Epidemiology of major trauma and trauma deaths in Los Angeles County

BACKGROUND

Our objective was to study population-based trauma-related injuries and deaths in the county of Los Angeles and to identify trends and progress towards meeting the "Year 2000 National Health Objectives."

STUDY DESIGN

We did a retrospective study for the year 1996. Data were obtained from the Trauma Registry of the Emergency Medical Services of the Department of Health Services, and the Coroner's Department of the County of Los Angeles. Traumatic injuries and deaths per 100,000 of the population were calculated according to mechanism, race, age, and gender.

RESULTS

During 1996, there were 12,136 major trauma admissions in the 13 trauma centers in Los Angeles County. Another 1,929 victims died at the scene or were certified dead at nontrauma centers and were taken to the Coroner's Department (total 14,065 victims). The overall major injury rate was 151.0 per 100,000 population and the death rate was 30.9 per 100,000. The trauma death rate per 100,000 population was 56.4 for African-Americans, 33.5 for Hispanics, 26.3 for Caucasians, and 11.6 for Asians. Homicides were the leading cause of traumatic deaths (45.3%) followed by traffic accidents (31.9% of deaths). Firearms were responsible for 3,899 major injuries or deaths (41.7 per 100,000 population). The overall homicide rate per 100,000 population was 14.0, with a much higher rate for African-Americans (40.4 per 100,000) and Hispanics (18.7 per 100,000) than Caucasians (4.0 per 100,000) or Asians (3.4 per 100,000). African-American males were at very high risk for homicide (73.3 per 100,000), and in the age group 15 to 34 years, this problem reaches epidemic proportions (164.2 per 100,000). Traffic accidents accounted for 69.0 major injuries and 9.6 deaths per 100,000 people. Males were at significantly higher risk of dying in traffic accidents than females. People over 60 years of age were at significantly higher risk of traffic-accident death than younger people, for both passenger and pedestrian groups (p < 0.01). Firearm-related suicides were responsible for 4.6 deaths per 100,000 population. Caucasian males over 65 years were at much higher risk of suicide by penetrating trauma (29.5 per 100,000) than were Hispanics (6.3 per 100,000), Asians (5.4 per 100,000), or African-Americans (no deaths) in the same gender and age group.

CONCLUSIONS

Trauma remains a major health problem in the county of Los Angeles. Despite the significant reduction of intentional trauma in 1996, it still exceeds national figures and is much higher than the targeted "Year 2000 National Health Objectives." Aggressive prevention strategies need to focus on the population groups at excessive risks of injury by assault, traffic accidents, and suicides.

Identification of an immunodominant sequential epitope in glycoprotein G of herpes simplex virus type 2 that is useful for serotype-specific diagnosis

A series of 67 oligopeptides that spanned the open reading frame of herpes simplex virus type 2 (HSV-2) glycoprotein G (gG2) were synthesized and tested for reactivity with 173 serum specimens collected from 117 individuals. The oligopeptides were made as multiple antigenic peptides consisting of four copies of a unique sequence attached to a branched lysine core and separated from the core by four glycine residues. The sera included HSV antibody-negative samples as well as sera from individuals from whom HSV had been isolated. Isolated viruses were typed by indirect fluorescence using a panel of type-specific monoclonal antibodies. One peptide, corresponding to residues 561 to 578 of gG2, did not react with any sera lacking HSV-specific antibodies of with sera from HSV-1-infected individuals, but did react with sera from HSV-2-infected individuals. For sera taken seven or more days after initialclinical lesions, the detection rate of the peptide was 92% (47/51), comparable with the 98% (50/51) of truncated glycoprotein D, a sensitive type-common reagent. We conclude that this peptide, of structure (PEEFEGAGDGEPPEDDDSG4)K3A, is an immunodominant type-specific epitope for human antibodies and should be useful for type-specific serodiagnosis of HSV-2. Surprisingly, the epitope lies within one of the most conserved regions of gG1 and gG2. The test can distinguish an initial HSV-2 infection in the presence of a preexisting HSV-1 infection.

