The alternative model

Consumers continue to believe in the power of unconventional medical treatments. They are expected to spend $31 billion on alternative and complementary therapies this year alone. But healthcare providers shouldn't see alternative medicine as an instant cash cow. The experts say it's best to start out small, as part of a seamless healthcare organization with established physician alliances.

Low temperature acoustic properties of amorphous silica and the tunneling model

Internal friction and speed of sound were measured on a-SiO2 above 6 mK using a torsional oscillator at 90 kHz, controlling for thermal decoupling, vibrational heating, background losses, and nonlinear effects. Strain amplitudes epsilon(A) = 10(-8) mark the transition between the linear and nonlinear regimes. In the former, agreement with the tunneling model was observed for both internal friction and speed of sound above 25 mK. The observed deviations in the speed of sound below 25 mK can be described with a cutoff energy of Delta(0, min)/k(B) = 6+/-0.5 mK. In the nonlinear regime, above 10 mK the behavior was typical for nonlinear harmonic oscillators, while below 10 mK different behavior was found.

Cardiovascular stress associated with concentric and eccentric isokinetic exercise in young and older adults

Heart rate (HR), mean arterial blood pressure (MAP), and rate-pressure product (RPP) responses to submaximal isokinetic concentric (CON) and eccentric (ECC) knee extension exercise were compared at the same absolute torque output in 20 young (mean+/-SD=23.2+/-1.7 years) and 20 older (mean+/-SD=75.2+/-4.6 years) adults. After determination of peak CON and ECC torques, subjects performed separate, randomly ordered, 2-minute bouts of isokinetic CON and ECC exercise (90 degrees/s, exercise intensity: 50% of CON peak torque). CON exercise elicited greater changes in HR, MAP, and RPP than ECC exercise (p<.001) for both age groups. There were no age-related differences in HR, MAP, or RPP responses for either CON or ECC exercise. At the same absolute torque output, isokinetic CON knee extension exercise elicited significantly greater increases in cardiovascular stress than ECC exercise in both young and older adults. This result has implications for determining appropriate fitness and rehabilitation programs.

A cost effectiveness analysis of goserelin compared with danazol as endometrial thinning agents

OBJECTIVE

To analyse the cost, effectiveness and cost effectiveness of two endometrial thinning agents prior to laser ablation for dysfunctional uterine bleeding: danazol and goserelin.

SETTING

A district general hospital.

DESIGN

A retrospective cost effectiveness analysis, from the perspective of the health service, based on data from an open, randomised, parallel group comparative study of 160 pre-menopausal women with dysfunctional uterine bleeding.

METHODS

Within the trial, length of operation and duration of hospital stay was recorded for each woman. Resource use due to complications of surgery and adverse drug events was evaluated by one of the authors (R.G.). Additional surgery after completion of the study was collected using a postal questionnaire which was distributed to every woman who had undergone surgery. Resource use was costed using detailed unit costs from a specific NHS trust and from published sources. A cost effectiveness analysis was undertaken relating differential cost to differential rates of amenorrhoea at women's last point of follow up.

RESULTS

Information on amenorrhoea was available from 138 women, of whom 111 had completed the questionnaire to indicate longer term follow up. Women who did not complete the clinical trial were not included in this economic evaluation. On average, women randomised to goserelin spent less time in theatre and on the ward. Based on longer term follow up, rates of retreatment were similar in the two groups. The mean (SD) health service cost of women in the goserelin group was pound sterling 323.84 (pound sterling 309.94), compared with pound sterling 243.45 (pound sterling 265.23) in the danazol group; median (range) costs were pound sterling 220.29 (pound sterling 191-pound sterling 2127) and pound sterling 159.76 (pound sterling 140-pound sterling 1426) in the two groups, respectively. These costs were significantly higher for goserelin (P = 0.0001). The goserelin group also had a higher rate of amenorrhoea (38.8% vs 28.6%, P = 0.23). Based on mean differences in cost, the incremental cost of goserelin per additional woman with amenorrhoea was pound sterling 788; based on median differences in cost the ratio was pound sterling 590.

