of these 7 girls vesico-ureteric reflux (VUR) was present and bacteriuria was persistent, but in 6 of them from one to three changes in the serotype of Esch. coli or bacterial species were noted during follow-up. These observations suggest that changes in bacterial flora may be a risk factor in the progression of kidney damage in girls with urinary tract infection and VUR.