Relative bradycardia in patients with traumatic hypotension

BACKGROUND

Tachycardia is considered a physiologic response to traumatic hypotension. The inability of the heart to respond to shock with tachycardia has been described as paradoxical bradycardia or relative bradycardia. The incidence and clinical significance of this condition in major trauma is not known. The objective of this study was to examine the incidence and prognostic significance of tachycardia and relative bradycardia in patients with traumatic hypotension. Relative bradycardia is defined as a systolic pressure < or = 90 mm Hg and a pulse rate < or = 90 beats per minute.

METHODS

This is a retrospective study conducted at a large Level I academic trauma center during a 4-year period. Seventeen demographic and injury severity factors were analyzed for their possible role in tachycardic or bradycardic response in hypotensive patients. Incidence and mortality were derived for each subpopulation. Bivariate analysis of the association of incidence and mortality with each risk factor was performed. Factors with p values < 0.2 were included in stepwise logistic regression analyses that identified significant risk factors and derived adjusted relative mortality risks between tachycardic and bradycardic hypotensive patients.

RESULTS

Excluding transfers and patients dead on arrival, 10,833 major trauma patients were seen during the study period. Seven hundred fifty patients (6.9%) had systolic blood pressure < or = 90 mm Hg; 533 patients had tachycardia (overall incidence of 4.9%, or 71.1% of hypotensive patients), and 217 patients had bradycardia (overall incidence of 2.0%, or 28.9% of hypotensive patients). The overall crude mortality was 29.2% among tachycardia patients and 21.7% among bradycardia patients (crude relative risk = 1.34; 95% confidence interval = 1.00-1.81; p = 0.047). The adjusted relative mortality risk between the two groups was 1.23 (95% confidence interval = 0.84-1.73; p = 0.284). Multivariate analysis showed that patients with relative bradycardia in the subgroups with Injury Severity Scores > or = 16, chest Abbreviated Injury Scale scores > or = 3, or abdominal Abbreviated Injury Scale scores > or = 3 had significantly better survival than patients with similar injuries presenting with tachycardia.

CONCLUSION

Relative bradycardia in hypotensive trauma patients is a common hemodynamic finding. Mortality among tachycardic patients was more predictable than among bradycardic patients using commonly used demographic and injury indicators. The presence of relative bradycardia in some subgroups of patients with severe injuries seems to be associated with better prognosis than the presence of tachycardia.

High-resolution mapping of crossovers in human sperm defines a minisatellite-associated recombination hotspot

Little is known about the fine-scale distribution of meiotic crossovers in human chromosomes. Methods have therefore been developed for detecting and mapping recombination products directly in human sperm DNA. Analysis of crossovers adjacent to the GC-rich minisatellite MS32, which is known to mutate by conversion and crossover within the repeat array, revealed an intense and highly localized recombination hotspot centered upstream of the locus and extending into the beginning of the minisatellite. Allele-specific cosuppression of crossovers and repeat instability suggests that the hotspot is responsible for driving repeat turnover at MS32 and thus that minisatellites might evolve as by-products of localized meiotic recombination in the human genome.

Selective management of renal gunshot wounds

BACKGROUND

Gunshot wounds to the kidney have been managed traditionally by surgical exploration. Concerns over increased nephrectomy rates and unnecessary explorations have placed this method under scrutiny. Selective renal exploration based on solid clinical and radiographic criteria may be a safer alternative and deserves evaluation.

METHODS

The medical records of 52 consecutive patients with renal gunshot wounds, who were managed between September 1994 and August 1995 by a protocol of selective exploration, were reviewed. Renal injuries were explored only if they involved the hilum or were accompanied by signs of continued bleeding. Main outcome measures were the numbers of kidneys lost, as well as the morbidity and mortality related to the management of the renal injury.

RESULTS

Three patients died from associated injuries shortly after admission. Fifteen patients suffered complications but only two had complications directly associated with the renal injury. Thirty-two patients underwent renal exploration and 17 of them required nephrectomy for major renovascular or parenchymal trauma (grade IV and V). Renal exploration was successfully avoided in the remaining 20 patients. No kidneys were lost unnecessarily as a result of this policy.