CONCLUSIONS

The shorter duration in theatre and stay in hospital provided a modest offset of the higher acquisition cost of goserelin, but the overall cost of management remained significantly higher than managing women with danazol. The rates of amenorrhoea indicated that goserelin was more effective at 24 weeks and approximately two years after surgery, although statistical significance was only achieved at 24 weeks. The economic impact of women withdrawn from treatment was not considered, but sensitivity analysis indicates that these women may have had a large effect on the overall result of this study. Purchasers will need to decide whether the additional cost of management with goserelin is justified by the increased rates of amenorrhoea and the reduced withdrawals from treatment.

Organized doctors. Unionization of physicians a small but significant force as relationships with hospitals change

The number of unionized physicians is still small, but those doctors are becoming a force to be reckoned with as organizing continues to grow and the fledgling union formed by the American Medical Association becomes more established. "The state of the unions in healthcare is excellent," says Barry Liebowitz, M.D., (left) president of the Doctors Council, which represents 16,000 physicians nationally.

Cidofovir protects mice against lethal aerosol or intranasal cowpox virus challenge

The efficacy of cidofovir for treatment of cowpox virus infection in BALB/c mice was investigated in an effort to evaluate new therapies for virulent orthopoxvirus infections of the respiratory tract in a small animal model. Exposure to 2(-5)x10(6) pfu of cowpox virus by aerosol or intranasally (inl) was lethal in 3- to 7-week-old animals. One inoculation of 100 mg/kg cidofovir on day 0, 2, or 4, with respect to aerosol infection, resulted in 90%-100% survival. Treatment on day 0 reduced peak pulmonary virus titers 10- to 100-fold, reduced the severity of viral pneumonitis, and prevented pulmonary hemorrhage. The same dose on day -6 to 2 protected 80%-100% of inl infected mice, whereas 1 inoculation on day -16 to -8 or day 3 to 6 was partially protective. Cidofovir delayed but did not prevent the death of inl infected mice with severe combined immunodeficiency. Treatment at the time of tail scarification with vaccinia virus did not block vaccination efficacy.

A child with hemimegalencephaly, hemihypertrophy, macrocephaly, cutaneous vascular malformation, psychomotor retardation and intestinal lymphangiectasia--a diagnostic dilemma

Although the clinical delineation of the majority of overgrowth syndromes is straightforward, we believe there is a subset of patients with overlapping features from a number of overgrowth syndromes. We report a patient with hemimegalencephaly, hemihypertrophy, macrocephaly, vascular lesions, psychomotor retardation and intestinal lymphangiectasia. The clinical history and findings posed a diagnostic dilemma as the features overlapped between several conditions, namely macrocephaly-cutis marmorata telangiectatica congenita (M-CMTC), Klippel-Trenaunay-Weber syndrome (KTWS), Proteus syndrome and a provisional unique syndrome described by Reardon et al. (1996, Am J Med Genet 66:144-149). We anticipate that only when the molecular basis is delineated will it become clear whether these disorders are separate entities or merely differing ends of the same spectrum.

Identification of randomized controlled trials from the emergency medicine literature: comparison of hand searching versus MEDLINE searching

STUDY OBJECTIVE

As part of an ongoing project to identify all the randomized controlled trials (RCTs) in the emergency medicine literature, in association with the Cochrane Collaboration, 2 discrete studies were undertaken; the first, to compare motives for active participation in hand searching of the literature by emergency medicine professionals, and the second, to compare hand searching with MEDLINE searching of a number of emergency medicine journals.

METHODS

All listed members of the British Association for Emergency Medicine (BAEM) and the Society for Academic Emergency Medicine (SAEM) received a standard letter outlining the objectives of the project, with 1 of 3 headings assigned on an alternate basis. Recruited volunteers hand searched journals prioritized from the emergency medicine literature. Each issue of each journal was hand searched for RCTs. In addition, a comprehensive MEDLINE search was conducted for each journal. The yields of RCTs from the 2 searching methods were compared for all journals and for each journal individually.

