Survey of the use of intracranial pressure monitoring in children in the United Kingdom

OBJECTIVE

To establish current practice for the monitoring and management of acute intracranial hypertension in children in United Kingdom intensive care units (ICUs).

DESIGN

Postal questionnaire, targetted by prior telephone survey, to all ICUs admitting five or more children per annum with acute neurological illness.

RESULTS

Of the units contacted 70 % responded, approximately one-half of which reported the use of intracranial pressure (ICP) monitoring. Only data from these units are presented. Nearly all of these units consider monitoring following serious head injury, but its use in non-traumatic brain injury is less widespread. The decision to institute ICP monitoring is based mainly upon neuroimaging appearances and Glasgow Coma Scale score. ICP and cerebral perfusion pressure targets differ markedly between centres, with only 46 % and 65 % of units, respectively, setting age-dependent parameters. Mannitol and varying degrees of hyperventilation are employed by all units to lower ICP. The majority also use barbiturates, diuretics, and fluid restriction. Controlled hypothermia is used in 52 % of units. Paediatric units are more likely to employ age-dependent cerebral perfusion pressure targets. Specific therapies employed to lower ICP are similar to those used in adult centres.

CONCLUSION

Faced with a lack of both evidence and consensus, the management of acute intracranial hypertension in childhood varies widely. National or international guidelines for the management of children with raised intracranial pressure are needed. These should incorporate the physiological differences between children of different ages.

Characterisation of N-methyl-D-aspartate receptor-specific [(3)H]Ifenprodil binding to recombinant human NR1a/NR2B receptors compared with native receptors in rodent brain membranes

We have performed [(3)H]ifenprodil binding experiments under NMDA receptor-specific assay conditions to provide the first detailed characterisation of the pharmacology of the ifenprodil site on NMDA NR1/NR2B receptors, using recombinant human NR1a/NR2B receptors stably expressed in L(tk-) cells, in comparison with rat cortex/hippocampus membranes. [(3)H]Ifenprodil bound to a single, saturable site on both human recombinant NR1a/NR2B receptors and native rat receptors with B:(max) values of 1.83 and 2.45 pmol/mg of protein, respectively, and K:(D) values of 33.5 and 24.8 nM:, respectively. The affinity of various ifenprodil site ligands-eliprodil, (R:(*), R:(*))-4-hydroxy-alpha-(4-hydroxyphenyl)-beta-methyl-4-pehnyl-1-pi per idineethanol [(+/-)-CP-101,606], cis-3-[4-(4-fluorophenyl)-4-hydroxy-1-piperidinyl]-3, 4-dihydro-2H:-1-benzopyran-4,7-diol [(+/-)-CP-283,097], and (R:(*), S:(*))-alpha-(4-hydroxyphenyl)-beta-methyl-4-(phenylmethyl)-1-piperid inepropanol [(+/-)-Ro 25-6981] was very similar for inhibition of [(3)H]ifenprodil binding to recombinant human NR1a/NR2B and native rat receptors, whereas allosteric inhibition of [(3)H]ifenprodil binding by polyamine site ligands (spermine, spermidine, and arcaine) showed approximately twofold lower affinity for recombinant receptors compared with native receptors. Glutamate site ligands were less effective at modulating [(3)H]ifenprodil binding to recombinant NR1a/NR2B receptors compared with native rat receptors. The NMDA receptor-specific [(3)H]ifenprodil binding conditions described were also applied to ex vivo experiments to determine the receptor occupancy of ifenprodil site ligands [ifenprodil, (+/-)-CP-101,606, (+/-)-CP-283,097, and (+/-)-Ro 25-6981] given systemically.

