Prospective study of the disadvantage of people from ethnic minority groups applying to medical schools in the United Kingdom

To assess whether the ethnic origin of applicants affects their likelihood of being accepted into medical school in the United Kingdom the outcome for the 2399 applicants who applied to read medicine at university in 1986 and included St Mary's Hospital Medical School as one of their five choices was studied prospectively. Altogether 2040 of the 2399 applicants were British (United Kingdom) nationals, constituting 24.7% (n = 8249) of all home applicants for medicine in 1986, and 1971 of them with postal addresses in the United Kingdom were sent questionnaires asking about their ethnic origin, whether English was their first language, and about their attitudes to ethnic monitoring. A total of 1817 (92.2%) applicants returned the questionnaire, 401 (22.6%) saying that they were from an ethnic minority group and 393 (21.6%) having non-European surnames. Multiple logistic regression identified 11 significant predictors of successful application, of which grades at O and A level, application after A levels, and date of application were the most important. After taking these four variables into account the predicted acceptance rates for home students on the basis of their application forms alone were 47.8% for white applicants and 35.6% for applicants from ethnic minority groups compared with actual acceptance rates of 49.6% and 27.3%, respectively. The difference in success of white and non-white applicants could partly but not entirely be explained by differences in the characteristics considered to be important in a professional context by selectors during shortlisting of candidates: academic ability, interests, and contribution to the community. No differences in the success rate of applicants from ethnic minority groups to individual medical schools could be identified. More research is needed to discover how perceptions of professional suitability are assessed from application forms and interviews.

Effect of oral nimodipine on cerebral infarction and outcome after subarachnoid haemorrhage: British aneurysm nimodipine trial

OBJECTIVE

To determine the efficacy of oral nimodipine in reducing cerebral infarction and poor outcomes (death and severe disability) after subarachnoid haemorrhage.

DESIGN

Double blind, placebo controlled, randomised trial with three months of follow up and intention to treat analysis. To have an 80% chance with a significance level of 0.05 of detecting a 50% reduction in an incidence of cerebral infarction of 15% a minimum of 540 patients was required.

SETTING

Four regional neurosurgical units in the United Kingdom.

PATIENTS

In all 554 patients were recruited between June 1985 and September 1987 out of a population of 1115 patients admitted with subarachnoid haemorrhage proved by the results of lumbar puncture or computed tomography, or both. The main exclusion criterion was admission to the neurosurgical units more than 96 hours after subarachnoid haemorrhage. There were four breaks of code and no exclusions after entry. One patient was withdrawn and in 130 treatment was discontinued early. All patients were followed up for three months and were included in the analysis, except the patient who had been withdrawn.

INTERVENTIONS

Placebo or nimodipine 60 mg was given orally every four hours for 21 days to 276 and 278 patients, respectively. Treatment was started within 96 hours after subarachnoid haemorrhage.

END POINTS

Incidence of cerebral infarction and ischaemic neurological deficits and outcome three months after entry.

MEASUREMENTS

Demographic and clinical data, including age, sex, history of hypertension and subarachnoid haemorrhage, severity of haemorrhage according to an adaptation of the Glasgow coma scale, number and site of aneurysms on angiography, and initial findings on computed tomography were measured at entry. Deterioration, defined as development of a focal sign or fall of more than one point on the Glasgow coma scale for more than six hours, was investigated by using clinical criteria and by computed tomography, by lumbar puncture, or at necropsy when appropriate. All episodes of deterioration and all patients with a three month outcome other than a good recovery were assessed by a review committee.

MAIN RESULTS

Demographic and clinical data at entry were similar in the two groups. In patients given nimodipine the incidence of cerebral infarction was 22% (61/278) compared with 33% (92/276) in those given placebo, a significant reduction of 34% (95% confidence interval 13 to 50%). Poor outcomes were also significantly reduced by 40% (95% confidence interval 20 to 55%) with nimodipine (20% (55/278) in patients given nimodipine v 33% (91/278) in those given placebo).