RESULTS

No clear motivation for participation in this work could be ascertained because of the low response rates from BAEM and SAEM (10.1% and 1.8%, respectively). Only 18 (29.0%) of the 62 journals identified were indexed by MEDLINE. In the 14 journals indexed by MEDLINE for which hand searching was completed, a total of 710 RCTs were identified by a combination of the 2 approaches; of these, 592 (83.4%) were identified by hand searching alone and 483 (68.0%) by MEDLINE searching alone. Both methods identified 365 (51. 4%) RCTs; hand searching revealed an additional 227 (32.0%) that were not identified by MEDLINE searching, and MEDLINE searching found 118 (16.6%) that were not identified by hand searching. The difference between the proportions identified by hand searching and by MEDLINE searching (15.4%; 95% confidence interval [CI], 12.7% to 17.9%) was statistically significant (McNemar's chi2 test, 1 df, 33. 8; P <.0001). This difference was not significant for 8 of the journals.

CONCLUSION

The response rates from mailing to members of the relevant professional organizations letters requesting participation in this work were very low and suggested that such an approach was not cost-effective. However, no formal costing exercise was undertaken. Searching results showed that, in the 14 emergency medicine journals indexed by MEDLINE for which hand searching was completed, hand searching led to identification of additional RCTs (primary articles) not found through MEDLINE searching. However, hand searching, although statistically significantly better than MEDLINE searching, failed to identify some of the RCTs found by MEDLINE searching, suggesting that hand searching is not a "gold standard" method and that the dual approach, promoted by the Cochrane Collaboration, may be the optimal approach for journals indexed by MEDLINE.

Familial overexpression of beta antithrombin caused by an Asn135Thr substitution

We have investigated the basis of antithrombin deficiency in an asymptomatic individual (and family) with borderline levels (approximately 70% antigen and activity) of antithrombin. Direct sequencing of amplified DNA showed a mutation in codon 135, AAC to ACC, predicting a heterozygous Asn135Thr substitution. This substitution alters the predicted consensus sequence for glycosylation, Asn-X-Ser, adjacent to the heparin interaction site of antithrombin. The antithrombin isolated from plasma of the proband by heparin-Sepharose chromatography contained amounts of beta antithrombin (the very high affinity fraction) greatly increased (approximately 20% to 30% of total) above the trace levels found in normals. Expression of the residue 135 variant in both a cell-free system and COS-7 cells confirmed altered glycosylation arising as a consequence of the mutation. Wild-type and variant protein were translated and exported from COS-7 cells with apparently equal efficiency, in contrast to the reduced level of variant observed in plasma of the affected individual. This case represents a novel cause of antithrombin deficiency, removal of glycosylation concensus sequence, and highlights the potentially important role of beta antithrombin in regulating coagulation.

Adjuvant chemotherapy and radiation therapy for elimination of residual microscopic non-small cell lung cancer

This study determined if patients with residual microscopic non-small cell lung cancer (NSCLC) following lung resection treated with combination chemotherapy and radiation realize prolonged survival. Ten men with microscopic NSCLC following resection were given chemotherapy and radiation therapy. Four (40%) of the ten patients were disease-free at 45 months and fully functional. Only two (20%) of the patients died of recurrent lung cancer. Of patients who died of lung cancer, recurrence occurred within five months of treatment and death occurred within one year. The findings suggest combination chemotherapy and radiation therapy delay or prevent recurrence from residual microscopic NSCLC following lung resection.

Finding out about filling-in: a guide to perceptual completion for visual science and the philosophy of perception

In visual science the term filling-in is used in different ways, which often leads to confusion. This target article presents a taxonomy of perceptual completion phenomena to organize and clarify theoretical and empirical discussion. Examples of boundary completion (illusory contours) and featural completion (color, brightness, motion, texture, and depth) are examined, and single-cell studies relevant to filling-in are reviewed and assessed. Filling-in issues must be understood in relation to theoretical issues about neural-perceptual isomorphism and linking propositions. Six main conclusions are drawn: (1) visual filling-in comprises a multitude of different perceptual completion phenomena; (2) certain forms of visual completion seem to involve spatially propagating neural activity (neural filling-in) and so, contrary to Dennett's (1991; 1992) recent discussion of filling-in, cannot be described as results of the brain's "ignoring an absence" or "jumping to a conclusion"; (3) in certain cases perceptual completion seems to have measurable effects that depend on neural signals representing a presence rather than ignoring an absence; (4) neural filling-in does not imply either "analytic isomorphism" or "Cartesian materialism," and thus the notion of the bridge locus--a particular neural stage that forms the immediate substrate of perceptual experience--is problematic and should be abandoned; (5) to reject the representational conception of vision in favor of an "enactive" or "animate" conception reduces the importance of filling-in as a theoretical category in the explanation of vision; and (6) the evaluation of perceptual content should not be determined by "subpersonal" considerations about internal processing, but rather by considerations about the task of vision at the level of the animal or person interacting with the world.