CONCLUSION

Mandatory exploration of all gunshot wounds to the kidney is not necessary. Injuries that produce stable peripheral haematomas do not require exploration.

Risk of pulmonary tuberculosis relative to silicosis and exposure to silica dust in South African gold miners

OBJECTIVES

To investigate the following questions. (1) Is silica dust on its own, without the presence of silicosis, associated with an increased risk of pulmonary tuberculosis (PTB) in workers exposed to silica dust? (2) In the absence of silicosis is the excess risk dose related? (3) What is the predominant chronological sequence between the development of PTB and the development of silicosis after the end of exposure to dust?

METHODS

A cohort of 2255 white South African gold miners has been followed up from 1968 to 1971, when they were 45-55 years of age, to 31 December 1995 for the incidence of PTB. During the follow up 1592 (71%) men died. Of these, 1296 (81%) had a necropsy done at the National Centre for Occupational Health (NCOH) to determine the presence of silicosis and PTB. The incidence of PTB in the cohort was studied relative to cumulative exposure to dust and the onset of silicosis. For the miners with necropsy, the incidence for PTB was studied relative to the severity of silicosis found at necropsy.

RESULTS

There were 115 subjects who developed PTB. The total person-years of follow up was 39,319. For the whole cohort, the factors associated with increased risk of PTB were cumulative exposure to dust (mg/m3.y) (the adjusted rate ratio (RR) 1.07; (95% confidence interval (95% CI) 1.04 to 1.10)), silicosis diagnosed radiologically (3.96 (2.59 to 6.06)), and tobacco pack-years (1.02 (1.01 to 1.03)). The RR (95% CI) for PTB increased with increasing quartiles of cumulative exposure to dust 1.0, 1.51 (0.78 to 2.91), 2.35 (1.28 to 4.32), and 3.22 (1.75 to 5.90). In miners who did not have radiologically diagnosed silicosis (n = 1934, PTB = 74), the adjusted RR (95% CI) for PTB and cumulative exposure to dust was 1.10 (1.06 to 1.13), and increased with quartiles of cumulative exposure to dust as 1.00, 1.46 (0.70 to 3.03), 2.67 (1.37 to 5.23), and 4.01 (2.04 to 7.88). For the subjects who had a necropsy (n = 1296, PTB = 70), the adjusted RR (95% CI) for PTB increased with the severity of silicosis found at necropsy; 1.0 for no silicosis, 1.88 (0.97 to 3.64) for negligible, 2.69 (1.35 to 5.37) for slight, and 2.30 (1.16 to 4.58) for moderate or marked silicosis. For subjects who had a necropsy and no silicosis (n = 577, PTB = 18), the adjusted RR (95% CI) increased slightly with quartiles of cumulative dust 1.0, 1.11 (0.31 to 4.00), 1.42 (0.43 to 4.72), and 1.38 (0.33 to 5.62).

CONCLUSION

Exposure to silica dust is a risk factor for the development of PTB in the absence of silicosis, even after exposure to silica dust ends. The risk of PTB increases with the presence of silicosis, and in miners without radiological silicosis, with quartiles of exposure to dust. The severity of silicosis diagnosed at necropsy was associated with increasing risk of PTB and even < 5 nodules--that is, undetectable radiologically--was associated with an increased risk of PTB. The diagnosis of PTB was on average 7.6 years after the end of exposure to dust, at around 60 years of age. The onset of radiological silicosis preceded the diagnosis of PTB in 90.2% of the cases with PTB who had silicosis. The results have implications for medical surveillance of workers exposed to silica dust after the end of exposure.