Rituximab monoclonal antibody as initial systemic therapy for patients with low-grade non-Hodgkin lymphoma

Rituximab, a chimeric antibody that targets CD20(+) B cells, produces a 48% response rate in patients with refractory low-grade non-Hodgkin lymphoma. In this phase II trial, patients with low-grade non-Hodgkin lymphoma who had previously received no systemic therapy were treated with rituximab, 375 mg/m(2), administered by IV infusion for 4 consecutive weeks. Patients with objective response or stable disease received repeat 4-week courses of rituximab at 6-month intervals. At the time of initial reevaluation at 6 weeks, 21 of 39 patients (54%) had objective response to treatment, and an additional 14 patients (36%) had stable disease or minor response. Response rates were similar in patients with follicular and small lymphocytic (CLL-type) lymphoma (52% versus 57%, respectively). At present, follow-up is short and only 13 patients have undergone a second course of rituximab treatment. However, 4 additional responses were documented either prior to the second course of rituximab (2 patients) or following the second course (2 patients) and 4 patients improved from partial to complete response. The current response rate is 64%, with 6 complete responses (15%). Treatment with rituximab was well tolerated, with only 1 patient experiencing grade 3/4 infusion-related toxicity. Rituximab is well tolerated and highly active in patients with low-grade non-Hodgkin lymphoma previously untreated with systemic therapy. Although further follow-up is required, the demonstration of minimal toxicity and considerable activity of this new biologic agent represents an important beginning of more specific, less toxic treatment for this important group of cancer patients.

Traumatic brain injury in children and adolescents

Traumatic brain injury is an insult to the brain caused by an external force that results in an impairment (transient or permanent) of cognitive, behavioral, emotional, or physical function. Traumatic brain injury encompasses shearing injury, which might be seen in a shaken infant, as well as penetrating injury from a foreign body, such as a bullet. This article addresses the recovery phase and functional sequelae following traumatic brain injury. Research and clinical experience over the past decade have led to a better understanding of the pathophysiology of head injury and, in turn, improved management.

Intercalated degrees, learning styles, and career preferences: prospective longitudinal study of UK medical students

OBJECTIVES

To assess the effects of taking an intercalated degree (BSc) on the study habits and learning styles of medical students and on their interest in a career in medical research.

DESIGN

Longitudinal questionnaire study of medical students at application to medical school and in their final year.

SETTING

All UK medical schools.

PARTICIPANTS

6901 medical school applicants for admission in 1991 were studied in the autumn of 1990. 3333 entered medical school in 1991 or 1992, and 2695 who were due to qualify in 1996 or 1997 were studied 3 months before the end of their clinical course. Response rates were 92% for applicants and 56% for final year students.

MAIN OUTCOME MEASURES

Study habits (surface, deep, and strategic learning style) and interest in different medical careers, including medical research. Identical questions were used at time of application and in final year.

RESULTS

Students who had taken an intercalated degree had higher deep and strategic learning scores than at application to medical school. Those with highest degree classes had higher strategic and deep learning scores and lower surface learning scores. Students taking intercalated degrees showed greater interest in careers in medical research and laboratory medicine and less interest in general practice than their peers. The effects of the course on interest in medical research and learning styles were independent. The effect of the intercalated degree was greatest in schools where relatively few students took intercalated degrees.

CONCLUSIONS

Intercalated degrees result in a greater interest in research careers and higher deep and strategic learning scores. However, the effects are much reduced in schools where most students intercalate a degree. Introduction of intercalated degrees for all medical students without sufficient resources may not therefore achieve its expected effects.

Novel protein targets for organophosphorus compounds

Inhibition of tritiated di-isopropyl phosphorofluoridate labelling by a range of organophopshorus compounds was used to screen for novel OP-reactive targets in rat-brain homogenates. Analysis of target proteins was conducted by SDS/PAGE and detection of tritiated proteins using a thin layer chromatography (TLC) linear analyser. Two major sites of 3H-DFP labelling were found with relative molecular masses of 30 and 85 kDa. Rates of reaction of these labelling sites with a range of OP compounds were compared to that of acetylcholinesterase. The 30 kDa band was found to be more sensitive to paraoxon, dichlorvos and diazoxon than acetylcholinesterase. The 85 kDa band was found to be more sensitive to dichlorvos and diazoxon than acetylcholinesterase. Neither labelling band reacted with chlorfenvinphos or demeton-s-methyl at significant rates.

Do UK Medical School Applicants Prefer Interviewing to Non-Interviewing Schools?