CAG repeat expansion in autosomal dominant familial spastic paraparesis: novel expansion in a subset of patients

Autosomal dominant familial spastic paraplegia (FSP) is a genetically heterogeneous neurodegenerative disorder displaying anticipation for which three loci have been mapped to the chromosomal positions 14q11.2-q24.3 (SPG3), 2p21-p24 (SPG4) and 15q11.1 (SPG6). The repeat expansion detection (RED) method has been used to demonstrate expanded CAG repeats in some FSP families that map to SPG4. We analyzed 20 FSP families, including four for which there is evidence for linkage to SPG4, and found that in most cases the repeat expansion detected by RED is due to non-pathogenic expansions of the chromosome 18q21.1 SEF2-1 or 17q21.3 ERDA1 locus. Polymorphic expansions at SEF2-1 and ERDA1 appear frequent and may confound RED studies in the search for genes causing disorders demonstrating anticipation. In six FSP families, however, CAG repeat expansion was detected in a subset of affected and at-risk individuals that did not result from expansion of the SEF2-1 and ERDA1 loci. Overall, 11 of 37 (30%) of the FSP patients with a CAG/CTG repeat expansion are unaccounted for by the SEF2-1 and ERDA1 loci, compared with two of 23 (9%) of the unaffected at-risk individuals and none of 19 controls. In the majority of cases these novel expansions were shorter than those previously reported.

Baller-Gerold syndrome associated with congenital portal venous malformation

We report a 4 year old boy in whom the clinical features of craniosynostosis and bilateral absent radii led to a diagnosis of Baller-Gerold syndrome. Additional congenital abnormalities included midface hypoplasia, atrial and ventricular septal defects, right hydronephrosis, partial sacral agenesis, and anterior ectopic anus. Evidence of portal venous hypertension was present from 8 months and a congenital portal venous malformation was discovered at 2 years. This is the first reported case of Baller-Gerold syndrome associated with a congenital portal venous malformation. We discuss the diagnostic confusion between this syndrome and other overlapping malformation syndromes and propose optimal evaluation strategies aimed at clarifying the nosology of these syndromes.

A multidisciplinary study investigating radiotherapy in Ewing's sarcoma: end results of POG #8346. Pediatric Oncology Group

PURPOSE

To determine if involved field radiation (IF) is equivalent to standard whole bone radiation (SF) in local tumor control; to establish patterns of failure following treatment; and to determine response, event-free survival (EFS), and overall survival rates from multidisciplinary therapy in Ewing's sarcoma.

METHODS AND MATERIALS

Between 1983 and 1988, 184 children with Ewing's sarcoma were enrolled onto Pediatric Oncology Group 8346 (POG 8346). A total of 178 (97%) met eligibility criteria; 6 had pathology other than Ewing's sarcoma. Induction chemotherapy of cyclophosphamide/doxorubicin (adriamycin )(C/A) x 12 weeks was followed by local treatment either surgery or radiation therapy and C/A, dactinomycin, and vincristine for 50 weeks. Resection was advised for patients with small primary tumors if accomplished without functional loss. Forty patients were randomized to receive SF, whole bone radiation to 39.6 Gy plus a 16.2 Gy boost (total 55.8 Gy) or IF to 55.8 Gy, and the remainder were assigned to IF radiation.