One hundred five penetrating cardiac injuries: a 2-year prospective evaluation

OBJECTIVES

To analyze the parameters measured in the field, during transport, and upon arrival of the physiologic condition of patients sustaining penetrating cardiac injuries, along with the Cardiovascular Respiratory Score (CVRS) component of the Trauma Score, the mechanism and anatomical site of injury, operative characteristics, and cardiac rhythm as predictors of outcome. We also set out to identify a set of patient characteristics that best predict mortality outcome and to correlate cardiac injury grade as determined by the American Association for the Surgery of Trauma-Organ Injury Scale (AAST-OIS) with mortality.

METHODS

This report was a prospective study at American College of Surgeons Level I urban trauma center. Interventions included thoracotomy, sternotomy, or both, for resuscitation and definitive repair of cardiac injury. The main outcome measures used were those parameters measuring physiologic condition of patients, CVRS, mechanism and anatomical site of injury, mortality, and grade of injury.

RESULTS

A total of 105 patients sustained penetrating cardiac injuries: 68 injuries (65%) were gunshot wounds and 37 injuries (35%) were stab wounds. The mean Injury Severity Score was 36. Of the 105 wounds, 23 wounds (22%) involved multiple-chamber injuries. The overall survival was 35 of 105 patients (33%): survival of gunshot wound victims was 11 of 68 patients (16%); survival of stab wound victims was 24 of 37 patients (65%). Emergency department thoracotomy was performed in 71 of the 105 patients (68%) with 10 survivors (14%). CVRS: 94% mortality (50 of 53) when CVRS = 0, 89% mortality (57 of 64) when CVRS = 0 to 3, and 31% mortality (12 of 39) when CVRS 4 to 11 (p < 0.001). The presence of sinus rhythm when pericardium was opened predicted survival (p < 0.001). Anatomical site of injury (injured chamber) and the presence of tamponade did not predict survival. Stepwise logistic regression analysis identified gunshot wound, exsanguination, and restoration of blood pressure as most predictive variables of mortality. AAST-OIS injury grade and mortality: grade I, 0 of 1 (0%); grade II, 1 of 2 (50%); grade III, 2 of 3 (66%); grade IV, 28 of 50 (56%); grade V, 29 of 38 (76%); grade VI, 10 of 11 (91%). Overall incidence: grades IV-VI, 99 of 105 (94%).

CONCLUSIONS

Parameters measuring physiologic condition, CVRS, and mechanism of injury are significant predictors of outcome in penetrating cardiac injuries. AAST-OIS injury grades I-III are rare in penetrating cardiac trauma. AAST-OIS Injury grades IV-VI are common in penetrating cardiac trauma and accurately predict outcome.

Antioxidant defenses influence HIV-1 replication and associated cytopathic effects

HIV-infected cells often exhibit reduced levels of antioxidant enzymes and thiols. To investigate the role of cellular antioxidant defenses in the progression of an acutely spreading HIV-1 infection, human Sup-T1 T cells were engineered to overexpress the selenium-dependent glutathione peroxidase, GSHPx-1. This enzyme represents a major cellular defense mechanism against toxicity associated with reactive oxygen species (ROS). T cells engineered to produce elevated GSHPx-1 activity displayed accelerated viral replication and associated cytopathic effects compared to control cells. Conversely, the inhibition of the synthesis of glutathione with buthione sulfoximine (BSO) resulted in the attenuation of viral replication in Sup-T1 cells. Similarly, exposure of human peripheral blood lymphocytes (PBLs) to low, nontoxic levels of BSO resulted in an approximately 80% decline in HIV-1 replication as indicated by Western blot analysis of viral proteins.

Microbiological quality of Australian beef carcass meat and frozen bulk packed beef

