Outcomes for schizophrenia patients with clozapine treatment: how good does it get?

The objective of this study was to describe the extent/change (2000-2004) of clozapine prescribing in schizophrenia in New Zealand and examine the outcomes associated with increasing treatment duration, and vs. those who discontinue clozapine. Consecutive chart reviews were conducted for adult outpatients in Auckland/Northland regions (T1 = 31 March 2000, T2 = 31 October 2001, T3 = 31 March 2003, T4 = 31 October 2004). Data collected included: patient characteristics, social/functional indicators, diagnosis, duration of illness, psychiatric admissions and treatment information (psychotropic medication, dose, route of administration). Between 2000 and 2004, clozapine for schizophrenia increased from 21.0% to 32.8%. Of those prescribed clozapine at T1, 86.1% were engaged with community services at T4 and 93.2% still prescribed clozapine. Continuing clozapine treatment (vs. other treatment) led to a trend to higher rates of regular occupational activity (37% vs. 14.3%) and lower rates of compulsory treatment (25.1% vs. 46.4%) and significantly lower hospitalisation rates (mean = 0.6 vs. mean = 3.1). For those prescribed clozapine at T4, increasing treatment duration (< or = 10 months, 2-3 years, >3 years) led to a trend to higher rates of living independently (18% vs. 29.2% vs. 34%) and regular occupational activity (26.2% vs. 32.6% vs. 37.5%), and significantly reduced compulsory treatment (44.3% vs. 36.9% vs. 28.6%) and hospitalisation rates in the previous 18 months (1.5 vs. 0.5 vs. 0.2). Clozapine use increased significantly over 4.5 years to expected rates of treatment-resistant schizophrenia. Low clozapine discontinuation rates were found and continuing treatment was associated with real-world improvements in functional and clinical outcomes. These findings support the recommendation of prolonged clozapine trials to improve cost-effectiveness in the most seriously unwell schizophrenia patients.

Total versus subtotal hysterectomy: a survey of current views and practice among British gynaecologists

This paper reports the results of a postal questionnaire, with a response rate of 61 per cent. It is clear from the results that subtotal hysterectomy is an unpopular operation in the United Kingdom. Although a majority of consultants felt that subtotal hysterectomy was less likely to affect urinary, bowel and sexual function, this did not seem to affect decision making. Seventy-eight per cent of female gynaecologists would prefer a total hysterectomy for themselves rather than a subtotal procedure.

Uptake of SigmaDDT, arsenic, cadmium, copper, and lead by lettuce and radish grown in contaminated horticultural soils

Horticultural soils can contain elevated concentrations of selected trace elements and organochlorine pesticides as a result of long-term use of agrichemicals and soil amendments. A glasshouse study was undertaken to assess the uptake of weathered SigmaDDT {sum of the p, p'- and o, p-isomers of DDT [1,1,1-trichloro-2,2- bis( p-chlorophenyl)ethane], DDE [1,1-dichloro-2,2- bis( p-chlorophenyl)ethylene] and DDD[1,1-dichloro-2,2- bis( p-chlorophenyl)ethane]}, arsenic (As), cadmium (Cd), copper (Cu), and lead (Pb) residues by lettuce ( Lactuca sativa) and radish ( Raphanus sativus) from field-aged New Zealand horticultural soils. Concentrations of SigmaDDT, DDT, DDE, Cd, Cu, and Pb in lettuce increased with increasing soil concentrations. In radish, similar relationships were observed for SigmaDDT, DDE, and Cu. The bioaccumulation factors were less than 1 with the exception of Cd and decreased with increasing soil concentrations. Lettuce Cd concentrations for plants grown on four out of 10 assayed soils were equivalent to or exceeded the New Zealand food standard for leafy vegetables of 0.1 mg kg (-1) fresh weight. Concentrations of As, Pb, and SigmaDDT did not exceed available food standards. Overall, these results demonstrate that aged residues of SigmaDDT, As, Cd, Cu, and Pb in horticultural soils have remained phytoavailable. To be protective of human health, site-specific risk assessments and soil guideline derivations for residential settings with vegetable gardens need to consider the produce consumption pathway.