RESULTS

Of 178 eligible patients, 141 (79%) had localized disease and 37 (21%) had metastases at presentation. Their 5-year EFS was 51% (SE 5%) and 23% (SE 7%) respectively. The response rate to induction chemotherapy was 88% (28% complete, 60% partial), but after radiotherapy the response rate increased to 98%. Thirty-seven of the localized patients underwent resection, of whom 16 (43%) required postoperative radiotherapy; the 5-year EFS of these surgical patients was 80% (SE 7%). The remaining 104 localized patients were eligible for randomization or assignment to receive radiotherapy; the 5-year EFS of these patients was 41% (SE 5%), with no significant difference in EFS between those randomized to SF vs. IF. Site of primary tumor correlated with 5-year EFS: distal extremity 65% (SE 8%), central 63% (SE 10%), proximal extremity 46% (SE 8%), and pelvic-sacral 24% (SE 10%) (p=0.004). Initial tumor size did not correlate significantly with EFS. Patterns of failure among the 141 localized patients revealed 23% of patients experienced a local failure, while 40% had a systemic failure. The 5-year local control rate for the surgical patients +/- postoperative radiotherapy was 88% (SE 6%), while for the patients undergoing radiotherapy alone it was 65% (SE 7%). There was no difference in local control between those randomized to SF vs. IF. The 5-year local control rate for the patients with pelvic-sacral tumors was 44% (SE 15%), significantly worse than the local control rates for those with central tumors 82% (SE 8%), distal extremity 80% (SE 8%), or proximal extremity 69% (SE 9%) (p=0.023). However, quality of radiotherapy correlated with outcome. Patients who had appropriate radiotherapy had a 5-year local control of 80% (SE 7%), while those with minor deviations had 5-year local control of 48% (SE 14%), and those with major deviations had a local control of only 16% (SE 15%) (p=0.005). The local failure was within an irradiated volume in 62% of patients, outside the irradiated volume in 24% of cases, while the precise location could not be determined in the remaining 14%.

CONCLUSIONS

As most failures in Ewing's sarcoma are systemic, improved EFS requires more effective systemic chemotherapy. Adequate IF radiotherapy requires treatment to appropriate volumes as defined by MRI imaging and full radiation doses. Pretreatment review of radiologic images with a musculoskeletal radiologist to determine appropriate tumor volumes, as well as use of conformal radiotherapy techniques are important for improved outcome.

Utility and cost-savings of diagnostic laparoscopy in low-probability gunshot wounds of the abdomen

Gunshot wounds of the abdomen are associated with a 90% or greater incidence of intra-abdominal injury, prompting many trauma centers to routinely explore these patients via laparotomy. Increasingly, diagnostic laparoscopy has been used to evaluated the abdomen to exclude peritoneal violation by the missile. Retrospective analysis of the experience at a Level I Trauma Center with 20 isolated abdominal gunshot wound patients who did not have obvious indications for laparotomy such as peritonitis or shock is detailed. Outcome and cost analysis were compared in patients who had diagnostic laparoscopy or laparotomy. Patients who underwent diagnostic laparoscopy instead of laparotomy had a 42% reduction in operative time, a 33% reduction in hospital charges, and a reduction in hospital length of stay from an average of 3.5 days to less than one day. The only operative complication noted was in a patient who underwent laparotomy. Diagnostic laparoscopy may be used in select patients to exclude significant intra-abdominal injuries following gunshot wounds of the abdomen with reduction in health care costs and morbidity.

A model for estimating the cost-utility of clinical audit. The example of thrombolysis for suspected acute myocardial infarction

Economic evaluation of quality assurance programs is often called for but rarely reported. A study was designed to estimate the cost-utility of audit of thrombolysis in four U.K. district general hospitals, using the quality-adjusted life year. Although the results obtained were imprecise, the model used could be applied in future evaluations.

Why is evaluation of the cost effectiveness of audit so difficult? The example of thrombolysis for suspected acute myocardial infarction

BACKGROUND

Cost effectiveness analysis is an established technique for evaluation of delivery of health care, but its use to evaluate clinical audit is rarely reported. Thrombolysis for suspected acute myocardial infarction is a commonly used therapy of established effectiveness and an appropriate subject for audit in many healthcare settings.

OBJECTIVE

To measure the cost effectiveness of audit of thrombolysis in some district general hospitals.

MAIN OUTCOME MEASURE

Cost of audit per extra patient treated with thrombolysis (incremental cost effectiveness ratio).