Two studies were undertaken to determine the microbiological of beef carcass meat and frozen boneless bulk packed beef produced in Australia. Samples were collected from 1,063 beef carcasses and from 929 cartons of frozen boneless bulk packed beef over a period of approximately 12 months. Samples were collected from works processing beef carcasses for the Australian domestic market and from works targeting export markets. On carcasses processed for export markets, where bacterial counts were obtained, the log10 mean of the APC (aerobic plate count) was 3.13 CFU/cm2, the geometric mean of the coliform count was 19 MPN/cm2, and the geometric mean of Escherichia coli was 13 MPN/cm2. A small percentage (0.59%) of export samples were found positive for Listeria monocytogenes, 0.16% were positive of r coagulase-positive for Campylobacter jejuni/coli, 0.22% were positive for Salmonella spp., and 29% were positive for coagulase-positive Staphylococcus spp. Bacterial numbers were lower on carcasses processed for export markets and higher carcasses chilled for more than 24 h. Escherichia coli O157 was recovered from 4 of 893 export carcasses tested (0.45%). Of the export frozen boneless bulk packed beef samples that tested positive, the log10 mean of the APC was 2.5 CFU/g, the geometric mean of the coliform count was 15 MPN/g, and the geometric mean number of e. coli was 15 MPN/g. Three of 787 export frozen samples (0.38%) tested positive for Salmonella spp., E. coli O157 was not isolated from any of the 685 export frozen samples tested for this bacteria. Export samples tested for this bacteria. Export samples on average had lower APCs than domestic samples. Results from both surveys are compared with data from similar studies in other countries.

Developing an AHC-MCO alliance for research and care

Academic health centers (AHCs) and managed care organizations (MCOs) appear to be on a collision course. Is it possible to develop a partnership to enable both parties to achieve their respective goals and objectives? The Kimmel Cancer Center of Thomas Jefferson University and AEtna US Healthcare, one of the nation's largest MCOs, have developed an alliance designed to generate cancer prevention and control research. This arrangement engages the participants in a collaborative effort that is aimed at creating new knowledge that can be used to enhance the provision of health care to a defined population.

Prediction of response to hepatitis B vaccine in health care workers: whose titers of antibody to hepatitis B surface antigen should be determined after a three-dose series, and what are the implications in terms of cost-effectiveness?

We identified the demographics of 385 health care workers (HCWs) to identify those whose chance of developing a protective response to a standard primary hepatitis B immunization series was so high that the need for testing for antibodies to hepatitis B surface antigen (anti-HBs) would be obviated following immunization. In addition, using sensitivity analysis, we analyzed the economic consequences of not determining anti-HBs titers for any individual after primary immunization and of using the Centers for Disease Control and Prevention (CDC)-recommended post-hepatitis B exposure prophylaxis for high-risk HCWs. Nonsmoking women < 50 years old with a weight-height index of < 42 had a 98.2 +/- 0.9% chance of developing a protective anti-HBs titer. Male nonsmokers < 50 years old with a weight-height index of < 29 had a 94.7 +/- 1.8% chance of a protective response. Economic analysis revealed that use of the CDC guidelines for post-hepatitis B exposure prophylaxis in male HCWs whose anti-HBs status is unknown is always more cost-effective than determining anti-HBs titers following primary immunization for those at high risk. In female HCWs, post-hepatitis B exposure prophylaxis is more cost-effective until hepatitis B exposure rats are approximately 50%. It is possible to predict who will have a high probability of developing a protective response to hepatitis B vaccine; for these people, determining postimmunization anti-HBs titers is unnecessary and not cost-effective.

TRISS methodology in trauma: the need for alternatives

BACKGROUND

Trauma and Injury Severity Score (TRISS) methodology has become a standard tool for evaluating the performance of trauma centres and identifying cases for critical review. Recent work has identified several limitations and questioned the validity of the methodology in certain types of trauma.

METHODS

The usefulness and limitations of the TRISS methodology were evaluated in an urban trauma centre. Trauma registry data of 5445 patients with major trauma were analysed with respect to 30 demographic, prehospital, injury severity and hospitalization attributes. The performance of TRISS was measured primarily by the percentage of misclassifications, including false positives and false negatives, comparing the survival status predicted by TRISS with the true status. Sensitivity, specificity, and positive and negative predictive values were also measured for subgroups defined by the 30 attributes. Logistic regression analysis was used to identify significant independent factors related to the performance of TRISS.