CONCLUSIONS

Oral nimodipine 60 mg four hourly is well tolerated and reduces cerebral infarction snd improves outcome after subarachnoid haemorrhage.

Synthesis and biological properties of the lipophilic technetium-99m complex 99mTc(acac)3

In the development of technetium-99m radiopharmaceuticals for the evaluation of regional cerebral perfusion, one series of complexes that has remained unexplored is the neutral lipophilic tris complexes formed with beta-diketonato ligands. The prototype complex of this series, tris(2,4-pentanedionato) technetium(III), has been prepared via a new synthetic route and chemically characterized using 99Tc and the biodistribution of the no-carrier-added 99mTc complex has been determined. The 99mTc complex was found to be distributed throughout the body with persistent high blood levels indicative of a high degree of protein binding. The primary route of excretion was the hepatobiliary system as indicated by the appearance of 99mTc in the gut and feces at longer sample times post-injection. Although this complex was not retained by the brain, it does provide a starting point from which a more effective agent might be developed.

Reliability of interviewing in medical student selection

Six interviewing panels which had assessed candidates for places at a medical school in 1984 were reconvened in 1987 to assess videotapes of the interviews conducted by themselves and by other panels. Overall recommendations made by panels showed excellent reliability within panels and high reliability between panels.

The clinical significance of elevated CSF and plasma histamine in cerebral aneurysm surgery utilizing cardiopulmonary bypass with total circulatory arrest

Recently there has been a renewed interest in the neurosurgical treatment of large cerebral aneurysms and AV malformations utilising cardiopulmonary bypass (CPB) and total circulatory arrest (TCA). However, the differing tolerance limits of coagulation and bleeding, pH control and fluid constraint are difficult to reconcile. Although clinical assessment, electro encephalogram (EEG) and intracranial pressure-monitoring assist in identification of cerebral damage, CPB and TCA inflict their own penalties with resultant uncertainty in post-operative neurological evaluation, and producing difficulties in interpretation and management. Additionally, an unanswered question is, to what extent the known cardiac and cerebral effects of circulating histamine might influence the post-circulatory arrest recovery in these patients, and whether this would further compromise the neurological result. We report our experience of 9 such cases who underwent this procedure, and were able to achieve a satisfactory neurological result in 7 patients with differing lesions. During the operation both CSF (from the open cranium) and blood (from the right internal jugular vein) were sampled at intervals for subsequent plasma histamine estimation. Despite markedly elevated histamine levels during CPB and TCA, this was not associated with an unfavourable neurological outcome. These early findings have given us encouragement to the useful role of CPB and TCA in these complex neurosurgical presentations, and raise interesting questions about the clinical importance of histamine-evoked cerebral ischaemia that has been demonstrated in experimental models.

Hemispherectomy for childhood epilepsy: a 36-year study

Between 1950 and the present day 17 patients who had been treated for hemiplegic epilepsy by hemispherectomy were followed up. The outcomes of surgery in terms of survival, arrest of dementia, relief from gross disorders of behaviour and from habitual epilepsy were uniformly good. It is concluded that hemispherectomy has an enduring rôle in the treatment of hemiplegic epilepsy for patients who are carefully selected, prepared and postoperatively rehabilitated.

Choice and ordering of medical school applications: cause for concern

The probability of admission to medical school in the UK can be predicted from the choices of schools and their order on the UCCA form, even after academic factors have been taken into account. The effect may of itself influence a candidate's chance of admission by a factor of about four times. This situation justifies the recurrent complaints of applicants about the problems of medical school choice and ordering. The disadvantage imposed on many applicants would be reduced if rank ordering of choices was replaced by alphabetical ordering.

