Ethnicity as an independent predictive factor for the results of computed tomography pulmonary angiography and ultrasonography of the lower limbs.

BACKGROUND: Asians, Pacific Islanders and Maori have significantly lower rates of venous thromboembolism (VTE) compared to Europeans, but its clinic implication regarding diagnosis and prevention is unclear. AIMS: To investigate if ethnicity affects the yield of computed tomography pulmonary angiography (CTPA) and ultrasonography of the lower limbs. METHODS: Data previously collected for 523 patients from another study were used to analyse the effect of ethnicity on the results of CTPA; 1587 consecutive ultrasonography of lower limbs was retrospectively analysed according to ethnicity. The Wells score was retrospectively calculated to determine the pretest probability of VTE. RESULTS: The positive rates of CTPA were 23.3% for European patients and 9.3% for non-European patients. The rate ratio was 2.50 (confidence interval [CI] 1.27-4.95). European patients were 2.5 times more likely to have a positive scan result than non-Europeans, given same pretest probability. There was a larger difference among patients with low and moderate pretest probability with a rate ratio of 4.27 (CI 1.62-11.3). The positive rates of ultrasound scans (USS) among European patients were 16.6 and 9.0% for non-European patients. Rate ratio was 1.85 (CI 1.27-4.95). The difference was also more significant amongst patients with low and moderate pretest probability. The rate ratio was 2.31 (CI 1.38-3.86) for European patients compared to non-European patients. CONCLUSION: Given the same pretest probability according to the Wells score, European patients had significantly higher positive rates of CTPA and ultrasonography of the lower limbs than non-European patients. Further prospective studies are required to confirm our findings and establish an appropriate pretest assessment tool for non-European patients.

The costs of falls in the community to the North East Ambulance Service.

BACKGROUND: This study set out to quantify the immediate costs to the North East Ambulance Service (NEAS) of attending to fallers. METHODS: Data from the Newcastle, UK area were collated by NEAS to identify those aged over 65 who had fallen and required an assistance only call or were subsequently transported to an Accident and Emergency (A&E) department. The 2001 census data for the total population served by NEAS in Newcastle were obtained. RESULTS: The total population of Newcastle over the age of 65 was 41,338. Over 7 months NEAS attended to 1504 falls in Newcastle (at 115 pounds sterling per call out, this equates to 172,960 pounds sterling). The faller was transported to A&E on 1339 occasions, while 165 falls required assistance only (11% of total) (36 falls requiring NEAS assistance per 1000 Newcastle population aged over 65 in 7 months). The total time on site for ambulance crews attending to fallers was 377.1 h (15.7 days in 7 months or 2.25 days per month). As the cost of emergency ambulance time is 123 pounds sterling/h, the total cost was 46,383.30 pounds sterling. Therefore, in Newcastle, attending to fallers in the community costs NEAS 376,018 pounds sterling per year (145.83 pounds sterling per fall or 9.10 pounds sterlingper person over the age of 65 per year). CONCLUSION: NEAS attend to a significant number of older people who fall in the community. In Newcastle alone the cost of this service equates to over 2 days of emergency ambulance crew time per month. Studies are needed to determine whether responding to falls in the community differently would be cost effective.

Laboratory procedures for the isolation of chlamydia trachomatis from the human genital tract.

The technique of isolating Chlamydia trachomatis from the human gential tract by centrifuging clinical specimens on to cell monolayers with subsequent incubation has been improved and simplified. Gentamicin in the media was found to be superior to streptomycin in reducing bacterial contamination of specimens. The infectivity of chlamydial suspensions of laboratory cultured material was significantly reduced by storage at +4 degrees C for more than 48 hours, and by immediate freezing to -70 degrees C. When compared with immediate processing of the specimens, freezing to -70 degrees C was found to reduce the isolation rate of C.trachomatis from men with non-gonococcal urethritis (NGU) by approximately 20%. McCoy cells pretreated with idoxuridine were compared with irradiated McCoy cells for the isolation of C. trachomatis from clinical specimens. There was no significant difference in sensitivity between the two systems, but the former is considerably simpler. The effect of the centrifugal force used for inoculating specimens on to the cell monolayers on the isolation rate of C. trachomatis was studied in groups of men with NGU. Maximal isolation rates were obtained with forces of about 3000 G, which were not significantly raised by further increasing the force used. It is suggested that the isolation of C. trachomatis from the genital tract is now well within the capacity of any laboratory equipped with simple cell culture facilities.

