Risk assessment in Lyme borreliosis

A 3-year EU-funded project (EUCALB), initially involving 14 countries and more than 30 scientists and physicians, was undertaken with the main objective of identifying practical risk assessment criteria for Lyme borreliosis. A major part of the project was dedicated to the improvement of data quality. European case definitions were formulated and quality assurance schemes were developed for serological diagnosis and the detection of infection in ticks. Studies on the standardisation of immunoblot interpretation criteria are still in progress. Data on the clinical risk from tick bites were obtained and considerable progress was made in elucidating the complex ecology of the disease. A study on habitat assessment throughout Europe concluded that high risk was associated with highly heterogeneous recreational woodland and case data from both high and low incidence countries suggested that most infections were acquired in recreational areas. Considerable work is still required to relate clinical data to the epidemiology and ecology of the disease in order to assess risk in Lyme borreliosis.

Cancer risk in primary biliary cirrhosis: a study in northern England

BACKGROUND

Suggestions that breast cancer may be more common in patients with primary biliary cirrhosis (PBC) have been challenged. It has recently been proposed that total cancer rates may be higher in patients with PBC, as well as liver cancers.

AIMS

To investigate these proposals on a strictly defined case series.

SUBJECTS

A total of 769 prevalent or incident PBC patients with "definite" or "probable" disease detected in a defined area of the north-east of England during 1987-94.

METHODS

Cancer events and deaths were identified by obtaining information from one or more of the following sources: Office for National Statistics (ONS) Central Registers, Regional Cancer Registry, and clinical case records. Standardised cancer incidence (SIR) and mortality ratios (SMR) were calculated using the local region as the standard population.

RESULTS

There were 97 cancer events during 1987-96. SIR from cancer registrations for all cancers was 1.7 (95% confidence interval (CI) 1.3 to 2.2), for liver cancer was 74 (95% CI 32 to 146), and for breast cancer was 1.1 (95% CI 0.4 to 2.4). SMR for all cancers was 1. 8 (95% CI 1.4 to 2.4), for liver cancer was 39 (95% CI 20 to 68), and for breast cancer was 0.4 (95% 0.1 to 1.6). The results were similar after excluding the first year of follow up after PBC diagnosis.

CONCLUSIONS

There was some evidence of a small increase in overall cancer incidence and mortality in PBC patients. With the exception of liver cancer, it is unlikely that there is a high excess incidence for PBC patients from any cancer at a particular site, and specifically breast cancer.

No evidence for association of multiple sclerosis with the complement factors C6 and C7

Four genome screens in multiple sclerosis have been completed and each has identified evidence for linkage in the pericentromeric region of chromosome 5. This region encodes a number of candidate genes including those for the complement components C6, C7 and C9. We have used a multiplexed oligoligation assay (OLA) to test single nucleotide polymorphisms (SNPs) from the C6 and C7 genes for evidence of association with multiple sclerosis in our sibling pair families. There was no statistically significant difference in the allele frequencies of these polymorphisms in the index cases from our families when compared with locally derived controls. No evidence for transmission distortion was seen with any of the polymorphisms, or with the haplotype built from the three SNPs from the C7 gene. Despite offering themselves as potential candidates these complement genes appear not to confer susceptibility to multiple sclerosis.

A screen of candidates from peaks of linkage: evidence for the involvement of myeloperoxidase in multiple sclerosis

We tested 11 microsatellite markers for evidence of transmission distortion in 744 trio families with multiple sclerosis. Ten of the markers lie within or near to candidate genes selected on the basis that they map within the regions of potential linkage identified in our previously reported linkage genome screen, while the eleventh is an anonymous marker which had previously shown modest evidence for transmission distortion in our sibling pair families. Only the marker related to the myeloperoxidase (MPO) gene revealed tentative evidence for linkage disequilibrium and further work on this gene is clearly needed in order to resolve the status of this region in conferring susceptibility to multiple sclerosis.

Quality procedures in non-gynaecological cytology laboratories in England and Wales

All non-gynaecological cytology laboratories in England and Wales (n = 212) were surveyed by telephone. The aim was to investigate what concepts of quality applied in this context and to establish what tools and techniques of quality improvement were used. The overall response was 146 (69%). The respondents mainly comprised NHS Trusts and University Departments. The study showed that there was a diverse approach to quality. All types of quality assurance and customer focus procedure questioned were undertaken but to a varied extent; three laboratories (2%) used a complete range and three (2%) used no procedure at all. Accreditation was associated with staffing adequacy and use of surveys, but not quality assurance (QA) or user focus. Laboratories with a high priority for quality performed more QA and reported a higher staffing adequacy. Critical incident analysis was dependent on workload. Computerization did not affect quality procedures and involvement in the Breast Screening Programme did not result in different quality measures. The time since last update was independent of all factors and external quality assurance (EQA) was not widely available. The study suggested that an integrated approach to quality had not been adopted in English and Welsh cytology laboratories and that there may be a need for a more strategic approach with greater availability of EQA, guidelines on quality tools, closer linkage of accreditation and quality procedures and the production of minimum and ideal standards. The ideal standard could be the complete range of procedures, and the minimum standard could comprise those processes in most frequent use, i.e. critical incident analysis, correlation methods, action on information, analysis of what is done with diagnostic information, a complaints procedure and customer surveys.