AIDS and the neurosurgeon

AIDS is a fatal viral infection transmitted by body fluids, primarily blood, which is becoming more common in the U.K., and if the gloomiest predictions are true will affect millions in the next decade. Most, if not all, of these patients will at stage develop neurological manifestations: therefore the neurosurgeon will find it difficult to avoid close contact with the syndrome. As the presentation may mimic a number of neurological conditions, or patients with AIDS may suffer head injury, subarachnoid haemorrhage, or other common conditions, it is probably wise to assume all patients have AIDS and to modify operating technique and other procedures where blood may be spilt to minimise the risks of acquiring the infection.

Return migration from Australia: a case study

"The study investigates the departure from Australia of former settlers who arrived during the 1980 calendar year. The 1980 settler arrival cohort [consists] of 75,167 visaed migrants.... The study has three main aims: (i) to analyse departures from Australia of the 1980 settler arrival cohort with a view to gauging the success of Australia's immigration program in retaining settlers; (ii) to examine the retention rates of settlers with respect to characteristics...including age, sex, marital status, country of last residence, and settler eligibility category; and (iii) to consider implications of the findings." Australia's present immigration policy is discussed, previous research on return migration from Australia is summarized, and a detailed analysis of the departure data is presented. "This study found that by August 1984, 12.4 per cent of non-refugee settlers who arrived in Australia during 1980 had departed permanently but that only 0.6 per cent of the 1980 refugee cohort had done so." These figures represent a decline in immigrant departure rates since the 1960s and early 1970s. Small differences in departure rates by place of birth, age, and marital status, which may have demographic consequences if sustained over time, are noted. (SUMMARY IN FRE AND SPA)

Methods of Analysis for Infant Formula: Food and Drug Administration and Infant Formula Council Collaborative Study, Phase III

Phase III of the collaborative study of methods of assay for nutrients in infant formulas was conducted. The study included assay of chloride, phosphorus, proxiraates (ash, fat, protein, total solids, and carbohydrates), thiamine, total pantothenates, and vitamins A, Bu, and E. Most of the methods were those in Official Methods of Analysis, 13th edition, with slight modifications, or methods of the Infant Formula Council. On the basis of the results obtained by the collaborators, the methods for chloride, phosphorus, proximates, thiamine, and vitamin Bu have been adopted official first action. Methods for total pantothenates, vitamin A, and vitamin E were not recommended for adoption at this time because of anticipated improvements in methodology in the foreseeable future.

Prospective survey of performance of medical students during preclinical years

The performance during the preclinical course of 517 students who had applied to this medical school for admission in 1981 and who had been accepted by the school or by another British medical school was analysed in relation to variables measured at the time of application to find factors that predicted success in the preclinical course, whether students chose to take an intercalated degree, and the class achieved in the intercalated degree. Thirty one of the 507 students who entered medical school withdrew from the course or failed their examinations; these students were particularly likely not to have an A level in a biological science. O level grades were of minimal predictive value for performance during the preclinical course. A level grades discriminated between successful and unsuccessful students but had too low a specificity or sensitivity to be of use in individual prediction. Mature entrants performed better overall than school leavers. Background variables accounted for only 14.2% of the variance in performance, implying that motivation and personality may be more important in determining performance. The 80 students who chose to take an intercalated degree were more likely to be men and not to be mature entrants; for a further 50 students intercalated degrees were obligatory. Performance in the intercalated degree related to performance during the preclinical course and to assessments made at the selection interview but not to achievement at O or A level.

Effect of respiratory motion on pulmonary activity determinations by positron tomography in dogs

