Noise exposure and children's blood pressure and heart rate: the RANCH project

BACKGROUND

Conclusions that can be drawn from earlier studies on noise and children's blood pressure are limited due to inconsistent results, methodological problems, and the focus on school noise exposure.

OBJECTIVES

To investigate the effects of aircraft and road traffic noise exposure on children's blood pressure and heart rate.

METHODS

Participants were 1283 children (age 9-11 years) attending 62 primary schools around two European airports. Data were pooled and analysed using multilevel modelling. Adjustments were made for a range of socioeconomic and lifestyle factors.

RESULTS

After pooling the data, aircraft noise exposure at school was related to a statistically non-significant increase in blood pressure and heart rate. Aircraft noise exposure at home was related to a statistically significant increase in blood pressure. Aircraft noise exposure during the night at home was positively and significantly associated with blood pressure. The findings differed between the Dutch and British samples. Negative associations were found between road traffic noise exposure and blood pressure, which cannot be explained.

CONCLUSION

On the basis of this study and previous scientific literature, no unequivocal conclusions can be drawn about the relationship between community noise and children's blood pressure.

Selecting doctors for postgraduate training in paediatrics using a competency based assessment centre

The design and implementation of an assessment centre in the South Yorkshire and South Humberside deanery for selecting doctors into postgraduate training in paediatric medicine is described. Eleven competency domains were identified in the job analysis. An assessment centre comprising of four exercises was implemented to assess candidates. There were modest relationships between candidates' performance on the various assessment centre exercises. Outcomes based on interview performance were related to, but not the same as, outcomes based on the combined results of the three other assessment centre exercises. Candidates perceived the assessment centre to be a fair selection method. It is concluded that an assessment centre approach to SHO recruitment is feasible and provides a greater breadth and depth of information about candidates than does a structured interview.

Mothers' attitudes to the randomized controlled trial (RCT): the case of acute lymphoblastic leukaemia (ALL) in children

OBJECTIVES

Survival rates for childhood cancer have improved substantially partly as a result of national and international randomized clinical trials (RCT). However, the decision for families is complex and emotional. Our aim was to describe the views of mothers of children newly diagnosed with ALL regarding consent to randomized controlled trials.

DESIGN

Qualitative interview to explore mothers knowledge, and reasons for involving their child in RCTs. Interviews took place in mothers' homes.

PARTICIPANTS

Fifty mothers of children with newly diagnosed ALL (age 4-16 years; mean = 7.4) recruited through research nurses at outpatient appointments.

RESULTS

All but three families had consented for their child to be treated in the RCT, although there was wide variation in their understanding of the aims, costs and benefits. Most mothers reported the aim of the trial to compare 'old' and 'new' treatments.

CONCLUSION

Despite detailed verbal and written information, mothers were poorly informed about the purpose of the trial, and possibility of side effects. Individual preferences for either standard or new treatment were routinely reported. The data raise questions about the extent to which families give truly informed consent to recruitment of their child to an RCT.

The role of distance learning in specialist medical training

The Quality Assurance Agency for Higher Education (QAA) defines distance learning (DL) as "a way of providing higher education that involves the transfer to the student's location of the materials that form the main basis of study, rather than the student moving to the location of the resource provider".

Portfolios, appraisal, revalidation, and all that: a user's guide for consultants

From April 2005 all doctors in the UK will be expected to be able to demonstrate their fitness to practice as part of the GMC revalidation procedures. The revalidation process is explicitly linked to the consultant appraisal process implemented in 2001. Central to both processes is the development of a folder (portfolio) of supporting evidence. Many consultants have no experience of developing portfolios and are unclear about how to meaningfully do so and what sort of evidence is suitable for revalidation. Furthermore, they are uncertain about whether there is any evidence to support their use for appraisal or assessment. This paper describes what a portfolio is, summarises the evidence for their use in appraisal and assessment, and provides guidance on the collection of evidence for revalidation purposes. In addition, it explores the distinction between appraisal and revalidation. Some evaluation data on perceived benefits and drawbacks by participants in appraisal in a paediatric setting is also included to inform conclusions and thoughts on planning for the future.

How should paediatric examiners be trained?

Analysis of both the content and process of examinations is central to planning the appropriate education and training of examiners in paediatric clinical examinations. This paper discusses the case for developing training, reviews the current literature, and suggests the desirable attributes of examiners and the components of a training programme. Potential areas of further research are also considered.