The subjective effects of smoking on nasal symptoms

One hundred and forty-four volunteers completed a validated questionnaire, to investigate the association between smoking, non-smoking and passive smoking status, and the degree of a range of 10 common nasal symptoms. Logistic regression showed that smokers were four times and passive smokers six times more likely to report hyposmia compared to non-smokers. No significant differences were found between the three groups for any of the other nine symptoms.

Primary biliary cirrhosis once rare, now common in the United Kingdom?

There is a widespread impression that the number of patients with the autoimmune liver disease primary biliary cirrhosis (PBC) is increasing, although its incidence and prevalence vary widely. Using thorough case-finding methods and rigorous definitions to assess changes in incidence and prevalence with time and to explore the symptomatology and mortality of the disease in a large group of unselected patients, we performed a descriptive epidemiological study of PBC in a well defined population over a fixed period of time using established diagnostic criteria and with clinical follow-up of all cases. In a population of 2.05 million in northern England 770 definite or probable PBC cases were identified. Prevalence rose from 201.9 per 10(6) in the adult population and 541. 4 per 10(6) women over 40 in 1987 to 334.6 per 10(6) adults and 939. 8 per 10(6) women over 40 in 1994. Incidence was 23 per 10(6) in 1987 and 32.2 per 10(6) in 1994. Three hundred patients died in median follow-up of 6.27 years (141 liver deaths); the standardized mortality ratio was 2.85. At presumed diagnosis, 60.9% had no symptoms of liver disease. By June 1994 62% of prevalent patients had liver symptoms. PBC is apparently increasing. It is still unclear whether this is because of a true increase, case finding, or increased disease awareness. The study draws attention to (1) high mortality from liver disease and non-liver-related causes even in patients initially with no liver symptoms and (2) apparently poor diagnostic awareness of the disease.

Telematics in the neonatal ICU and beyond: improving care, communication and information sharing

In October of 1998, the Beth Israel-Deaconess was awarded one of 19 contracts from the National Library of Medicine (NLM) to develop, implement and test a telemedicine application to support the care of Very Low Birth Weight Infants. This project is the only one to focus on the care of newborns. We believe that this project will provide a new national approach to managing the care of high-risk newborns by leveraging evolving communication technology.

Management of ischaemic heart disease in primary care: towards better practice. STaRNet. South Thames Region Network

BACKGROUND

Ischaemic heart disease is the commonest cause of mortality in the United Kingdom. The objective of this study was to assess the management of patients with ischaemic heart disease in primary care, focusing particularly on the management of hypercholesterolaemia.

METHODS

A cross-sectional survey was carried out of the clinical records of patients aged 25-74 years with confirmed ischaemic heart disease in six general practices (total list size 56 600).

RESULTS

Recording of risk factors varied from 97 per cent for blood pressure to 73 per cent for cholesterol measurement. Seventy-two per cent of the patients had adequate blood pressure control, based on their last recorded blood pressure. Sixty-one per cent (267) were known to be taking aspirin daily and 29 per cent (125) had undergone revascularization treatment. Sixty-eight per cent (296) of the patients had pre-treatment cholesterol levels of 5.5 mmol/l or greater and 34 per cent (147) were currently taking lipid lowering drugs. Statins were the most commonly used cholesterol lowering agents and were being taken by 30 per cent (131) of the patients. Patients who had undergone revascularization treatment had levels of recording of risk factors similar to other patients with ischaemic heart disease but were more likely to be taking daily aspirin (71 per cent versus 57 per cent, relative risk 1.24, 95 per cent confidence intervals (CI) 1.07-1.44). The mean pre-treatment cholesterol was 6.49mmol/l and the mean post-treatment cholesterol 5.80 mmol/l (difference 0.69 mmol/l, 95 per cent CI 0.55-0.84 mmol/l).

CONCLUSIONS

Systematic searches of computerized and paper medical records can identify subgroups of patients who will benefit from continuing follow-up in primary care. The results of this study suggest that ischaemic heart disease remains an area where there is scope to improve the management of patients in primary care. Considerable effort will be required from the members of the primary health care team to achieve this objective, particularly in the areas of computerized data collection and in the identification and recall of patients.