The effect of respiratory motion on pulmonary activity determinations by positron emission tomography (PET) was studied in dogs with experimentally created pulmonary emboli (PE). The location of the PE was evaluated by planar 99mTc lung imaging to determine the appropriate sites for transaxial PET scans. PET scans of the lung then were obtained after i.v. injection of 68Ga-labeled microspheres. PET scans were acquired during slow (15 breaths/min) and fast (30 breaths/min) breathing with the same minute ventilation and then postmortem. Lung perfusion patterns were documented by i.v. injection of India ink before sacrifice. Cross sections of the excised lungs were made at the same levels as the PET scans, and eight sections containing 14 perfusion defects were analyzed. The scans obtained during slow breathing consistently showed edge blurring and demonstrated defects less well than scans obtained during fast breathing or postmortem. The normal-to-defect activity ratios during fast breathing and on the postmortem studies were similar and approximately 17% higher (P less than .01) than in scans obtained in the same animals during slow breathing. The results demonstrate the need for motion correction during quantitative analysis of regional lung activity by positron tomography, and suggest that high-frequency respiration at small tidal volumes may be one means for obtaining this correction.

Microsurgery for stroke

Stroke remains a major problem in the Western world but microneurosurgical procedures are applicable only to a minority of victims, namely those with intracranial carotid occlusion and those with aneurysms or arteriovenous malformations. The operating microscope has made the technical approach to these feasible. However, questions remain as to the validity of the extracranial-intracranial bypass in carotid occlusion and the timing of aneurysm surgery. These questions tend to overshadow the technical advances following on from use of the operating microscope.

Focal epilepsy with mesial temporal sclerosis after acute meningitis

Following acute meningitis associated with severe convulsions in childhood, two patients had chronic, drug-resistant, temporal lobe epilepsy. This disorder was preceded by an entirely natural development, in one case extending for nine years and in the other case for eight years. Each patient was treated with right anterior temporal lobectomy. Classic mesial temporal sclerosis (Ammon's horn sclerosis) was found in both patients. Relief of the epilepsy was associated with remission of the concomitant social and psychiatric handicaps. At least ten years of follow-up are required in the evaluation of the treatment of early brain infections. Chronic focal epilepsy after childhood meningitis with febrile convulsions merits neurosurgical consideration.

Immunoreactivity and biodistribution of indium-111-labeled monoclonal antibody to a human high molecular weight-melanoma associated antigen

The anti-human, high molecular weight-melanoma associated antigen (HMW-MAA) MoAb 225.28S was chelated with 111In and then tested for its in vitro reactivity with cultured human melanoma cells and for its biodistribution in human melanoma bearing nude mice. In vitro studies showed that the radiolabeled antibody reacted specifically with cultured melanoma cells. However, binding of DTPA to the monoclonal antibody reduced its titer with cultured melanoma cells from 1:1024 to 1:512. Further labeling of the DTPA-antibody conjugate with 111In caused an additional reduction of its titer to 1:128. Injection of the radiolabeled monoclonal antibody into nude mice resulted in the accumulation of significantly (p less than 0.001) higher radioactivity in melanoma tissue than in nude mice injected with either [111In] chloride or 111In-labeled antibody to human acid phosphatase. The specificity of the distribution of the radiolabeled antibody in nude mice also was indicated by its poor localization in lesions other than melanoma (e.g., human prostate carcinoma and chronic abscess). The localization of antibody in liver and kidney was also high, although lower than that achieved in tumor. These results indicate that 111In-labeled monoclonal antibodies to human tumor associated antigens may be useful for localizing malignant lesions. However, there is a need to improve labeling and/or purification of antibody in order to decrease renal and hepatic activity.

The development and in-vivo behavior of tin containing radiopharmaceuticals--II. Autoradiographic and scintigraphic studies in normal animals and in animal models of bone disease

Various 117mSn (2+ and 4+) compounds in well defined oxidation states were studied in normal mice using whole body autoradiography (WBARG), tissue distribution and scintigraphy in animal models of vitamin A induced bone disease, fracture, infected fracture and ischemic muscle lesions. The 117mSn4+-DTPA showed high affinity to normal bone with low soft tissue concentration. Increased deposition of this compound in fractures and ischemic lesions in muscle was also demonstrated. In hypervitaminosis A, reduced bone uptake of 117mSn4+-DTPA was shown to occur. Nude mice bearing osteogenic sarcoma of human origin showed uptake in spiculated pattern. The similar distribution of 117mSn4+-DTPA which does not contain phosphate or phosphonate groups, and the 99mTc(Sn) skeletal imaging compounds may indicate that tin is important in binding to bone. 117mSn4+-DTPA may not be ideal for routine imaging except when long term follow up is required. It should however be considered for therapy of bone tumors because of the long physical half-life of 117mSn (t1/2 = 14.03 days), abundance of short-range conversion and Auger electrons and its preferential deposition in cortical bone as indicated by our results.

