Interim estimates of influenza vaccine effectiveness in 2012/13 from Canada's sentinel surveillance network, January 2013.

The 2012/13 influenza season in Canada has been characterised to date by early and moderately severe activity, dominated (90%) by the A(H3N2) subtype. Vaccine effectiveness (VE) was assessed in January 2013 by Canada's sentinel surveillance network using a test-negative case-control design. Interim adjusted-VE against medically attended laboratory-confirmed influenza A(H3N2) infection was 45% (95% CI: 13-66). Influenza A(H3N2) viruses in Canada are similar to the vaccine, based on haemagglutination inhibition; however, antigenic site mutations are described in the haemagglutinin gene.

Relationship between enteric pathogens and acute gastroenteritis disease severity: a prospective cohort study.

OBJECTIVES: To evaluate the relationship between individual bacterial and viral pathogens and disease severity. METHODS: Children <18 years with three or more episodes of vomiting and/or diarrhoea were enrolled in two Canadian paediatric emergency departments between December 2014 and August 2016. Specimens were analysed employing molecular panels, and outcome data were collected 14 days after enrolment. The primary outcome was severe disease over the entire illness (symptom onset until 14-day follow-up), quantified employing the Modified Vesikari Scale (MVS) score. The score was additionally analysed in two other time periods: index (symptom onset until enrolment) and follow-up (enrolment until 14-day follow-up). RESULTS: Median participant age was 20.7 (IQR: 11.3, 44.2) months; 47.4% (518/1093) and 73.4% (802/1093) of participants had index and total MVS scores ≥11, respectively. The most commonly identified pathogens were rotavirus (289/1093; 26.4%) and norovirus (258/1093; 23.6%). In multivariable analysis, severe disease over the entire illness was associated with rotavirus (OR = 9.60; 95%CI: 5.69, 16.19), Salmonella (OR = 6.61; 95%CI: 1.50, 29.17), adenovirus (OR = 2.53; 95%CI: 1.62, 3.97), and norovirus (OR = 1.43; 95%CI: 1.01, 2.01). Pathogens associated with severe disease at the index visit were: rotavirus only (OR = 6.13; 95%CI: 4.29, 8.75), Salmonella (OR = 4.59; 95%CI: 1.71, 12.29), adenovirus only (OR = 2.06; 95%CI: 1.41, 3.00), rotavirus plus adenovirus (OR = 3.15; 95%CI: 1.35, 7.37), and norovirus (OR = 0.68; 95%CI: 0.49, 0.94). During the follow-up period, rotavirus (OR = 2.21; 95%CI: 1.50, 3.25) and adenovirus (OR = 2.10; 95%CI: 1.39, 3.18) were associated with severe disease. CONCLUSIONS: In children presenting for emergency department care with acute gastroenteritis, pathogens identified were predominantly viruses, and several of which were associated with severe disease. Salmonella was the sole bacterium independently associated with severe disease.

Learning without performance in PKC-deficient Drosophila.

The performance of a task is often assumed to be a prerequisite for the learning of many tasks, including the associative conditioning of courtship in the fruit fly, Drosophila melanogaster. Transgenic flies specifically inhibited for the enzyme protein kinase C dissociate the acquisition of learning and memory from performance of the task. They fail to show immediate suppression of courtship but nonetheless develop normal memory of it.

Primary care of patients with sexually transmitted diseases or genitourinary symptoms in Hong Kong.

OBJECTIVES: To determine the adequacy of care received from general practitioners by patients with sexually transmitted diseases or genitourinary symptoms. DESIGN: Prospective study. SETTING: Hong Kong. PARTICIPANTS: Diagnoses and drug data obtained from logbooks submitted by doctors studying for the Diploma in Family Medicine and candidates for Fellowship examinations between 1999 and 2002. MAIN OUTCOME MEASURES: Diagnosis or symptom of a sexually transmitted disease and prescribed treatment. RESULTS: Sexually transmitted diseases and genitourinary symptoms accounted for 1.1% of the workload of these community doctors in Hong Kong. The majority of patients were young adult males. The overall standard of treatment was inadequate: both multi-pharmacy and inappropriate treatment was common; in up to 30% of cases, doctors ignored local or international guidelines. CONCLUSION: Primary care doctors play an important role in the diagnosis and management of sexually transmitted diseases or genitourinary symptoms in Hong Kong. A high index of suspicion should be maintained and continuing education made available if doctors are to provide an equally high standard of care.

The accuracy of Pap smear utilization self-report: a methodological consideration in cervical screening research.

One method used to determine utilization rates of cervical screening is women's self-report. Few studies have assessed the accuracy of this measure--none has been conducted in Australia--although there are a number of reasons for suspecting its validity. This study examined and quantified the accuracy of self-report of Pap smear use among a randomly selected sample of women from an Australian community. Accuracy of Pap smear utilization self-report within a three-year period was assessed by comparison with pathology records. Results indicated that almost half of the women who have not had Pap smears within three years will be missed by a self-report measure of utilization. Some implications for the measurement and use of self-report data are discussed.