RESULTS

The overall misclassification rate was 4.3 per cent. However, in many subgroups of patients with severe trauma the misclassification rate was very high: 34 per cent in patients older than 54 years with Injury Severity Score (ISS) greater than 20; 29 per cent in those with fall injuries and ISS above 20; 29 per cent in patients with injuries involving four or more body areas and ISS greater than 20; 28.6 per cent in patients with injuries needing admission to the intensive care unit (ICU) and ISS greater than 20; 26.4 per cent in patients in severe distress before reaching hospital with ISS greater than 20; and 26.1 per cent in patients whose ISS score was above 20 and who had complications in hospital.

CONCLUSION

The TRISS methodology has major limitations in many subgroups of patients, especially in severe trauma. In its present form TRISS has no useful role in major urban trauma centres. Its use should be seriously reconsidered, if not abandoned.

The effect of dosage cards on compliance with directly observed tuberculosis therapy in hospital

We evaluated the effect of a dosage card signed by both patient and health worker on compliance in a tuberculosis ward. Compliance was assessed by testing a urine specimen from each patient for the presence of isoniazid and rifampicin pre-intervention and at two weeks, six weeks and 16 months post-intervention. Pre-intervention compliance was 62% and increased to 88%, 91% and 93% in the short, medium and long-term, respectively (P = 0.03, P = 0.02, P < 0.01). The assumption that directly observed therapy is successfully practised in hospital is not always correct. Simple inexpensive measures can improve compliance and have an impact on tuberculosis control.

The Clinical Standards Advisory Group (CSAG) Cleft Lip and Palate Study

A national study of care and outcomes in children born with a unilateral cleft lip and palate (UCLP) was performed over a 15-month period. Two cohorts of children ('5-year-olds' and '12-year-olds') were examined. There were 57 active cleft teams in the U.K. with 105 consultant orthodontists involved in the care of these children. Only 36 teams could provide basic data such as patients names. Of the patients, 47-51 per cent had neonatal appliances. The dental arch relationships were measured with the Goslon Index and a Five-Year-Old Index, 37-39 per cent of both age groups were either 'poor' or 'very poor'. Seventy per cent of the 12-year-old patients had a Skeletal III relation and 42 per cent of bone grafts were seriously deficient or failed. Dental treatment for active caries was needed by 40 per cent of 5-year-olds and 20 per cent of 12-year-olds. In addition, the training of recently appointed consultant orthodontists involved in the care of these children was scrutinized. As a whole, the results were disappointing with standards of care not significantly raised in the last decade. Recommendations have been made to the Department of Health and the implications for the orthodontic profession are explored. Overall, it seems that fewer orthodontists will need to be involved in a centralized care model for these children.

Penetrating cardiac injuries: a prospective study of variables predicting outcomes

BACKGROUND

Penetrating cardiac injuries are one of the leading causes of death from urban violence.

STUDY DESIGN

This is a prospective, 1-year study in a Level I Trauma Center with the objective of analyzing: (1) the parameters measuring the physiologic condition of patients sustaining penetrating cardiac injuries in the field during transport and on arrival, (2) the cardiovascular-respiratory score (CVRS) component of the trauma score, (3) the mechanism and anatomic site of injury, (4) the presence or absence of tamponade, and (5) the cardiac rhythm as a predictor of outcomes. We attempted to correlate cardiac injury grade (AAST-OIS) with mortality. Our main intervention was thoracotomy for resuscitation and definitive repair of cardiac injury. Main outcomes measures were all parameters measuring the physiologic condition of patients, CVRS, mechanism and anatomic site of injury, operative findings and maneuvers, mortality, and grade of injury.