Radiological changes ten years after St. Georg Sled unicompartmental knee replacement

Failure of a unicompartmental knee replacement (UKR) may be caused by progressive osteoarthritis of the knee and/or failure of the prosthesis. We have examined the fate of the other compartments of the knee by radiological assessment 10 years after operation. A total of 50 UKRs were performed on 45 carefully selected patients between 1989 and 1992. Fifteen patients died, two patients were lost to follow-up and two knees were revised. Standard long-leg weight-bearing anteroposterior views of the knee and skyline views of the patellofemoral joint were taken pre-operatively and at 8 months and 10 years after operation. The radiographs of the remaining 30 knees were reviewed three times by blind and randomized assessment to measure the progression of osteoarthritis within the joints. Two knees showed evidence of progression of osteoarthritis within the patellofemoral joint and three knees showed some progression of the opposite tibiofemoral compartment--but only on one of the radiological grading systems used for assessment. It is concluded that progression of arthritis in the unreplaced compartments is not a significant problem after fixed bearing UKR.

Bloodstream infection-associated sepsis and septic shock in critically ill adults: a population-based study

BACKGROUND

Few studies have investigated the epidemiology of sepsis and septic shock in a large population and none have been from Canada. The objective of this study was to define the epidemiology of bloodstream infection (BSI)-associated sepsis and septic shock among all critically ill patients in a large, fully integrated health region in Canada.

PATIENTS AND METHODS

All critically ill adults admitted to multidisciplinary intensive care units (ICU) in the Calgary Health Region during May 1, 1999 to April 30, 2000 were included. Clinical, microbiologic and outcome information was obtained from regional databases.

RESULTS

We surveyed 1981 patients having at least one ICU admission. Systemic inflammatory response syndrome (SIRS) was diagnosed in 92%, BSI-associated sepsis (BSI with SIRS) in 6% and BSI-associated septic shock (BSI with SIRS and hypotension) in 3%; respective hospital mortality rates were 36%, 40% and 49%. The most common BSI etiologies were Staphylococcus aureus, Escherichia coli and Streptococcus species; only one isolate (1%) was highly antibiotic resistant. Independent risk factors for death among patients with SIRS included age (>or= 65), hypothermia (< 35 degrees C), and higher APACHE II and TISS scores. A surgical diagnosis was associated with decreased mortality risk. Neither a positive blood culture nor hypotension at presentation independently predicted death.

CONCLUSION

Knowledge of the epidemiology of these syndromes is important for assessing the burden of disease and providing background information for investigating new therapies.

Can Mary Shelley's Frankenstein be read as an early research ethics text?

The current popular view of the novel Frankenstein is that it describes the horrors consequent upon scientific experimentation; the pursuit of science leading inevitably to tragedy. In reality the importance of the book is far from this. Although the evil and tragedy resulting from one medical experiment are its theme, a critical and fair reading finds a more balanced view that includes science's potential to improve the human condition and reasons why such an experiment went awry. The author argues that Frankenstein is an early and balanced text on the ethics of research upon human subjects and that it provides insights that are as valid today as when the novel was written. As a narrative it provides a gripping story that merits careful analysis by those involved in medical research and its ethical review, and it is more enjoyable than many current textbooks! To support this thesis, the author will place the book in historical, scientific context, analyse it for lessons relevant to those involved in research ethics today, and then draw conclusions.

The pathology of rotavirus-associated deaths, using new molecular diagnostics

Rotavirus, the most common cause of severe, dehydrating gastroenteritis among children worldwide, annually causes approximately 500,000 deaths among children aged <5 years. The primary site of rotavirus infection is the small intestine. Pathologic investigations of patients who died of rotavirus infection are limited to data from a few reported autopsies, and dehydration with electrolyte imbalance is believed to be the major cause of death. Several recent reports suggest that children who died during a rotavirus illness were viremic before death, because rotavirus was detected at several extraintestinal sites. We report 3 rotavirus-associated deaths among children, 2 of whom had evidence of rotavirus genome in extraintestinal tissues detected by use of novel molecular diagnostic methods. The part played by rotavirus in fatal cases is unclear and requires additional investigation of diarrhea-associated deaths, because a better understanding might alter the approach to treatment and the need for antiviral therapy.