The development and in-vivo behavior of tin containing radiopharmaceuticals--I. Chemistry, preparation, and biodistribution in small animals

Tin is an essential ingredient of most technetium-99m radiopharmaceutical preparations but its in-vivo distribution and long-term fate are not well understood. Tin-117m (t1/2 14d; gamma 159 keV, 86%) is an ideal tracer for studying biological behavior of tin compounds as well as for developing clinically-useful radiopharmaceuticals. This work describes the preparation and in-vivo distribution in mice of a number of tin-117m labeled compounds with commonly used ligands. High bone uptake of most compounds studied as well as the unexpectedly high bone uptake of Sn4+-DTPA indicates a high bone affinity of tin bound to chemically diverse ligands. Various compounds show subtle but significant differences in blood clearance, excretion, and soft-tissue uptake. Differences among Sn2+ and Sn4+ compounds with the same ligand are particularly noteworthy. For stannic chelates, higher bone uptake, faster blood clearance, and reduced soft-tissue concentration were observed. It appears that tin compounds bind to bone predominantly through the tin atom and that the differences in biodistribution depend on factors such as the net charge on the complex, the oxidation state of tin, and hydrolytic and kinetic stabilities of the complexes. The results indicate that the favorable half-life and decay characteristics of tin-117m in various stannic compounds, especially stannic-DTPA, make it potentially useful as an agent for skeletal scintigraphy and radiotherapy of bone tumors.

Audit of admission to medical school: III--applicants' perceptions and proposals for change

Applicants to St Mary's Hospital Medical School were asked to comment freely on the process of selection. They were particularly concerned about the role of interviews, excessive emphasis on academic achievement, the problem of rank-ordering choices on the UCCA form, and possible biases in selection. These concerns and the results of our survey suggest that candidates should not be asked to rank their choices in order of preference, that UCCA applications for medicine should be subject to an early closing date, that as many applicants as possible should be interviewed, that applicants should be encouraged to apply after taking A levels, that educational opportunity should be taken into account in assessing A level grades, and that mature students should be encouraged, not least by providing mandatory awards for a second degree in medicine.

Audit of admission to medical school: II--Shortlisting and interviews

Analysis of shortlisting of applicants for interview at St Mary's Hospital Medical School showed that factor analysis could reduce the selection criteria to three independent scales--"academic ability," "interests," and "community service"--all of which contributed to the interview decision. Early applicants scored more highly on all three factors but were still at a greater advantage in selection for interview than would have been predicted. The dean's judgment of priority for interview from the UCCA form was found to predict a candidate's chance of acceptance at other medical schools besides St Mary's. Analysis of interviewing showed high correlations among interviewers in their assessments, although there was evidence of influence by the chairmen. Factor analysis showed three major factors--academic suitability, non-academic suitability, and health--of which non academic suitability was the major determinant of interview success. Non academic suitability was related to personality (high extraversion and low psychoticism) and to the choices made on the UCCA form. The system of admission interviews enabled greater emphasis to be put on broader interests and achievements than if selection had been on the basis of UCCA application form alone.