RESULTS

The study consisted of 60 patients sustaining penetrating cardiac injuries, 35 gunshot wound (58%) and 25 stab wounds (42%). The injury severity score (ISS) was > 30 in 22 patients; overall survival was 22 of 60 (36.6%); gunshot wound (GSW) survival, 5 of 35 (14%); and stab wound (SW) survival, 17 of 25 (68%). An emergency department thoracotomy was performed in 37 of 60 (61.7%) with 6 of 37 survivors (16%). CVRS: 96% mortality (25 of 26) when CVRS = 0; 67% mortality (6 of 9) when CVRS = 1-3; and 25% mortality (7 of 25) when CVRS > 4 (p < 0.001). Mechanism of injury, and presence of sinus rhythm when pericardium opened predict outcomes (p < 0.001). Anatomic site of injury and tamponade do not predict outcomes (not significant). AAST-OIS injury grade and mortality: grade IV, 31 of 60 (52%); grade V, 20 of 60 (75%), and grade VI, 6 of 60 (100%).

CONCLUSIONS

Parameters measuring physiologic condition, CVRS, and mechanism of injury plus initial rhythm are significant predictors of outcomes in penetrating cardiac injuries. The need for aortic crossclamping and the inability to restore an organized rhythm or blood pressure after thoracotomy were also predictors of outcomes. The presence of pericardial tamponade was not.

Screening for fragile X syndrome

BACKGROUND AND AIM OF REVIEW. In 1991, the gene responsible for fragile X syndrome, a common cause of learning disability, was discovered. As a result, diagnosis of the disorder has improved and its molecular genetics are now understood. This report seems to provide the information needed to decide whether to use DNA testing to screen for the disorder. HOW THE RESEARCH WAS CONDUCTED. A literature search of electronic reference databases of published and 'grey' literature was undertaken together with hand searching of the most recent publications. RESEARCH FINDINGS. NATURAL HISTORY. Physical characteristics of fragile X syndrome include facial atypia, joint laxity and, in boys, macro-orchidism. Most affected males have moderate-to-severe learning disabilities with IQs under 50 whereas most females have borderline IQs of 70-85. Behavioural problems are similar to those seen with autism and attention-deficit disorders. Although fragile X syndrome is not curable there are a number of medical, educational, psychological and social interventions that can improve the symptoms. About 6% of those with learning disabilities tested in institutions have fragile X syndrome. Population prevalence figures are 1 in 4000 in males and 1 in 8000 in females. GENETICS. The disorder is caused by a mutation in a gene on the X chromosome which includes a trinucleotide repeat sequence. The mutation is characterized by hyper-expansion of the repeat sequence leading to down-regulation of the gene. In males an allele with repeat size in excess of 200, termed a full mutation (FM), is always associated with the affected phenotype, whereas in females only half are affected. Individuals with alleles having repeat size in the range 55-199 are unaffected but in females the sequence is heritably unstable so that it is at high risk of expansion to an FM in her offspring. This allele is known as a pre-mutation (PM) to contrast it with the FM found in the affected individual. No spontaneous expansions directly from a normal allele to an FM have been observed. SCREENING STRATEGIES. The principal aims of screenng for fragile X syndrome is to reduce the birth prevalence of the disorder, by prenatal diagnosis and selective termination of pregnancy, or by reducing the number of pregnancies in women who have the FM or PM alleles. Possible screening strategies are: routine antenatal testing of apparently low risk pregnancies, preconceptual testing of young women, and systematic testing in affected families ('cascade' screening). A secondary aim is to bring forward the diagnosis of affected individuals so that they might benefit from early treatment. Active paediatric screening and neonatal screening could achieve this but there is no direct evidence of any great benefit from early diagnosis. SCREENING TESTS. Cytogenetic methods are unsuitable for screening purposes. Southern blotting of genomic DNA can be used but is inaccurate in measuring the size of small PMs, there is a long laboratory turnaround time, and it is relatively expensive. The best protocol is to amplify the DNA using polymerase chain reaction on all samples, and when there is a possible failure to amplify, a Southern blot.(ABSTRACT TRUNCATED)

An evaluation of practice nurses working with general practitioners to treat people with depression

BACKGROUND

The diagnosis and treatment of depression constitutes a significant component of a general practitioner's workload. A pilot study has suggested that the practice nurse may have an important contribution to make in the care of patients with depression.

AIM

To evaluate an extended role for practice nurses in improving the outcome of depression through two specially-designed interviews running in parallel.