First evidence of leptospirosis in Vanuatu.

The clinical picture of leptospirosis is often confusing and biological confirmation with reference tests (microagglutination test or isolation of the organism) is not usually possible in tropical countries where the disease remains undiagnosed. We report here the first human cases of leptospirosis in Vanuatu (South Pacific), which occurred during the 1989-1990 epidemic of dengue, and discuss the differential diagnosis of the 2 diseases.

Malaria epidemiology, glucose 6-phosphate dehydrogenase deficiency and human settlement in the Vanuatu Archipelago.

Vanuatu is located at the southeast margin of the malarious band extending from southeast Asia to eastern Melanesia. We analysed the malaria situation on different islands of Vanuatu, using passive case detection and malariometric survey data from 1985 to 1992, i.e. after the DDT residual programme ceased and before the impregnated bed-nets programme started on a larger scale. Malaria was mainly hypo-mesoendemic but with hyperendemic spots in certain years and on some islands. The transmission was generally more intense in the northern islands than in the south. In the late 1980s, annual parasite incidence per one thousand population (API) was around 180. The overall parasite rate was 11.9% with Plasmodium falciparum, P. vivax and P. malariae rate of 5.2, 6.7, and 0.1%, respectively. There was a seasonal fluctuation of P. falciparum incidence, whereas the P. vivax incidence was rather stable. Vivax malaria was confined to children less than 10 years old, while the intense in the northern islands than in the south. In the late 1980s, annual parasite incidence per one thousand population (API) was around 180. The overall parasite rate was 11.9% with Plasmodium falciparum, P. vivax and P. malariae rate of 5.2, 6.7, and 0.1%, respectively. There was a seasonal fluctuation of P. falciparum incidence, whereas the P. vivax incidence prevalence of P. falciparum only changed moderately with age. The mean rate of glucose 6-phosphate dehydrogenase (G6PD) deficiency among male subjects was in 7.4% but with a wide variation of 0-14.3% on different islands. A positive rank-order correlation was found between malaria incidence and G6PD deficiency rate on the different islands. A reasonable hypothesis is that malaria was introduced to the islands with the first human settlement 4000 years ago, with a geographical malaria distribution similar to the present situation. Different malaria endemicities possibly then selected different prevalences of G6PD deficiency over many generations.

A clinical study of the Brånemark dental implant system.

A clinical study using the Brånemark dental implant system was carried out on 13 patients aged 41 to 68 years. Clinical and psychological effects of treatment were assessed at 6-monthly intervals over a period of 3 years by means of a clinical examination, a personality assessment using Cattell's 16 PF Questionnaire and a general subjective questionnaire. Six per cent of implants failed to osseointegrate. Fifty per cent of bridges became loose, but remained stable after retightening. A similar percentage of fractures occurred, mainly teeth separating from acrylic gumwork. There was some soreness of peri-implant mucosa, particularly on cleaning. Despite these problems, there was considerable evidence of improved well-being of patients, who felt more secure following treatment and, as a result, their personal and social relationships improved.

Practising dermatology via telemedicine.