Medical schools select applicants; applicants who hold two or more offers also select medical schools. In this study we examine a large cohort of applicants applying for admission to UK medical schools in October 1991, and show that when presented with a choice, applicants are more likely to select an interviewing school over a non-interviewing school. Preferences for individual schools are examined in detail using the Bradley-Terry method for paired comparisons. The analysis shows that the preference for interviewing schools cannot be explained in terms of a preference for Oxford and Cambridge (which both interview), nor is it due to confounding by more non-interviewing schools being in the north of the UK. Nevertheless, interviewing status does not account for all the preferences expressed by applicants. The preference for interviewing schools is perhaps explained by applicants feeling closer and more involved with schools which they have visited, which have talked to them personally, and which have selected them individually, rather than on the basis of an impersonal application form.

Clinical experience, performance in final examinations, and learning style in medical students: prospective study

OBJECTIVE

To assess whether the clinical experience of undergraduate medical students relates to their performance in final examinations and whether learning styles relate either to final examination performance or to the extent of clinical experience.

DESIGN

Prospective, longitudinal study of two cohorts of medical students assessed by questionnaire at time of application to medical school and by questionnaire and university examination at the end of their final clinical year.

SUBJECTS

Two cohorts of students who had applied to St Mary's Hospital Medical School during 1980 (n = 1478) and 1985 (n = 2399) for admission in 1981 and 1986 respectively. Students in these cohorts who entered any medical school in the United Kingdom were followed up in their final clinical year in 1986-7 and 1991-2.

MAIN OUTCOME MEASURES

Student's clinical experience of a range of acute medical conditions, surgical operations, and practical procedures as assessed by questionnaire in the final year, and final examination results for the students taking their examinations at the University of London.

RESULTS

Success in the final examination was not related to a student's clinical experiences. The amount of knowledge gained from clinical experience was, however, related to strategic and deep learning styles both in the final year and also at the time of application, five or six years earlier. Grades in A level examinations did not relate either to study habits or to clinical experience. Success in the final examination was also related to a strategic or deep learning style in the final year (although not at time of entry to medical school).

CONCLUSIONS

The lack of correlation between examination performance and clinical experience calls into question the validity of final examinations. How much knowledge is gained from clinical experience as a student is able to be predicted from measures of study habits made at the time of application to medical school, some six years earlier, although not from results of A level examinations. Medical schools wishing to select students who will gain the most knowledge from clinical experience cannot use the results of A level examinations alone but could assess a student's learning style.

The incidence of coronary artery calcification on standard thoracic CT scans

Coronary artery calcification indicates the presence of atheromatous disease and can represent an area of severe stenosis. The absence of calcification does not correlate with the absence of coronary artery disease, but an incidental finding of calcification has important prognostic implications. The best method available at present is electron beam computed tomography (EBCT) but these are often dedicated units in specialist centres and currently this modality is not widely available in the UK. This is the first study to establish the age/sex frequency with which incidental coronary artery calcification is detected using standard CT scanning in a large population. The methods used are simple, reproducible and based on standard thoracic protocols. The presence of calcification is easily detected using readily available equipment. The reported incidence of calcification using EBCT, the most sensitive method available, was compared with standard CT detection rates. While standard CT underestimates the presence of calcification, the age/sex trends are very similar. Standard CT probably detects the most dense lesions, missing areas of mild calcification, recent studies having shown that these lesions are most likely to represent areas of stenosis. This study shows that, with very little change in current practice and on readily available equipment, it is possible to obtain important diagnostic information suggesting the presence of severe coronary artery disease.

Final examination performance of medical students from ethnic minorities

It has recently been claimed that UK medical students from ethnic minorities perform less well than White students in final undergraduate examinations and that this results from discrimination in clinical examinations. In this paper the authors examine the performance of students in two prospective studies of 1981 and 1986 entrants to London medical schools taking finals in 1986, 1987, 1991 and 1992. Overall, 18.2% of students in the survey failed one or more examinations at finals. UK ethnic minority students were 2.09 times more likely to fail one or more examinations than were UK White students. Male students were also 1.65 times more likely to fail an examination than female students. More detailed analysis of individual marks confirmed that UK ethnic minority students performed less well than UK White students, although non-UK ethnic minority students performed better than UK White students. The difference between UK White and ethnic minority students could not be explained by differences in educational achievement, study habits or clinical experience. The poorer performance of UK ethnic minority students extended across multiple-choice questions (MCQ), essay, clinical and oral examinations. Ethnic minority students performed particularly poorly on examinations in medicine and surgery as compared with pathology and clinical pharmacology. Although UK-born ethnic minority students perform less well in final examinations than UK White students, this is unlikely to be explained by racial discrimination as the difference is present in MCQ examinations marked by machine and as non-UK ethnic minority students perform better than UK White students. The cause of the difference in performance is therefore not clear and requires further study.