Cannabis use and risk of lung cancer: a case-control study

The aim of the present study was to determine the risk of lung cancer associated with cannabis smoking. A case-control study of lung cancer in adults <or=55 yrs of age was conducted in eight district health boards in New Zealand. Cases were identified from the New Zealand Cancer Registry and hospital databases. Controls were randomly selected from the electoral roll, with frequency matching to cases in 5-yr age groups and district health boards. Interviewer-administered questionnaires were used to assess possible risk factors, including cannabis use. The relative risk of lung cancer associated with cannabis smoking was estimated by logistic regression. In total, 79 cases of lung cancer and 324 controls were included in the study. The risk of lung cancer increased 8% (95% confidence interval (CI) 2-15) for each joint-yr of cannabis smoking, after adjustment for confounding variables including cigarette smoking, and 7% (95% CI 5-9) for each pack-yr of cigarette smoking, after adjustment for confounding variables including cannabis smoking. The highest tertile of cannabis use was associated with an increased risk of lung cancer (relative risk 5.7 (95% CI 1.5-21.6)), after adjustment for confounding variables including cigarette smoking. In conclusion, the results of the present study indicate that long-term cannabis use increases the risk of lung cancer in young adults.

Rapid point-of-care HIV testing in community-based anonymous testing program: a valuable alternative to conventional testing

Our goal was to determine whether introducing rapid point-of-care (POC) whole-blood HIV testing as alternative to standard laboratory-based testing is acceptable and changes the rate of receiving test results at an anonymous testing program. From December 2001 through April 2002 all patients requesting HIV testing at Hassle Free Clinic in Toronto were offered rapid POC or standard testing. Routine clinical data was collected. All patients were invited to complete a questionnaire evaluating testing procedure. Test counselors also completed evaluation questionnaires. HIV-positive patients were invited to an in-depth interview. There were 1610 patients, 91% chose the rapid POC test. Overall 98.9% of patients received final results, compared with 93% in the previous year. Among the rapid testers, 100% received an initial result, and 18 of 22 testing positive returned for confirmatory results. Among standard testers 90.8% returned for results (p < 0.001 compared to rapid testers) including all of the 4 with positive tests. There were 1257 (79%) patients who completed questionnaires, 4 with positive tests agreed to interviews, and test counselors evaluated every visit. Standard testers indicated significantly greater difficulty than rapid testers with the testing procedure. Test counselors also indicated that standard testers had greater difficulty. HIV-positive patients coped well with the testing procedure and indicated high quality counseling was important. Rapid HIV testing was acceptable to patients and test counselors, provided more patients with test results and reduced total time and number of visits. High-quality pretest and posttest counseling is particularly important for rapid testers with positive results. The impact of false-positive results requires further study.

Cryptosporidiosis in two alpaca (Lama pacos) holdings in the South-West of England

Cryptosporidiosis was investigated on two alpaca (Lama pacos) holdings in the South-West of England. Diagnosis was initially confirmed in a cria with diarrhoea from each holding. Cohort faeces samples were subsequently collected and examined for presence of Cryptosporidium oocysts by immunofluorescence microscopy. On the first holding, 30 samples (24 adults, 6 crias) were tested, and oocysts were detected in three of the cria samples but in none of the adults. On the second holding, 14 floor faeces samples representing apparently healthy crias and one faeces sample from a cria with diarrhoea were collected. Oocysts were detected in four of the "healthy" faeces samples and the sample of diarrhoeic faeces. All isolates were confirmed as Cryptosporidium parvum using polymerase chain reaction restriction fragment length polymorphism of the cryptosporidium oocyst wall protein (COWP) and ssu rRNA genes. Sequence analysis of a 741bp region of ssu rDNA was carried out on nine of these and revealed high sequence homology with previously reported C. parvum isolates. This investigation highlights the possibility of alpaca crias subclinically shedding oocysts, which has implications for epidemiology and transmission in animals as well as raising zoonotic concerns for human contacts. Gene sequencing of UK isolates from South American camelids is also described for the first time.

Purpura fulminans in a child secondary to Panton–Valentine leukocidin-producing Staphylococcus aureus

A case of purpura fulminans (PF) in a child secondary to infection with meticillin-sensitive Staphylococcus aureus (MSSA) encoding the Panton–Valentine leukocidin (PVL) toxin genes is presented. Occasional cases of PF have been documented secondary to S. aureus infection in adults, but, to the authors' knowledge, not in children. Here the first UK case of MSSA-PVL leading to PF is presented.

Non-invasive metabolic monitoring of patients under anaesthesia by continuous indirect calorimetry—an in vivo trial of a new method

BACKGROUND

Oxygen uptake is an important form of metabolic monitoring for patients under anaesthesia. In critically ill patients oxygen uptake has been shown to provide valuable clinical information in directed therapy and acts as a useful monitor of cardiovascular dysfunction. A new method of continuous real time monitoring of metabolic gas exchange was tested in patients during anaesthesia.