METHOD

Two naturalistic, random allocation studies took place concurrently over four months. Study 1 evaluated the effectiveness of standardized psychiatric assessment by a practice nurse and feedback of information to the general practitioner (GP). Study 2 evaluated the above assessment and feedback combined with nurse-assisted follow-up care. Twenty general practices participating in the Medical Research Council General Practice Research Framework took part in the study. Subjects included general practice attenders identified as depressed by their GP. The main outcome measures were a change in Beck Depression Inventory (BDI) scores and in the proportion of patients fulfilling DSM-III criteria for major depression.

RESULTS

A total of 577 patients were recruited; 516 [89% (95% CI = 86-92%)] were rated as depressed on the BDI and 474 [82% (95% CI = 79-85%)] met criteria for DSM-III major depression. Altogether, 524 (91%) patients completed follow-up at four months. All groups of patients showed improvement, but no difference in the rate of improvement was shown for the nurse intervention groups. BDI mean scores fell from 18.54 (95% CI = 17.53-20.06) to 11.53 (95% CI = 10.02-13.04) in Study 1, and from 21.01 (95% = CI 20.26-21.86) to 10.62 (95% CI = 9.73-11.51) in Study 2. The proportion of patients fulfilling criteria for DSM-III major depression in Study 1 fell from 80% (95% CI = 73-87%) to 30% (95% CI = 22-38%), and in Study 2 from 80% (95% CI = 76-84%) to 27% (95% CI = 23-31%). Prescription rates of antidepressant medication were higher than expected, ranging between 63% and 76% in the two studies.

CONCLUSION

There was an increase in the rate of antidepressant prescription, but no additional benefit could be adduced for patients who received a nurse intervention.

Cost-effectiveness of oral cholera vaccine in a stable refugee population at risk for epidemic cholera and in a population with endemic cholera

Recent large epidemics of cholera with high incidence and associated mortality among refugees have raised the question of whether oral cholera vaccines should be considered as an additional preventive measure in high-risk populations. The potential impact of oral cholera vaccines on populations prone to seasonal endemic cholera has also been questioned. This article reviews the potential cost-effectiveness of B-subunit, killed whole-cell (BS-WC) oral cholera vaccine in a stable refugee population and in a population with endemic cholera. In the population at risk for endemic cholera, mass vaccination with BS-WC vaccine is the least cost-effective intervention compared with the provision of safe drinking-water and sanitation or with treatment of the disease. In a refugee population at risk for epidemic disease, the cost-effectiveness of vaccination is similar to that of providing safe drinking-water and sanitation alone, though less cost-effective than treatment alone or treatment combined with the provision of water and sanitation. The implications of these data for public health decision-makers and programme managers are discussed. There is a need for better information on the feasibility and costs of administering oral cholera vaccine in refugee populations and populations with endemic cholera.

The second national hospital costing study: background, results and implications

The costing of hospital outputs, and especially of acute admitted patients categorised by DRG, has been the focus of considerable attention in the last decade. Many individual hospitals now routinely estimate the costs of their main products, several State and Territory health authorities undertake periodic multi-site studies, and there have been a few one-off national studies. This paper summarises the methods and results of the most recent national study, which measured costs at a sample of public and private hospitals around Australia for the 1996-97 financial year. We briefly describe the main results and note some implications.

An intervention study with husband and wife carers of older people with a psychiatric illness

BACKGROUND

Individual packages of care were devised for spouses of older people with psychiatric illness.

METHOD

Randomised controlled trial with blind follow up. Intervention group members were offered multidisciplinary packages while controls received no extra help. Both groups were reassessed 12-14 weeks later. The initial control group then received intervention; both were reassessed at 24-28 weeks.

RESULTS

Although no significant differences emerged in group mean scores for affective illness or social difficulties, carers who were mentally ill at outset improved significantly.

CONCLUSION

Interventions targeted at caregiving spouses with affective disorder are acceptable and efficacious.

LIMITATION

It was impossible to compare treatment with no treatment.