Shingles in one family practice

One hundred twenty-four patients presented with herpes zoster in a small-town, solo practice between 1983 and 1992. This article reviews the clinical features and natural history of herpes zoster, followed by a description of the cases seen in the study practice. This common disease, easily diagnosed and treated by the family physician, usually responds well to treatment with acyclovir.

Medical school applicants from ethnic minority groups: identifying if and when they are disadvantaged

OBJECTIVE

To assess whether people from ethnic minority groups are less likely to be accepted at British medical schools, and to explore the mechanisms of disadvantage.

DESIGN

Prospective study of a national cohort of medical school applicants.

SETTING

All 28 medical schools in the United Kingdom.

SUBJECTS

6901 subjects who had applied through the Universities' Central Council on Admissions in 1990 to study medicine.

MAIN OUTCOME MEASURES

Offers and acceptance at medical school by ethnic group.

RESULTS

Applicants from ethnic minority groups constituted 26.3% of those applying to medical school. They were less likely to be accepted, partly because they were less well qualified and applied later. Nevertheless, taking educational and some other predictors into account, applicants from ethnic minority groups were 1.46 times (95% confidence interval 1.19 to 1.74) less likely to be accepted. Having a European surname predicted acceptance better than ethnic origin itself, implying direct discrimination rather than disadvantage secondary to other possible differences between white and non-white applicants. Applicants from ethnic minority groups fared significantly less well in 12 of the 28 British medical schools. Analysis of the selection process suggests that medical schools make fewer offers to such applicants than to others with equivalent estimated A level grades.

CONCLUSIONS

People from ethnic minority groups applying to medical school are disadvantaged, principally because ethnic origin is assessed from a candidate's surname; the disadvantage has diminished since 1986. For subjects applying before A level the mechanism is that less credit is given to referees' estimates of A level grades. Selection would be fairer if (a) application forms were anonymous; (b) forms did not include estimates of A level grades; and (c) selection took place after A level results are known.

Nursing Documentation: A Program to Promote and Sustain Improvement

Pertinent, timely, and accurate nursing documentation promotes consistency in client care and effective communication among nurses and other health team members. Alternative documentation systems, continuing education efforts, and ongoing quality management activities are necessary to ensure that standards of record keeping are maintained. A pilot project using such methods was conducted on two hospital units to promote adherence to a specific documentation system. Education was integrated with peer auditing and follow-up over a 6-month period. The nursing staff significantly improved the quality of their documentation and sustained this improvement over time. Staff's knowledge about documentation improved significantly. Furthermore, there was a statistically significant decrease in documentation errors. The integration of peer auditing and continuing education enabled nurses to attain and maintain specific documentation standards.

Foot agility and social anxiety in older children (9-15 years)

According to Paul MacLean's phylogenetic model of the brain, the anterior cingulate should be associated with interpersonal emotional bonding. If this assumption is correct, then foot agility (primarily affected by the dorsal medical surface of the cerebrum) should be associated with attenuated bonding and enhanced social anxiety. It would not be associated with finger agility, finger agnosia, or toe agnosia because their integrity involves more distal portions of the cortex. Strong age-dependent and linear increases in agility but not agnosia were shown for the fingers and the feet for normal children (28 girls, 28 boys) between 9 and 15 years of age. As predicted, a correlation of -0.50, not confounded by age or other measures, was noted between foot agility and social anxiety, but was statistically significant for the girls, not for the boys.

Are cerebral aneurysms atherosclerotic?

BACKGROUND AND PURPOSE

The aim of our study was to investigate plasma and genetic risk factors for rupture of cerebral aneurysms.

METHODS

In London, a case-control study was made of 56 consecutive patients admitted to a regional neurosurgical service for treatment of ruptured cerebral aneurysm and of 93 control subjects. A further 40 consecutive patients admitted in Arhus with ruptured cerebral aneurysm also were studied.