The Humber catchment and its coastal area: from UK to European perspectives

The present water quality of the Humber rivers and coastal zone depends on a complex interplay of factors, including physical ones, such as the underlying geology, which influences soil type, climatic ones, such as the rainfall, which influences runoff, socio-economic ones, which influence present-day human activities in the catchment, and the legacy of former activities, such as contaminated sediments from mining. All of these factors affect the fluxes of nutrients and other contaminants to the rivers and coastal zone. The Water Framework Directive (WFD) requires the production of a river basin management plan intended to lead to the achievement of good chemical and ecological status for all water bodies in the catchment over the next two decades. This paper provides an overview of the current environmental and socio-economic state of the Humber catchment and coastal zone, and broadly examines how socio-economic drivers affect the fluxes of nutrients and contaminants to the coastal zone, using the driver-pressure-state-impact-response (DPSIR) approach. This is followed by an overview of future research, describing the use of scenarios to simulate future fluxes and provide a consistent framework to evaluate potential policies to improve water quality in the estuary. The Humber catchment is one of eight case studies within a European research project, EUROCAT (EVK1-CT-2000-00044), which aims to achieve integrated catchment and coastal zone management by analysing the response of the coastal sea to changes in fluxes of nutrients and contaminants from the catchments. For the Humber case study, the research focuses on the fluxes of two nutrient elements, N and P, and four metal contaminants, As, Cu, Pb and Zn. The project requires the integration of scientific and socio-economic approaches, bringing together quantitative environmental data garnered for individual river catchments and coastal zones in previous research programmes, and local and regional socio-economic data, to aid decision-makers in their search for integrated and sustainable coastal zone management strategies.

Laparascopic sigmoid colectomy for diverticular disease in a patient with situs inversus

We present the case of a 50-year-old man with situs inversus who underwent laprascopic colonic resection for diverticulitis. The patient, who had right-sided pain due to inversion of the viscera mimicking appendicitis, initially presented a diagnostic challenge. A barium meal confirmed situs inversus and the diagnosis of diverticulitis. We present an overview of the operative technique of what is the first documented laparoscopic colectemy in a patient with situs inversus. We then discuss the benefits of the laproscopic approach to colectomy, with reference to this interesting case with unusual anatomy.

Ischaemic preconditioning of skeletal muscle

Ischaemic preconditioning is a process by which exposure of a tissue to a short period of non-damaging ischaemic stress leads to resistance to the deleterious effects of a subsequent prolonged ischaemic stress. It has been extensively described in the heart, but few studies have examined the possibility that it can occur in skeletal muscle. We have used a rat model of ischaemia of one limb to examine this possibility. Exposure of the hind limb to a period of ischaemia of five minutes and reperfusion for five minutes significantly protected the tibialis anterior muscle against the structural damage induced by a subsequent period of limb ischaemia for four hours and reperfusion for one hour. This protection was evident on examination of the muscle by both light and electron microscopy. Longer or shorter times of prior ischaemia had no effect.

Ischaemic preconditioning of skeletal muscle

We have previously shown that prior exposure of rat hind limbs to ischaemia for five minutes and reperfusion for five minutes reduced the structural damage to skeletal muscle which followed a subsequent period of ischaemia for four hours and reperfusion for one hour. We have now examined the potential mechanisms by which this ischaemic preconditioning protocol may be effective in reducing damage to skeletal muscle induced by prolonged ischaemia and reperfusion. Prior exposure of the hindlimb to ischaemia for five minutes and reperfusion for five minutes did not prevent the fall in the ATP content of tibialis anterior which occurred after a subsequent period of ischaemia for four hours and reperfusion for one hour. Similarly, no effect of the preconditioning protocol was seen on the elevated muscle myeloperoxidase, indicative of an elevated neutrophil content, or abnormal muscle cation content. Reperfused ischaemic muscle was also found to have an increased content of heat-shock protein (HSP) 72, but the preconditioning protocol did not further increase the content of this or other HSPs indicating that it was not acting by increasing the expression of these cytoprotective proteins. The protective effects of preconditioning appeared to be mimicked by the infusion of adenosine to animals immediately before exposure to the four-hour period, indicating a potential mechanism by which skeletal muscle may be preconditioned to maintain structural viability.

Clinical evaluation of Double Strength Isotrexin versus Benzamycin in the topical treatment of mild to moderate acne vulgaris

BACKGROUND

Topical retinoid therapy has been shown to be an effective means of treating both the inflammatory and non-inflammatory lesions of acne vulgaris.

