Suspected skin malignancy: a comparison of diagnoses of family practitioners and dermatologists in 493 patients

BACKGROUND

In the Irish health system, dermatology patients present to their family practitioner for diagnosis and treatment, and are referred to a dermatologist for a second opinion where diagnosis is in doubt or when there has been therapeutic failure. The level of expertise in dermatology amongst family practitioners varies considerably.

AIM

To compare the diagnoses of general practitioners and dermatologists over a selected period in patients with a possible diagnosis of skin cancer.

METHODS

Four hundred and ninety-three patients were seen by one of two dermatologists over a 1-year period at a rapid referral clinic for patients suspected by their family practitioners of having unstable or possibly malignant skin lesions; 213 of these patients had a diagnosis made on clinical examination by the dermatologist, while 264 had diagnostic or therapeutic biopsies performed; 16 patients defaulted on surgery.

RESULTS

The diagnoses of the family practitioners agreed with the diagnoses of the dermatologists on patients diagnosed clinically in 54% of cases. Thirty-eight patients had histologically proven skin malignancy. These were diagnosed accurately by the referring family practitioner in 22% of patients, while the dermatologists made the correct diagnosis prior to biopsy in 87%.

CONCLUSIONS

In over 50% of cases diagnosed clinically, the dermatologist and family practitioner agreed. Histologically proven skin cancers were diagnosed accurately in only 22% of cases by family practitioners, compared to 87% of cases by dermatologists. Specific areas of diagnostic difficulty for family practitioners include benign pigmented actinic and seborrheic keratoses, squamous cell carcinoma, and melanoma. Postgraduate education for family practitioners should be directed towards these areas of deficiency. Dermatologists had difficulty distinguishing pigmented actinic keratoses from melanoma.

Treatment with a growth hormone secretagogue in a model of developing heart failure: effects on ventricular and myocyte function

BACKGROUND

Exogenous administration of growth hormone (GH) and subsequently increased production of insulin-like growth factor-1 can influence left ventricular (LV) myocardial growth and geometry in the setting of congestive heart failure (CHF). This study determined the effects of an orally active GH secretagogue (GHS) treatment that causes a release of endogenous GH on LV function and myocyte contractility in a model of developing CHF.

METHODS AND RESULTS

Pigs were randomly assigned to the following treatment groups: (1) chronic rapid pacing at 240 bpm for 3 weeks (n=11); (2) chronic rapid pacing and GHS (CP-424,391 at 10 mg x kg(-1) x d(-1), n=9); and (3) sham controls (n=8). In the untreated pacing CHF group, LV fractional shortening was reduced (21+/-2% versus 47+/-2%) and peak wall stress increased (364+/-21 versus 141+/-5 g/cm(2)) from normal control values (P:<0.05). In the GHS group, LV fractional shortening was higher (29+/-2%) and LV peak wall stress lower (187+/-126 g/cm(2)) than untreated CHF values (P:<0.05). With GHS treatment, the ratio of LV mass to body weight increased by 44% from untreated values. Steady-state myocyte velocity of shortening was reduced with pacing CHF compared with controls (38+/-1 versus 78+/-1 microm/s, P:<0.05) and was increased from pacing CHF values with GHS treatment (55+/-7 microm/s, P:<0.05).

CONCLUSIONS

The improved LV pump function that occurred with GHS treatment in this model of CHF was most likely a result of favorable effects on LV myocardial remodeling and contractile processes. On the basis of these results, further studies are warranted to determine the potential role of GH secretagogues in the treatment of CHF.

Death of a psychiatric patient during physical restraint. Excited delirium--a case report

We report the case of a young man with a diagnosis of paranoid schizophrenia and multiple drug abuse who died in hospital following a period of prolonged physical restraint. The literature is reviewed, possible factors contributing to death discussed and measures which may reduce the incidence of such deaths in the future highlighted.

Capture-recapture: a useful methodological tool for counting traffic related injuries?

INTRODUCTION

Although the capture-recapture technique is increasingly employed in studies of human populations to correct for under-ascertainment in traditional epidemiological surveillance, it has rarely been used in injury research.

OBJECTIVES

To estimate the completeness of official data sources on traffic related injuries (TRIs) by using the capture-recapture technique and to calculate an ascertainment corrected number of fatal and serious TRIs among Scottish young people aged 15-24 years. The appropriateness of the approach in this context is also assessed.