DESIGN

Prospective agreement with physicians to undertake repeated audits of a specific aspect of the management of patients with acute myocardial infarction. Baseline measurement of the proportion of these patients given thrombolysis in each hospital were made, as were three subsequent retrospective audits, giving time series of measurements. Costs were estimated from records of staff time and other resources used in each hospital; effectiveness was estimated by fitting the results to a model which assumed a uniform rate of increase over time in the proportion of eligible patients given thrombolysis which might be accelerated by regular audit. Upper and lower limits for main outcome measure were derived from sensitivity analysis of costs and logistic regression of time series data.

SETTING

Five district general hospitals in North West Thames Regional Health Authority including one control hospital were used, starting in April 1991 when widespread medical audit was first introduced.

RESULTS

Between the first and last audits, the proportion of patients with suspected acute myocardial infarctions receiving thrombolysis rose in three of the hospitals undertaking audit by 20% to 37% and fell by 6% in the fourth (although this hospital started with a rate in excess of 90%). The corresponding change in the control hospital was an increase of 15%. The differences between each of the auditing hospitals and control hospital were not significant, except in one case, where 51 extra treatments per year were attributable to audit (95% confidence intervals (95% CIs) 0.5 to 61 cases per year). Estimated overall costs in each hospital ranged from 3700 Pounds to 5200 Pounds for data collection, a series of four audit meetings, and subsequent actions. The central estimate of cost effectiveness in the three responsive hospitals ranged from 101 Pounds to 392 Pounds per extra case given thrombolysis, with very wide 95% CIs. In the fourth hospital audit had zero effectiveness as defined in this study.

CONCLUSIONS

Methodological difficulties were encountered which need to be considered in future economic evaluations of clinical audit and related activities. These were: (a) adequate control for other factors influencing clinical behaviour; (b) uncertainties about the sustainability of changes in behaviour associated with audit; and (c) the relative infrequency in a single hospital of specific clinical events leading to small numbers for analysis. These difficulties constitute major challenges for the economic evaluation of clinical audit. They are most likely to be overcome in a large study which compares clinical audit with other interventions aiming for the same quality improvement, such as patient specific reminders or educational programmes.

Meta-analysis of chemotherapy versus combined modality treatment trials in Hodgkin's disease. International Database on Hodgkin's Disease Overview Study Group

DESIGN

To perform a meta-analysis of all randomized trials that compared chemotherapy (CT) alone versus combined modality treatment (CT + radiotherapy [RT]) for which individual patient data could be made available.

PATIENTS AND METHODS

Data on 1,740 patients treated on 14 different trials that included 16 relevant comparisons have been analysed. Eight comparisons were designed to evaluate the benefit of additional RT after the same CT (CT1 v CT1 + RT; additional RT design). Eight comparisons were designed to evaluate whether RT in a combined modality setting can be substituted by CT using either more cycles of the same CT or regimens that contain additional drugs (CT1 + CT2 v CT1 + RT or CT1 v CT2 + RT; parallel RT/CT design).

RESULTS

Additional RT showed an 11% overall improvement in tumor control rate after 10 years (P = .0001; 95% confidence interval [CI], 4% to 18%). No difference could be detected with respect to overall survival (P = .57; 95% CI, -10% to 4%). In contrast, when combined modality treatment was compared with CT alone in the parallel-design trials, no difference could be detected in tumor control rates (P = .43; 95% CI, -6% to 9%), but overall survival was significantly better after 10 years in the group that did not receive RT (P = .045; 8% difference; 95% CI, 1% to 15%). There were significantly fewer fatal events among patients in continuous complete remission (relative risk [RR], 1.73; 95% CI, 1.17 to 2.53; P = .005) if no RT was given.

CONCLUSION

Combined modality treatment in patients with advanced-stage Hodgkin's disease overall has a significantly inferior long-term survival outcome than CT alone if CT is given over an appropriate number of cycles. The role of RT in this setting is limited to specific indications.