METHODS

Using a standard anaesthetic machine with attached semi-closed circle absorber system, oxygen uptake was measured continuously throughout surgery in 30 patients undergoing cardiopulmonary bypass surgery and compared with paired measurements made with the reverse Fick method. The method is an indirect calorimetry technique which uses fresh gas rotameters for control, regulation and measurement of the gas flows into the system, with continuous sampling of mixed exhaust gas.

RESULTS

When compared with the reverse Fick method the oxygen uptake showed a mean difference (and sd) of 20.7 ml min(-1) or 12.1% (25.3 ml min(-1)) pre-bypass and 13.9 ml min(-1) or 8.1% (27.0 ml min(-1)) post-bypass. This bias is consistent with previous studies comparing oxygen uptake measured at the mouth against oxygen uptake by reverse Fick, which have shown a difference of approximately 10-15% accounted for by the consumption of oxygen by lung tissue.

CONCLUSIONS

As the method allows continuous measurement of gas exchange and can be adapted to a modern anaesthetic workstation it is an attractive method for use in clinical setting.

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

BACKGROUND

This study set out to quantify the immediate costs to the North East Ambulance Service (NEAS) of attending to fallers.

METHODS

Data from the Newcastle, UK area were collated by NEAS to identify those aged over 65 who had fallen and required an assistance only call or were subsequently transported to an Accident and Emergency (A&E) department. The 2001 census data for the total population served by NEAS in Newcastle were obtained.

RESULTS

The total population of Newcastle over the age of 65 was 41,338. Over 7 months NEAS attended to 1504 falls in Newcastle (at 115 pounds sterling per call out, this equates to 172,960 pounds sterling). The faller was transported to A&E on 1339 occasions, while 165 falls required assistance only (11% of total) (36 falls requiring NEAS assistance per 1000 Newcastle population aged over 65 in 7 months). The total time on site for ambulance crews attending to fallers was 377.1 h (15.7 days in 7 months or 2.25 days per month). As the cost of emergency ambulance time is 123 pounds sterling/h, the total cost was 46,383.30 pounds sterling. Therefore, in Newcastle, attending to fallers in the community costs NEAS 376,018 pounds sterling per year (145.83 pounds sterling per fall or 9.10 pounds sterlingper person over the age of 65 per year).

CONCLUSION

NEAS attend to a significant number of older people who fall in the community. In Newcastle alone the cost of this service equates to over 2 days of emergency ambulance crew time per month. Studies are needed to determine whether responding to falls in the community differently would be cost effective.

Sample prevalence and molecular characterisation of Cryptosporidium andersoni within a dairy herd in the United Kingdom

Bovine cryptosporidiosis is usually an acute diarrhoeal disease of young calves caused by Cryptosporidium parvum. However, chronic infection with Cryptosporidium andersoni has been associated with gastritis, reduced milk yield and poor weight gain in adult cattle. Here we describe the first genetic confirmation and characterisation of C. andersoni from cattle in the United Kingdom and its sample prevalence within a dairy herd. Oocysts measured 7.5+/-0.4 microm x 5.5+/-0.4 microm (7.0-8.5 microm x 4.5-6.5 microm) with a length-to-width ratio of 1.37 (1.08-1.60). The within-herd sample prevalence was 16% (95% confidence intervals=10.4-21.6%). Nested polymerase chain reaction (PCR)-restriction fragment length polymorphism (RFLP) and sequence analysis of the small subunit rDNA was used to confirm the species and characterise the isolates. Due to the lack of overt, acute, clinical symptoms, the incidence, prevalence and importance of this parasite is probably currently underestimated in cattle in the UK. The potential for zoonotic transmission is unknown.

Normal anatomy and common labral lesions at MR arthrography of the shoulder

MR arthrography of the shoulder is the most accurate imaging modality in demonstrating abnormalities of the glenoid labrum and associated structures. Tears of the labrum, the capsule or the gleno-humeral ligaments can lead to pain, catching, popping or instability. The anatomy of this region is complex. We present the normal anatomy of the glenoid labrum, biceps anchor and gleno-humeral ligaments together with their normal variants and then describe common labral-ligamentous pathologies.

Axial oblique MR imaging of the intrinsic ligaments of the wrist: initial experience

OBJECTIVE

To evaluate two separate MR sequences acquired in the axial oblique plane, parallel to the long axis of the scapholunate (SL) and lunotriquetral (LT) ligaments, to determine whether the addition of these sequences to the standard MR wrist examination improves visualization of the intrinsic ligaments, and the evaluation of their integrity. To our knowledge, this plane has not been described in the literature previously.