METHOD

A two sample capture-recapture technique was applied to two official sources of TRI data. Data on TRIs were obtained from the Scottish Health Service and the STATS19 dataset at the University of Essex Data Archive for 1995. Four standards (A-D) of matching were applied to fatalities and serious TRIs to allow plausible relaxation of matching standards within the context of the data collection setting. The completeness of each data source was assessed, and an ascertainment corrected number of fatalities and serious TRIs calculated.

RESULTS

The ascertainment corrected number of TRI fatalities among 15-24 year olds using standard D was 104. This represents only a small increase in the number of fatalities using capture-recapture than when using each individual dataset. The completeness of the Scottish Health Service database for TRI fatalities was 93%. The STATS19 database was 95% complete. The ascertainment corrected number of TRI hospital admissions was 1969. The STATS19 and the Scottish Health Service databases were approximately two thirds and three quarters complete respectively for non-fatal TRIs requiring hospitalisation.

CONCLUSIONS

Injury researchers have advocated the linkage of major datasets to supplement and improve the quality of injury data. Using capture-recapture we found that routine databases enumerate TRI fatalities accurately, in contrast to injury morbidity databases that do not. Capture-recapture is a potentially useful method of evaluating the completeness of data sources and identifying biases within datasets. However, ascertainment corrected rates should be viewed with caution. A number of requirements of the capture-recapture technique are unachieved in this study of injury in the human population.

Trends in injury mortality among young people in the European Union: a report from the EURORISC working group

PURPOSE

To examine the trends in injury mortality among young people aged 15-24 years residing in the 15 current member states of the European Union between 1984 and 1993.

METHODS

As part of a European Commission-funded project entitled European Review of Injury Surveillance and Control (EURORISC), mortality data for all externally caused physical injuries (International Classification of Disease Codes E800-999) were obtained from the World Health Organization. Data were analyzed to generate age-specific injury mortality rates and proportional differences in rates over the study period. Linear regression was used to represent the linear component of the mortality profile.

RESULTS

Almost a quarter of a million young people died as a result of sustaining an externally caused physical injury (either unintentional or intentional) in the study countries between 1984 and 1993. Injury accounted for two-thirds of all deaths in this age group. Over three-quarters (76%) of deaths were due to unintentional injury, a further 17% to self-inflicted injuries, and the remaining 7% to homicide and other violent causes. Motor vehicle traffic fatalities accounted for 84% of unintentional injury deaths. Although a decline in injury mortality was observed throughout Europe, rates of mortality owing to both unintentional injuries and suicide varied widely among study countries at both the beginning and end of the study period.

CONCLUSIONS

Whereas injury mortality rates in young people in most European countries are lower than in other parts of the world (including the United States), injuries represent a major public health problem in the European Union. The death toll from motor vehicle traffic crashes is a particular cause for concern.

A woman with leprosy is in double jeopardy

The double jeopardy associated with female leprosy patients is the central theme underpinning this essay. It constitutes a combination of biological factors unique to women and culturally defined bias, resulting in more stigmatization and isolation for women. Having examined the female immunological response and biological roles, the essay continues by focusing on the gender-culture perspective of leprosy. It draws upon an historical analysis of the experiences of Indian and African women to illustrate the ways in which gender roles impact upon health education and the utilization of health care services. Concluding comments suggest strategies that might improve female leprosy patient status, and views towards future research.

A subependymal giant cell astrocytoma in a cat

A 6-year-old spayed female Domestic Shorthair cat presented with a 1 to 2-month history of blindness and altered behavior. At necropsy, a 1-cm-diameter, firm white mass was found arising from the subependymal region of the right lateral ventricular wall that protruded into and partially filled the lumen. Histologically, there was a well-demarcated, expansile paraventricular neoplasm composed of moderately pleomorphic cells within a richly fibrillar matrix arranged in interlacing streams and perivascular pseudorosette-like patterns. Neoplastic cells varied in morphology from small spindloid cells to larger polygonal cells with eccentric vesicular nuclei to neuronlike cells with vesicular nuclei and prominent nucleoli. The mitotic index was low. Immunohistochemically, neoplastic cells were positive for S-100 protein, glial fibrillary acidic protein, and neuron-specific enolase and negative for neurofilament protein. Ultrastructurally, the cells contained few to abundant bundles of intermediate filaments with variable numbers of mitochondria, endoplasmic reticulum, and ribosomes. These features are characteristic of subependymal giant cell astrocytoma (SEGA) in humans. To our knowledge, this is the first reported case of SEGA in domestic animals.