AIM

To assess the efficacy and safety of the test product, a gel containing isotretinoin 0.1% w/w and erythromycin 4.0% w/w, with a currently used and effective treatment for mild to moderate acne vulgaris, a gel containing benzoyl peroxide 5.0% w/w and erythromycin 3.0% w/w.

METHODS

This multi-centre, single-blind (investigator blind), parallel group study compared the efficacy and safety of isotretinoin/erythromycin gel (Double Strength Isotrexin) once daily against benzoyl peroxide/erythromycin gel (Benzamycin twice daily in the topical treatment of mild to moderate acne vulgaris. Patients (n = 188) with a history (mean duration 3.3 years) of facial acne vulgaris and with 15-100 inflammatory lesions and/or 15-100 non-inflammatory lesions, but not more than three nodulocystic lesions, were included. At baseline and weeks 2, 4, 8 and 12, the investigator assessed efficacy (total number and severity of inflammatory and non-inflammatory lesions and acne grade) while subjective global change assessments of facial acne from baseline and symptom-specific skin tolerance were assessed by the patient. The investigator recorded an overall global assessment of skin tolerability at week 12. Adverse events were recorded throughout.

RESULTS

The treatments were comparable with regard to their effects on inflammatory and non-inflammatory lesions and acne grade. Few adverse events were considered to be treatment-related. Both the isotretinoin/erythromycin and benzoyl peroxide/erythromycin gels were generally well tolerated. Compliance was better with the isotretinoin/erythromycin gel, which had the advantages of not requiring mixing or storage in a refrigerator, and was applied once rather than twice daily.

CONCLUSIONS

Isotretinoin/erythromycin gel given only once daily showed comparable efficacy with benzoyl peroxide/erythromycin given twice daily in the treatment of mild to moderate acne vulgaris of the face.

Dexamethasone and antibiotics for the empirical treatment of bacterial meningitis in Canadian children: A survey of paediatric infectious diseases specialists

PURPOSE

With the changing epidemiology of the etiological agents causing bacterial meningitis in Canada, the purposes of this study were to determine what empirical antibiotic(s) is/are advocated, and whether dexamethasone is recommended as adjunctive therapy by paediatric infectious diseases specialists for suspected meningitis caused by Streptococcus pneumoniae, Neisseria meningitides, Haemophilus influenzae type b, and partially treated (PT) bacterial meningitis.

METHODS

A questionnaire invoking the specialists' preferred choices in treating bacterial meningitis was circulated by e-mail in March 1999 to 41 paediatric infectious diseases specialists or microbiologists (Paediatric Investigators Collaborative Network on Infections in Canada [PICNIC] members) who practised in 13 paediatric centres located in eight provinces.

RESULTS

Thirty-two (78% response rate) replies were received by July 1999 from 11 paediatric centres in seven provinces. Dexamethasone was recommended by 11 of 32 (34%) respondents for suspected S pneumoniae, four of 32 (12%) for suspected N meningitides, 18 of 32 (56%) for suspected H influenzae type b and five of 32 (16%) for suspected PT meningitis. A trend for more frequent recommended use of dexamethasone for S pneumoniae, H influenzae type b and N meningitides meningitis was found in eastern provinces (Ontario, Quebec and Nova Scotia), as opposed to the western provinces (Manitoba, Saskatchewan, Alberta and British Columbia). The most commonly recommended first line empirical antibiotic therapy was vancomycin plus 3rd-generation cephalosporin (V+3C). This was recommended by 27 of 32 (84%) respondents for suspected S pneumoniae, seven of 32 (22%) for suspected N meningitides, six of 32 (19%) for suspected H influenzae type b and 24 of 32 (75%) for PT meningitis; the remainder recommended using a 3C empirically for each type of meningitis. The major reason cited by respondents for using V+3C for suspected S pneumoniae was the presence of high-and intermediate-level penicillin-resistant S pneumoniae in their centres. No differences were found in the choice of antibiotic(s) between practitioners in the eastern and western provinces.

CONCLUSIONS

Although regional differences exist, the majority of paediatric infectious diseases experts no longer favour the use of dexamethasone for empirical therapy in most cases of bacterial meningitis. V+3C has become the regimen of choice in Canada for most cases of suspected bacterial meningitis.