DESIGN AND PATIENTS

In total we evaluated 26 patients with chronic wrist pain or instability, referred for MR imaging following assessment by an orthopedic surgeon or physiatrist. All patients underwent initial conventional tri-compartment wrist arthrography, which served as the reference standard. This was immediately followed by MR arthrography, in the standard coronal and true axial planes, as well as in the axial oblique plane. The SL and LT ligaments were initially assessed for the presence or absence of tear, using the standard coronal and true axial sequences, and subsequently re-evaluated with the addition of the axial oblique planes.

RESULTS

A total of ten intrinsic ligament tears were identified with conventional arthrography: six SL and four LT tears. Five of the six SL tears were identified on the standard sequences. All six were diagnosed with the addition of the oblique sequences. There were three false-positive SL tears identified using standard MR imaging, and two false-positives with the addition of the oblique sequences. No LT tear was identified on standard sequences, whereas all four were confidently seen with the addition of oblique images. No false-positives of the LT ligament were recorded with either standard or axial oblique sequences.

CONCLUSION

The study suggests that the addition of axial oblique MR sequences helps identify tears to the intrinsic ligaments of the wrist, particularly the LT ligament. In addition, the axial oblique images assist in localization of the tear.

What services do young children with autism spectrum disorder receive?

BACKGROUND

In recent years, standards of good practice have been set for services to young children with autism spectrum disorders.

METHODS

Data were analysed on children's use of local services during a 2-year follow-up of families involved in an evaluation of a group course for parents. Data collection began prior to publication of the standards.

RESULTS

Families' reported experiences changed over time, but for most did not meet standards suggested: involvement with a multi-agency team of professionals, having someone who acted as a key worker, and the child accessing 15 h per week of specialist provision.

CONCLUSION

The development of flexible and responsive services appears to have a long way to go to meet standards set in the Autistic Spectrum Disorders Good Practice Guidance (2002) and the National Autism Plan for Children (2003).

Monitoring the use of amiodarone: compliance with guidelines

AIM

Careful monitoring of amiodarone is recommended because it produces a range of potentially severe adverse effects. The aim of this study was to compare existing practice at our hospitals with the current international guidelines for the use of this drug.

METHODS

A retrospective audit was carried out on all patients aged 15 years or older, with a primary discharge diagnosis of tachyarrhythmia and who were commenced and discharged alive on amiodarone between 1 January 2000 and 30 June 2002 from Wellington and Kenepuru Hospitals, Capital and Coast District Health Board, Wellington, New Zealand. The medical records were examined for baseline measurements of renal, liver, thyroid and pulmonary function, the electrocardiogram and chest X-ray. Follow-up arrangements were sought postdischarge. A questionnaire was sent to the general practitioner requesting information on follow-up testing.

RESULTS

During the trial period, 743 patients were admitted with a primary diagnosis of tachyarrhythmia. Eighty-six patients satisfied the entry criteria, and of these 58 were followed for at least 1 year postdischarge. Baseline testing of the electrocardiogram, full blood count and renal function testing was excellent (95-100%). Chest X-rays were carried out in 80% of patients. Baseline testing of thyroid (61%) and liver (44%) function was suboptimal. Two percent of patients had pulmonary function testing and no patient had a formal eye examination. At 6 months, only 32% had thyroid function tests and 41% had liver function tests. At 1 year, of those still on treatment, 35% had both liver and thyroid function tests.

CONCLUSION

Monitoring of thyroid, liver and pulmonary function tests in patients on amiodarone is less than ideal. This is probably because of lack of awareness of current guidelines.

Survey of the Royal Australasian College of Physicians examination candidates: preparation and impact on lifestyle

Candidates currently view the Royal Australasian College of Physicians' written examination as a major undertaking, knowing that approximately one-third fail on their first attempt. We anonymously surveyed New Zealand registrars who sat the written examination in 2004. We found that the majority of candidates spend long hours preparing over a several months, and that the examination had a detrimental impact on their personal lives. The results of this survey have important implications in the context of efforts to reduce the stress of doctors, and should lead to a change in either the examination itself or an increase in support provided to registrars preparing for it.

Accuracy of the Foldes-Biro equation for measurement of oxygen uptake during anaesthesia: a laboratory simulation

Laboratory benchtop testing was conducted of the Biro method for measurement of oxygen uptake from an anaesthetic breathing system by patients during low flow anaesthesia. A high precision flow and gas concentration measurement system was employed in conjunction with a physical gas exchange simulation model to test the theoretical basis of the method under controlled conditions. Simulated oxygen uptake values between 200 and 350 ml x min(-1) were modelled. The Biro-derived measurement of simulated O(2) uptake significantly underestimated the target value (mean difference -88.5 ml x min(-1), or -31.7%). The bias was directly proportional to the simulated O(2) uptake. The Biro method has a systematic bias that cannot be explained by random measurement imprecision.