Compliance with prescribed drugs: challenges for the elderly population

Compliance with prescribed drug regimens is particularly important among the elderly because of their increased vulnerability and greater burden of chronic disorders. This narrative review discusses the factors that are important to compliance, with particular reference to the elderly. These factors are the patient's perceptions of his disease and it's treatment, the physician's perceptions, the manner the physician assumes and the language he uses to communicate with the patient, the patient's living situation, regular medication review, and a continuity of health care provision. Since it is the patient who decides how to use the therapy, his or her involvement in the process of explaining and understanding it is the key to improved compliance.

Mycobacterial spindle cell pseudotumor of the brain: a case report and review of the literature

Spindle cell pseudotumors found in the skin, lymph nodes, bone marrow, spleen, lungs, and retroperitoneum have been reported recently in immunosuppressed patients, including those with acquired immunodeficiency syndrome. The authors report a similar lesion limited to the brain in a 38-year-old human immunodeficiency virus-negative man receiving steroid therapy for treatment of sarcoidosis. Histopathologically the lesions were composed of spindle and epithelioid histiocytes, small foci of necrosis, and numerous acid-fast bacilli. The acid-fast bacilli were determined by culture and polymerase chain reaction to be Mycobacterium avium intracellulare. Because of the uncommon histologic appearance of this lesion and the potential for treatment if recognized, mycobacterial spindle cell pseudotumors should be included in the differential diagnosis of spindle cell lesions in the brain in immunosuppressed patients.

Quality-of-life questionnaire for patients taking antihypertensive medication

This study was undertaken to construct a health-related quality-of-life (QOL) questionnaire for hypertensive patients from preexisting instruments and to validate its use in full form and in a shortened version. Two hundred seventy hypertensive patients who were stable while taking antihypertensive medication (control group), changing medication because of side effects, or newly treated for hypertension were enrolled in a prospective, observational, longitudinal study. At baseline and at months 1, 2, and 3, patients completed a questionnaire covering 7 domains of QOL. The criteria for evaluating the scales were internal consistency, test-retest reliability, construct validity, and responsiveness to change. Data were analyzed for the full questionnaire and the shortened version. Internal consistency and test-retest correlation values were 0.69 to 0.95 for scales in the full questionnaire and 0.57 to 0.92 in the shortened version. Construct validity was supported by statistically significant, positive correlations with a global QOL item for all but 1 scale in both versions. Responsiveness to change was supported by increases in scores between baseline and month 3 for all scales in patients changing their medication because of side effects; scores remained unchanged (on all but 1 scale) in the stable (control) group. By uniformly applying standard validation criteria to a set of preexisting instruments, we created a new QOL questionnaire. Results were similar in both the full form and shortened version.

Unintentional childhood injury mortality in Europe 1984-93: a report from the EURORISC Working Group

OBJECTIVE

To examine recent trends in unintentional childhood injury mortality in Europe, and to identify the contribution of specific causes.

SETTING

The 15 current member countries of the European Union.

METHODS

Analysis of mortality data (1984-93) obtained from the World Health Organisation and national government agencies.

RESULTS

Injuries continue to be the leading cause of childhood death in all study countries, with more than 4500 fatalities annually, accounting for over 30% of all child mortality. The major causes of death in all countries were injuries due to motor vehicle traffic accidents, drownings, fire and flames, and falls. Portugal experienced mortality rates double those of most other countries, with the differentials particularly stark early in the study period. Although a decrease in age standardised mortality rates was observed in all countries over the decade, the extent of the decrease varied widely, from -47% in the UK to -11% in Finland.

CONCLUSION

The pattern of childhood injury in Europe is similar to that observed elsewhere in the world. None the less, differences in rates of childhood injury mortality persist between countries. Identifying the reasons for these variations between countries may hold the key to the reduction injury rates in Europe as a whole.