Issues in the design and implementation of multicenter studies in pediatric nephrology

Multicenter studies in pediatric nephrology have been acknowledged in recent years to be an important means of studying renal disease in children. This review examines a number of issues that are important in the design and performance of a successful trial, with special emphasis on their significance for prospective clinical trials of antihypertensive medications in children and adolescents. Some issues to be covered include the most frequent difficulties that are encountered with multicenter studies, an historical perspective, specific design problems, the importance of close networking and communication, and the problems that may be anticipated with regards to authorship and financial reimbursement for time and effort. The paper concludes with a brief analysis of how multicenter studies involving hypertension protocols in children and adolescents might be conducted during the next few years.

Seroprevalence and subtype distribution of hepatitis C virus among blood donors and intravenous drug users in northern/northeastern Thailand

The prevalence of antibodies against hepatitis C virus (HCV) and the distribution pattern of HCV subtypes were analyzed among healthy blood donors and intravenous drug users (IVDUs) in northern/northeastern Thailand. The prevalence of anti-HCV antibodies was 3.2% (26/820) among blood donors in Khon Kaen, while it was 90% (71/79) among IVDUs in Chiang Rai. HCV RNA was detected in all anti-HCV-positive sera collected from blood donors and IVDUs tested, as determined by reverse transcription-PCR analysis. Sequence analyses of amplified fragments of the HCV genome revealed that in Khon Kaen and Chiang Rai, Thailand, HCV-3a (50-60%) was the most common HCV subtype, followed by HCV-1a, HCV-1b, and subtypes of clade 6, each at 10-20%.

Teaching public health to medical students in the United Kingdom--are the General Medical Council's recommendations being implemented?

BACKGROUND

Despite frequent calls to improve undergraduate medical public health teaching, little is known about whether curricula have changed. We report a survey of undergraduate public health teaching in UK medical schools in 1996. The survey aimed to assess whether the General Medical Council's 1993 recommendations to strengthen undergraduate medical education in public health have been implemented.

METHODS

We asked heads of academic departments of public health at all 26 UK medical schools to complete a questionnaire and provide supporting documentation for each undergraduate public health course or module. We compared results from the 1996 survey with those from a similar survey in 1992.

RESULTS

Twenty-one out of 26 (81 per cent) medical schools responded. All responding medical schools included public health teaching within their curriculum. The median number of public health courses per medical school was unchanged since 1992. A wide variety of topics were taught. Core public health subjects were taught at most schools, though over a quarter of medical schools did not cover some core topics. Between 1992 and 1996 the proportion of time devoted to teaching by lectures decreased, whereas the following all increased: teaching by small group methods; the proportion of courses using methods of assessment encouraging active learning; and the contribution of public health courses to the final degree assessment.

CONCLUSION

The findings suggest that many of the General Medical Council's recommendations for improving the delivery of undergraduate education are being addressed by public health teaching in UK medical schools. However, addressing the gaps in undergraduate public health teaching revealed in this survey is a continuing challenge for academic public health departments. Medical schools should review the content of their undergraduate public health teaching to ensure that tomorrow's doctors are adequately equipped with public health knowledge and skills.

Chromosome arm 20q gains and other genomic alterations in colorectal cancer metastatic to liver, as analyzed by comparative genomic hybridization and fluorescence in situ hybridization

Comprehensive information about the molecular cytogenetic changes in metastases of colorectal cancer is not yet available. To define such changes in metastases, we measured relative DNA sequence copy numbers by comparative genomic hybridization (CGH). Samples from 27 liver metastases and 6 synchronous primary tumors were analyzed. An average of 9.9 aberrations per tumor was found in the metastases. Gains of chromosome arms 20q (85%), 13q (48%), 7p (44%), and 8q (44%) and losses of chromosome arms 18q (89%), 8p (59%), 1p (56%), and 18p (48%) were detected most frequently. Chromosomes 14 and 15 were lost in 26% and 30% of the metastases, respectively. No consistent differences were observed between primary tumors and synchronous metastases. Fluorescence in situ hybridization (FISH) was used for further characterization of gains of chromosome arm 20q. Touch preparations of 13 tumors that had demonstrated 20q gain with CGH were examined with FISH by use of a set of probes mapping to different parts of 20q. A probe for 20p was used as a reference. FISH showed relative gain of at least one 20q locus in 12 of the tumors. High-level gains were detected in 38% of the tumors, preferentially for probes mapping to band 20q13. Our CGH data indicate that colorectal metastases show chromosomal changes similar to those that have been reported for primary tumors. Chromosomal losses were seen at higher frequency, particularly for chromosomes 14 and 15. By FISH, we identified subregions on chromosome arm 20q that are frequently involved in DNA amplifications in colorectal cancer and that may harbor candidate proto-oncogenes.