Intrathecal baclofen and homeopathy for the treatment of painful muscle spasms associated with malignant spinal cord compression

In this case study we describe a dual approach to the palliation of difficult muscle spasms using intrathecal baclofen via a fully implanted system, together with the homeopathic approach to symptom control. The homeopathy is seen to complement rather than to replace conventional prescribing and using both approaches together appears to have avoided the necessity for increasing drug doses and to have minimized side-effects. As well as encouraging us to take on experience from other disciplines, this case study also suggests that palliative care could be a forum for evaluating the effectiveness of the homeopathic approach in symptom control in carefully designed studies.

Negative interaction and body weight in later life

This study assesses the relationship between negative interaction and body mass index values among older adults. Throughout, an emphasis is placed on probing for individual differences in response to unpleasant encounters with significant others. Individual variations in personality (introversion-extraversion) as well as social status (gender) are evaluated within this context. Tests of the complex three-way interaction between negative interaction, gender, and introversion reveal that more negative interaction is associated with higher body mass index values among elderly women who are introverted. In contrast, a significant relationship between negative interaction, introversion, and body mass failed to emerge for older men.

Are rural general practitioner--obstetricians performing too many prenatal ultrasound examinations? Evidence from western Labrador

OBJECTIVE

To determine the frequency of prenatal ultrasonography (PNU) in western Labrador in 1994, assess the appropriateness of the ultrasound examinations according to current guidelines and determine whether there was any relation between number of PNU examinations and patient management and obstetric outcomes.

DESIGN

Review of all obstetric charts and PNU requisition forms for all deliveries in one hospital in 1994.

SETTING

Labrador City and Wabush, Newfoundland.

RESULTS

During the study period, there were 103 singleton deliveries, and these mothers underwent a total of 225 PNU studies (mean 2.16 studies per delivery). More than half (53.3%) of the examinations were classified as inappropriate. There were no significant differences in the number of studies between low- and high-risk pregnancies or between uncomplicated deliveries and those in which induction or instrumental or operative delivery occurred, nor was there any relation between number of PNU examinations and maternal or neonatal outcome.

CONCLUSION

Compared with PNU use as recommended by the Canadian Task Force on the Periodic Health Examination, this type of examination was overused in Labrador City and Wabush, although the rate of use was comparable to that reported in other Canadian studies. This overuse was not associated with any identifiable effect on maternal or neonatal outcome or on the management of pregnancy and labour. More judicious use of PNU, in accordance with evidence-based guidelines, is recommended.

Autosomal dominant Klippel-Feil anomaly with cleft palate

Klippel-Feil anomaly is characterized by the fusion of two or more cervical vertebrae. Most cases are sporadic but dominant and recessive inheritance are well described. Associated anomalies such as a cleft palate are common. We describe a unique family with autosomal dominantly inherited Klippel-Feil anomaly in six individuals associated with a cleft palate in four. One patient, a child, has a cleft palate only but may develop radiological cervical fusion with time, as documented in two other family members.

A gene for FG syndrome maps in the Xq12-q21.31 region

FG syndrome is an X-linked recessive condition in which mental retardation is associated with congenital hypotonia, macrocephaly, characteristic face, and constipation. This syndrome was mapped by Zhu et al. [Cytogenet Cell Genet 1991;58:2091A] to Xq21.31-q22 by linkage analysis with a max lod score of 1.2 for the DXYS1X, DXS178, DXS101, and DXS94 loci and crossovers at DXS16 (Xp22.31) and DXS287 (Xq22.3). However, this mapping was only provisional and needed to be refined. In this paper, we report the results of a new linkage analysis performed on 10 families including that studied by Zhu et al. [1991]. Two-point analysis demonstrated linkage with DXS441 (Zmax = 3.39 at theta = 0.12) at Xq13. In addition, separate analysis of the lod scores obtained for the Xq13 markers suggested linkage exclusion for three families. Genetic heterogeneity was confirmed by analysis of the linkage results with the HOMOG program (max logL = 4.07, theta = 0, alpha = 0.65). Localization of one FG gene between DXS135 and DXS1066 was suggested by analysis of crossovers found in those three families which were assumed to be linked to Xq13 with a probability of 0.95 or more. This region could be reduced to the DXS135-DXS72 interval after combining our data with those from deletions previously described in males in the Xq13-q21 region.