AIM: An interactive telemedicine service has been established between Taumarunui Hospital and the Department of Dermatology at Waikato Hospital. The first one hundred dermatological consultations were reviewed to see if the consultations were satisfactory for medical staff and patients. METHODS: A proprietary video conferencing system communicating via the Integrated Systems Digital Network was used to conduct dermatological consultations. Data were collected regarding waiting time, diagnosis and follow-up arrangements. Each patient was asked to complete a questionnaire after the consultation. RESULTS: Of these consultations, 83 were newly referred patients and the rest were follow-ups. The median waiting time for a new patient was 63 days. A variety of skin lesions (in 40 patients), inflammatory eruptions (31) and infections (13) were diagnosed and managed. Sixteen patients had to be seen at the base hospital for surgical treatment (7), face-to-face diagnosis (3), patch testing (3), a second opinion (2), or for personal reasons (1). The others were followed up locally. Savings in time and cost to patients were noted particularly. CONCLUSION: Only about 20% of consultations with new patients resulted in a further face-to-face appointment. The majority of patients found the telelink acceptable. The data supported the continuation and possible expansion of the dermatology telemedicine service. However, improved image quality is desirable.

Selecting anaesthetists: the use of psychological tests and structured interviews.

To test the predictive validity of a selection system for Senior House Officers (SHOs) and registrars in anaesthetics, 140 doctors short-listed from 635 applications between 1980 and 1987 were assessed by a semi-structured interview assessed and a personality questionnaire (Cattell 16PFQ-form C). The 62 doctors selected were followed up for between 3 and 8 years. Future performance was predicted from the psychological tests and by the interviewers. Academic, clinical, behavioural, and overall performance were used as criteria of outcome. Correlation coefficients between prediction and outcome measures were statistically highly significant (P < 0.01). Using multiple regression, equations could be derived from five of the Cattell personality factors to predict overall performance. Personality measures discriminated significantly between the best and poorest performers. Interview predictions were also statistically significant (P < 0.01). The method provides a blueprint for the effective selection of junior anaesthetists. Wastage in terms of those leaving the specialty was 16%.

Lung cancer in Malawi: experience of bronchoscopy in Zomba General Hospital.

In 1987, 11 cases of primary lung cancer were diagnosed on fibreoptic bronchoscopy and six patients were found to have clinical and radiological signs of lung malignancy. 12 of these patients were from Zomba district. This gives an estimated annual incidence of diagnosed lung cancer for Zomba of nearly 3 in 100,000. This figure is most probably an underestimate. Lung cancer was known to be rare in Malawi until 1980. If the actual incidence of this malignancy in Zomba can be applied to the rest of the country, it may be concluded that primary lung cancer is more common in Malawi than previously thought.

Intrinsic vs extrinsic motivation in learning disabled children.

44 children identified as learning disabled were administered Harter's Scale of Intrinsic Versus Extrinsic Orientation in the Classroom. Scores were correlated with several indices of school behavior, standardized achievement test scores, report-card letter grades, and teachers' behavioral ratings. No consistent pattern of relationship was evidenced between the scale and academic achievement as assessed by standardized tests and report-card letter grades. However, a weak but statistically significant pattern of relationship (rs .24 to .33) was noted between two subscales of the Harter scale and teachers' behavioral ratings. Internality on these subscales tended to be associated with higher teachers' ratings.

Malaria treatment in Vanuatu: new national treatment guidelines.

In Vanuatu malaria is a major killer, especially of young children. As most deaths occur outside the hospital it is very important to have simple, clear guidelines on the management of patients with suspected malaria for the primary health care workers who treat the majority of cases. Despite the encouragement of early treatment, malaria was the major cause of death in children after the neonatal period in 1988. During 1989 and 1990 the treatment of malaria in Vanuatu was reviewed with the aim of trying to reduce the morbidity and mortality from the disease. New guidelines were included in the Vanuatu Health Workers' Manual, issued to all nurses, nurse practitioners and doctors in 1991. The major changes were the introduction of immediate slide microscopy, the use of a combination of chloroquine and sulphadoxine-pyrimethamine for Plasmodium falciparum malaria and for children under 5 years and pregnant women, the discontinuation of single-dose primaquine (previously given as a gametocytocidal agent), and the use of a loading dose of quinine. The constraints of the previous guidelines, the rationale for the changes and the expected improvements resulting from using the new treatments are discussed.