Effectiveness of three community based strategies to promote screening for cervical cancer.

OBJECTIVE: Evaluation of three potential methods for increasing Pap smear use: television media, television media combined with letter based recruitment, and television media combined with general practitioner based (GP based) recruitment. SETTING: A trial of each intervention was carried out in three postal regions in New South Wales, Australia-a rural locality (containing about 1000 women), a country town (about 3000 women), and a major rural centre (about 10,000 women). Three control regions were selected to be demographically similar to the corresponding intervention regions. METHODS: Outcome data on regional Pap smear rates were obtained from government health insurance claims for cervical screening, and from pathology service records. Expected Pap smear rates for the three months after the intervention were predicted from 45 pre-intervention months and were compared with observed rates for this period. RESULTS: Television media alone was associated with a significant increase in attendances for screening in one of the three regions where a trial was carried out: 13.3% in the rural centre. The media/letter based campaign was associated with a significant increase in attendances in two out of three regions: 52.7% in the rural locality, 43.2% in the rural centre. The media/GP based campaign was associated with significant increases in attendances in all three regions: 50.2% in the rural locality, 80.8% in the country town, 15.7% in the rural centre. All three interventions were associated with significant increases in the number of women attending for cervical screening above those observed in the control regions. Furthermore, these increases were not restricted to women at low risk. They were also found for older women (aged 50-69 years) and women who had not had a Pap smear within the past three years.

The measurement of shock waves following heel strike while running.

A non-invasive method for demonstrating the shock wave which propagates through the skeletal system following heel strike is described. This wave was not seen in force plate studies where adequate shock absorption was provided by running shoes. In the present study six subjects ran across a force plate without shoes before and after they were fatigued on a treadmill to demonstrate possible changes in the heel strike transient. Most of the parameters measured were not altered by fatigue, and a relationship between the shock wave and height, but not the weight of the runner was demonstrated. The different mechanisms leading to this phenomenon, and its implication in the areas of osteoarthritic degeneration and running mechanics are discussed.

Alpha-fetoprotein and/or liver ultrasonography for liver cancer screening in patients with chronic hepatitis B.

BACKGROUND: Chronic hepatitis B infection may cause liver cancer (hepatocellular carcinoma (HCC)). Alpha-fetoprotein (AFP) and liver ultrasonography (US) are used to screen these patients for HCC. It is uncertain whether screening is worthwhile. OBJECTIVES: To review randomized trials on screening for HCC with alpha-fetoprotein and/or liver ultrasonography among people with hepatitis B surface antigen (HBsAg) whether asymptomatic or with clinical liver disease. SEARCH STRATEGY: Relevant reports were searched from electronic databases until August 2002 (The Cochrane Hepato-Biliary Group Controlled Trials Register, The Cochrane Controlled Trials Register, MEDLINE, EMBASE, HealthStar, and the Chinese Medical Literature Electronic Databases, MedCyber) supplemented with manual searches on the bibliographies of papers found and communication to people familiar with chronic hepatitis B. SELECTION CRITERIA: Randomized trials on screening for liver cancer were included irrespective of language. Studies were excluded if the hepatitis B status was uncertain, if patients were not adequately followed, if the screening tests were not sensitive, widely-used ones, or if the test was used for diagnosis rather than screening for HCC. DATA COLLECTION AND ANALYSIS: We analyzed independently all the studies considered for inclusion. We wrote to the relevant authors for further information. Data were analyzed with Peto's odds ratio (OR) with 95% confidence interval (CI). MAIN RESULTS: Two trials met the selection criteria. One trial (n = 18,816) compared bi-annual AFP plus US screening with no screening for five years. No data on all-cause mortality were available. The two groups did not differ significantly regarding HCC mortality (OR 0.81; 95% CI 0.54 to 1.22). Number of patients with HCC was significantly increased in the screeened group (OR 1.37; 95% CI 1.00 to 1.88). Most HCCs in the screened group, but none in the control group, were at an early stage. The survival rate of patients with resected HCC in the screened group reached 52.7% after three and five years, but was 0% for those in the control group. The authors' estimated lead-time for HCC was 5.4 months, suggesting that screening prolonged the survival of HCC. Another trial (n = 1069) compared AFP plus US versus AFP screening, but could not decide which approach was superior due to the small sample size (number of detected HCC: OR 0.74; 95% CI 0.26 to 2.12). REVIEWER'S CONCLUSIONS: There are not enough quality trials to support or refute screening of HBsAg-positive patients for HCC. It is possible that screening may be effective, but also that harm caused by screening/treatment may outweigh any gain. More and better-designed large randomized trials are required.

Shotcup petal abrasions in close range .410-caliber shotgun injuries.