Audit of admission to medical school: I--Acceptances and rejects

A prospective study of the process of application, selection, and admission to medical school was performed. St Mary's Hospital Medical School received 1478 UCCA applications for admission in October 1981: 94 (6.4%) applicants entered St Mary's in October 1981, 436 (29.5%) entered other medical schools, 176 (11.9%) read a subject other than medicine, and 772 (52.2%) did not enter university. The study included 12.6% of all applicants and 12.9% of all entrants to British medical schools in October 1981. Educational qualifications, demographic variables, type of schooling, family background, and the manner of application were examined in relation to overall selection. A level achievement was the major determinant of acceptance. O level achievement, early application, and medical parents had significant but smaller independent effects on the chance of acceptance. Social class, age, sex, and school type did not predict acceptance when corrected for academic and other factors. Few differences in personality, career preference, cultural interests or attitudes were found between those accepted and those rejected.

Developmental aspects of focal epilepsies of childhood treated by neurosurgery

Data on 50 patients treated surgically for intractable focal epilepsy were analysed. There were 10 hemispherectomies, 32 temporal lobectomies and eight operations to other areas of the brain. The median age at operation was 14 years. 29 patients were found to have mesial temporal sclerosis or sclerotic hemispheres and 17 had alien tissue and one sclerosis with heterotopia. No lesion was found in three cases. The nature of the first seizure was found to relate significantly to pathology. 30 patients had suffered an early convulsion. Between the convulsive insult and the onset of focal epilepsy there was a silent interval, the duration of which was biased by sex and side of lesion. The remaining 20 patients, of whom a highly significant number had alien tissue, had not had an early convulsion before the onset of focal epilepsy. The importance of accurate clinical histories is stressed. Clinical considerations alone predicted the pathology and laterality of the lesion in more than half the series. Regular EEG recordings and repeat scanning were found to be important investigations. Major disorders of behaviour had occurred in 44 patients. As adults, the series were free of severe psychiatric symptoms, but many required years of careful rehabilitation. 31 children had been excluded from normal schools before operation. Postoperatively, many patients continued their education in normal schools. Some required basic remedial teaching, others successfully undertook higher education and training. 49 patients benefited over-all from neurosurgical treatment. 34 had no more habitual epilepsy at all. Full global gains often took at least five years to achieve.

A comparison of the cyclic anhydride and mixed anhydride methods for 111In-DTPA chelation to monoclonal antibodies

The cyclic anhydride (CA) and the mixed anhydride (MA) of DTPA were synthesized and used to chelate 111In to an antimelanoma monoclonal antibody. The CA and MA methods showed mean labeling efficiencies of 25.7 and 20.5%, respectively (p = NS). The binding efficiency of labeled antibody to human melanoma cells in tissue culture also was similar (means = 52 and 50%, respectively, p = NS), as was tumor uptake in nude mice at 96 hrs post-injection (16%-CA vs 12%-MA). The method required less complicated chemical syntheses, much less preparation time, and the product was stable over a much longer period. The results suggest that the CA method is preferable for bifunctional chelate labeling of monoclonal antibodies with 111In-DTPA.

Long-term outcome in children with temporal lobe seizures. V: Indications and contra-indications for neurosurgery

One hundred unselected children with temporal lobe epilepsy were followed up between 1948 and 1982. The series was a personal one. None was lost to observation. For 42 patients, contra-indications for surgery had emerged before the end of their schooldays. 29 cases were considered for surgery. 16 were rejected on technical grounds, and none of these made an epileptic, social, psychiatric or personality recovery. 13 patients were operated on, none of whom continued to have habitual epilepsy: all their biographies were remarkably improved, though several years postoperative care sometimes was needed. The authors conclude that surgery plays a major rôle in the treatment of temporal lobe epilepsy of childhood, and those who would benefit usually can be recognised before leaving school.

Operative findings on microsurgical exploration of the cerebello-pontine angle in trigeminal neuralgia

The anatomical findings in 52 patients undergoing posterior fossa exploration for idiopathic trigeminal neuralgia are described. Anatomical abnormalities in the cerebello-pontine angle were found in 46. The commonest was an arterial loop indenting or distorting the nerve at the root entry zone. In view of this the operative procedure has been changed from root section to microvascular decompression.