RESULTS

The British case-control study showed that smoking was associated with an increased risk of ruptured cerebral aneurysm (odds ratio, 9.1; 95% confidence interval [CI], 3.4 to 23.8; P < .001 for a history of > 10 pack years). After age and sex adjustment, factors associated with ruptured cerebral aneurysm included a cholesterol concentration in the highest tertile (> or = 6.3 mmol/L; odds ratio, 10.2; 95% CI, 3.9 to 26.7; P < .001), an apolipoprotein B concentration in the highest tertile (> or = 0.84 g/L; odds ratio, 6.4; 95% CI, 2.5 to 16.3; P < .001), and concentrations of HDL cholesterol in the lowest tertile (< 1.1 mmol/L; odds ratio, 3.6; 95% CI, 1.4 to 8.2; P < .01). History of hypertension was of less importance (odds ratio, 4.0; 95% CI, 1.41 to 11.7; P < .01). Smoking history (P < .001) and increased concentrations of cholesterol (P < .0001) were the most important independent risk factors associated with ruptured cerebral aneurysm on multivariate analysis. The histories of hypertension and smoking, together with apolipoprotein B levels, in the Danish patients were similar to those in the British patients. In the entire patient group, the frequencies of two polymorphic variations in the type III collagen gene and polymorphisms at the apolipoprotein B, apolipoprotein C-III, and haptoglobin gene loci were not different from control subjects or the normal population; allele frequencies in British and Danish patients were similar.

CONCLUSIONS

An atherosclerotic profile including increased total cholesterol concentration and a long smoking history may contribute to the rupture of cerebral aneurysms. This study provides no support for the hypothesis that inherited abnormalities of type III collagen are a common cause of cerebral aneurysms.

Evaluation of ferric oxalate as an agent for use during surgery to prevent post-operative root hypersensitivity

The aim of this study was to evaluate the effectiveness of a 6% ferric oxalate solution applied during periodontal surgery to prevent post-operative tooth hypersensitivity. Twenty-five adult patients with similar bilateral periodontal defects participated in this study. Data were collected at baseline (1 week prior to surgery) and 1, 2, 4, and 6 weeks following surgery. Sensitivity level was determined using the visual analog scale (VAS) with the following stimuli: 1) mechanical stimulation with a No. 23 dental explorer; 2) water at 50 degrees C; 3) ice; and 4) electric pulp tester (EPT). Teeth were randomly assigned to either test (6% ferric oxalate in 0.9% saline) or control (0.9% saline) groups. Solutions were applied to the exposed root surfaces for 1 minute during surgery. Data were analyzed by repeated measures ANOVA, paired t-test, and Pearson's correlation test. Results from this study demonstrated statistically significant reduction in the responses to thermal stimuli, especially cold, between groups treated with ferric oxalate as compared to those treated with saline. For the cold test the difference increased with time from baseline to 6 weeks. Statistically significant (P < 0.05) differences in sensitivity to heat between groups were also observed, but only at 2 and 4 weeks following surgery. There were no differences at any time period between the test and control groups when tactile or EPT techniques were used. In addition, there was no correlation between sensitivity and other clinical parameters. It was concluded from this study that 6% ferric oxalate was effective in reducing post-surgical cold sensitivity when applied during periodontal surgical procedures.

Preliminary results from the third flight of the Millimeter Anisotropy Experiment (MAX)

Preliminary results from the June 1991 flight of MAX are presented. Simultaneous observations were made in bands centered at 6, 9, and 12 cm-1 with a bolometric receiver operating at 300 mK. The experimental sensitivities are the highest reported at angular scales of 0.3 degrees to 1.0 degrees. Interstellar dust is observed to have an emissivity [symbol, see text] nu 1.4+/-0.3 and to correlate with the Infrared Astronomical Satellite (IRAS) 100- map. After removal of emission from interstellar dust, 1.3 hr of integration on a 6 degrees scan yields an upper limit of temperature difference Delta T/T < 2.6 x 10(-5) at a Gaussian autocorrelation function centered at 0.5 degrees. The experiment and data analysis are described.