Shotcup petal abrasions centered around a shotgun wound of entrance are generally thought to occur at a range of 30 to 90 cm. A suicidal .410-caliber shotgun injury of the right eye is described in which typical petal abrasions were noted around the entrance wound. However, significant soot deposition around the wound suggested that the range of fire was less than 30 cm and perhaps closer to 15 cm. Test-firing of the weapon and ammunition used by the decedent showed some spread of the shotcup petals at a range of 7.5 cm, progressing to maximum spread at 30 to 52.5 cm. Further testing with other .410 ammunition, containing shotcups, confirmed the spread of shotcup petals at ranges less than 30 cm, irrespective of manufacturer, shotshell length, and birdshot size. When a variety of shotguns were tested, it was found that one weapon with a very short barrel and cylinder bore did not exhibit petal spread until a range of 30 cm was reached. The remaining shotguns, with longer barrels and full choke, all demonstrated definite petal spread at a range of 12.5 cm. The long, narrow configuration of .410 shotcup petals may explain their early spread and the production of petal abrasions at ranges of less than 30 cm.

Estate doctors and policy on family medicine.

Estate doctors were dismayed by the Hong Kong Council of Social Service's publication of a survey of patients leaving clinics after consultations. The data, however, show high levels of satisfaction from patients who consulted estate doctors, and most people (and their families) attended one doctor by choice, contrary to widespread perception of 'doctor shopping' in Hong Kong. Aspects of care in Hong Kong could be improved and include short consultation times, limited discussion, and frequent usage of short courses of medication. There is segregation of care: estate doctors see more working-age peolple and their families, while out-patient departments see older and unemployed people. The report concluded that further development of family medicine is needed in Hong Kong---a conclusion that the Estate Doctors Association shares. The survey demonstrates again some underlying problems of primary medical care in Hong Kong---problems which are largely related to the expectation and learned habits among both doctors and patients, and which must change for Hong Kong health care to reach the level expected in a modern, developed society.

Opinion survey of Hong Kong private primary care doctors about cervical screening.

The policy and practice of Hong Kong private primary care doctors regarding cervical screening were investigated by way of two different questionnaires sent to comparable random survey samples. The overall response rate was 60.8% (313/515). Both sexes of eligible doctors believed that cervical smears were effective and important, but only 40.2% (47/117) of male doctors performed the test compared with 65.5% (19/29) of female doctors. Those doctors who do not perform the test themselves usually refer their patients elsewhere. The small proportion of private doctors offering cervical smears may reduce opportunities for women who need them. Over 80% of private doctors recommended annual smears despite local recommendations for 3-yearly tests, while graduates from western countries were more likely to recommend longer intervals. Since the proportion of women in Hong Kong having Papanicolaou tests is still low, effort should focus on providing smears for more women, rather than repeated annual testing of those who already participate.

Preventive services advertised to the public by private hospitals in Hong Kong.

To evaluate the preventive activities offered to the public by private hospitals in Hong Kong, we obtained information from 11 of the 12 private hospitals about their screening programmes and evaluated them against the standards of the Canadian and United States task forces on preventive health care. We found that not all proven preventive activities are being offered, and many unproven or even possibly harmful actions are provided. The services focus on the application of technology rather than on behaviour change and immunisation, which are the most effective preventive strategies. This focus on testing may give the wrong impression to the public and divert effort from these worthwhile actions. A clear guideline focused on Hong Kong epidemiology and health care would be helpful.

A survey of running injuries in 1505 competitive and recreational runners.

A 33 item multiple choice questionnaire was circulated; completed questionnaires from 1505 runners (1130 male and 375 female) were obtained. Questions focused upon training, injuries sustained, and medical care. Biomechanical imbalances such as leg length inequality appear to be a major contributing factor to running injuries. Correction of an underlying biomechanical defect may be important in the treatment of many running injuries. Female runners were found to be more susceptible than males to stress fractures at higher mileages. The cause of this increased incidence may be attributable to lower bone mineral density levels as a result of hormonal factors. Factors such as running surface, age and stretching techniques do not appear to play a significant part in the pathogenesis of running injuries.

Salvage of the severely traumatized lower extremity.

The use of microsurgical techniques has significantly altered the management of lower extremity trauma. Indications for amputation or salvage continue to change, as microsurgical transplants have become more commonplace. Reconstruction of a severely traumatized leg usually involves multiple complicated procedures, each of which can cause its own set of complications. The historically high rate of complications of these procedures and the fact that the resultant limb is never completely normal has led some to the conclusion that severely traumatized limbs should not be salvaged. In order to evaluate our own results in light of these considerations we have reviewed our most recent experience with this difficult problem.

Notification of disease. Worthwhile or not?

Disease notification is part of the community surveillance system for control of infectious diseases, but it has fallen into disuse. Understanding the goals and mechanisms of surveillance allows us to respond most appropriately to the needs of both our patients and the community.

The use of antibiotics in upper respiratory tract infection.

The current literature is surveyed for evidence on which to base policies for prescribing antibiotics in upper respiratory tract infections. Moderation is recommended in the prescribing of antibiotics for sore throat in adults. Antibiotic treatment of otitis media and sinusitis is appropriate only when severe infection is likely. It is concluded that there is a need for further controlled trials in Australian general practice to provide data on streptococcal disease in children, to determine carrier rates and when to treat.