The changing clinical experience of British medical students

The UK National Health Service is undergoing fundamental reforms, which might have a detrimental effect on the training of doctors, not least with respect to the amount of clinical experience that medical students get. We compared the practical experience gained by two cohorts of students at medical schools throughout the UK, who had started their training in 1981 or 1986. The assessment was made by questionnaire at the end of their final clinical year. Experience of acute medical conditions, surgical operations, and practical procedures differed significantly between groups of medical schools, and showed a significant decline in the past five years. This decline in the clinical experience of medical students has coincided with the introduction of the health service reforms. We suspect that the university-based clinical education designed for a lifetime of change is in danger of being replaced by a dispersed clinical apprenticeship for current practice.

Why do medical school applicants apply to particular schools?

5427 applicants to British medical schools indicated the importance of each of 22 specific reasons for applying to the five choices they had put on their medical school application. The 24852 applications were aggregated by medical school, and the profile of reasons analysed for each school. Factor analysis showed four clear dimensions, labelled as 'Reputation', 'Personal contact', 'Location' and 'Prospectus'; scores and rank order for each school on each factor are reported. Scrutiny of the pattern of ratings of individual schools suggested that although many of the applicants' perceptions were probably valid, there were some perceptions which appeared inconsistent with other evidence. Cluster analysis showed that in general the London schools clustered together as did the provincial schools of England and Wales, and the Scottish schools; Oxbridge and Belfast were perceived as very separate from the other schools.

Monitoring of cerebral function

The cerebral function of sedated ventilated patients cannot be assessed by neurological examination, yet many of these patients may have changing cerebral function which needs urgent treatment. Many methods of measuring cerebral function are available and are reviewed in this article along with recommendations for practical monitoring within the intensive care unit.

Toe graphaesthesia as a discriminator of brain impairment: the outstanding feet for neuropsychology

Because of the vulnerability of the medial surfaces of the cerebral hemispheres to the consequences of shear forces, we hypothesized that quantitative sensori-motor deficits for the feet would be strong indicators of general brain dysfunction. On the basis of the Halstead-Reitan Impairment Index, 28 adults who had received closed head injuries were assigned to perfectly normal, normal, or (mildly to severely) impaired groups. Foot tap and finger tap as well as agnosia and graphaesthesia for the fingers and toes were measured. Deficits in toe graphaesthesia were the most powerful group discriminator. Potential usefulness of haptic/motor, finger/toe comparisons for recording the progress of degenerative diseases, such as AIDS, is also suggested.

Tobacyk's sex differences in the experiences of ego-alien intrusions

Tobacyk's Revised Paranormal Belief Scale and an inventory that infers temporal lobe signs were administered to 44 men and 54 women who were enrolled in first-year university courses. Women believed more in psi phenomena, witchcraft, and spiritualism than did men, who believed more in extraterrestrial life forms. Although complex partial epileptic-like signs were moderately (0.40) correlated with total beliefs for both sexes, these signs were dominated by experiences of ego-alien intrusions for women only. The results support the concept of greater interhemispheric coherence in women compared to men and emphasize the importance of limbic processes in the formation and maintenance of religious and paranormal beliefs.

Effects of discrimination by sex and race on the early careers of British medical graduates during 1981-7

OBJECTIVE

To examine the possible effects of discrimination by sex and race on the career patterns of doctors up to six years after qualifying.

DESIGN

Postal questionnaire follow up survey.

PARTICIPANTS

1572 Doctors who graduated from five British medical schools in 1981, 1983, and 1985, including 587 women and 131 doctors from ethnic minorities.

MAIN OUTCOME MEASURES

Reported success rates of applications for training posts.

RESULTS

Comparison of the career patterns of women and men yielded no evidence of discrimination against women in competition for posts. In contrast, there were striking differences in career patterns between graduates of native European origin and those of ethnic minority origin. Graduates from ethnic minorities reported lower success rates and more difficulty in obtaining house officer posts, registrar posts, and places in vocational training schemes in general practice. Most of this discrimination seemed to occur at the stage of shortlisting for interview. Graduates from ethnic minorities were more likely than graduates of native European origin to have experienced spells of unemployment while seeking work. They were also more likely to have changed their original choice of career because of difficulty in obtaining suitable training posts or unfavourable career prospects.

CONCLUSIONS

Discrimination against ethnic minorities occurs in the competition for training posts among graduates from British medical schools. There was no evidence of discrimination against women graduates. Shortlisting procedures based on objective scoring systems may help to ensure equality of opportunity in future.