The role of kreisler in segmentation during hindbrain development

The mouse kreisler gene is expressed in rhombomeres (r) 5 and 6 during neural development and kreisler mutants have patterning defects in the hindbrain that are not fully understood. Here we analyzed this phenotype with a combination of genetic, molecular, and cellular marking techniques. Using Hox/lacZ transgenic mice as reporter lines and by analyzing Eph/ephrin expression, we have found that while r5 fails to form in these mice, r6 is present. This shows that kreisler has an early role in the formation of r5. We also observed patterning defects in r3 and r4 that are outside the normal domain of kreisler expression. In both heterozygous and homozygous kreisler embryos some r5 markers are induced in r3, suggesting that there is a partial change in r3 identity that is not dependent upon the loss of r5. To investigate the cellular character of r6 in kreisler embryos we performed heterotopic grafting experiments in the mouse hindbrain to monitor its mixing properties. Control experiments revealed that cells from even- or odd-numbered segments only mixed freely with themselves, but not with cells of opposite character. Transposition of cells from the r6 territory of kreisler mutants reveals that they adopt mature r6 characteristics, as they freely mix only with cells from even-numbered rhombomeres. Analysis of Phox2b expression shows that some aspects of later neurogenesis in r6 are altered, which may be associated with the additional roles of kreisler in regulating segmental identity. Together these results suggest that the formation of r6 has not been affected in kreisler mutants. This analysis has revealed phenotypic and mechanistic differences between kreisler and its zebrafish equivalent valentino. While valentino is believed to subdivide preexisting segmental units, in the mouse kreisler specifies a particular segment. The formation of r6 independent of r5 argues against a role of kreisler in prorhombomeric segmentation of the mouse hindbrain. We conclude that the mouse kreisler gene regulates multiple steps in segmental patterning involving both the formation of segments and their A-P identity.

Childhood injury mortality in Scotland, 1981-95

OBJECTIVE

To examine the trends in childhood injury mortality in Scotland between 1981 and 1995.

DESIGN

Analysis of mortality data from the Registrar General for Scotland.

SETTING

Scotland, UK.

SUBJECTS

Children aged 0-14 years.

MAIN RESULTS

A total of 1,728 children died in Scotland as a result of an injury between 1981-1995. While a significant decrease in the rates of unintentional injury mortality was observed for both sexes, all ages and most causes over the study period, the proportion of total child deaths due to injury decreased only slightly. Road traffic accidents were the major cause of injury mortality in this age group, representing over 40% of all injury deaths both at the beginning and the end of the study period. Males and young children of both sexes had consistently higher injury mortality rates. Similar reductions in injury mortality rates were observed for males and females.

CONCLUSIONS

Childhood injury mortality rates have declined in Scotland, affecting all injury causes. The analysis of injury mortality rates in the population is helpful in highlighting potential environmental hazards that result in injury and in monitoring progress towards the achievement of national and local targets.

Injury surveillance in an accident and emergency department: a year in the life of CHIRPP

BACKGROUND

The design of childhood injury prevention programmes is hindered by a dearth of valid and reliable information on injury frequency, cause, and outcome. A number of local injury surveillance systems have been developed to address this issue. One example is CHIRPP (Canadian Hospitals Injury Reporting and Prevention Program), which has been imported into the accident and emergency department at the Royal Hospital for Sick Children, Glasgow. This paper examines a year of CHIRPP data.

METHODS

A CHIRPP questionnaire was completed for 7940 children presenting in 1996 to the accident and emergency department with an injury or poisoning. The first part of the questionnaire was completed by the parent or accompanying adult, the second part by the clinician. These data were computerised and analysed using SPSSPC for Windows.

RESULTS

Injuries commonly occurred in the child's own home, particularly in children aged 0-4 years. These children commonly presented with bruising, ingestions, and foreign bodies. With increasing age, higher proportions of children presented with injuries occurring outside the home. These were most commonly fractures, sprains, strains, and inflammation/oedema. Seasonal variations were evident, with presentations peaking in the summer.

CONCLUSIONS

There are several limitations to the current CHIRPP system in Glasgow: it is not population based, only injuries presented to the accident and emergency department are included, and injury severity is not recorded. Nevertheless, CHIRPP is a valuable source of information on patterns of childhood injury. It offers local professionals a comprehensive dataset that may be used to develop, implement, and evaluate child injury prevention activities.

Expression of Delta1 and Serrate1 (Jagged1) in the mouse inner ear

The Notch signalling pathway is thought to play a key part in controlling the production of sensory hair cells in the vertebrate inner ear via lateral inhibition; but there is disagreement as to which Notch ligands are expressed in hair cells as they develop. We show, using a mouse Delta1:LacZ knock-in as a reporter, that nascent hair cells, but not their neighbours, express Delta1. Expression of Serrate1 (Jagged1), meanwhile becomes restricted to the supporting cells of each sensory patch. Delta1 is also expressed: (a) at early stages, at the site of otic neurogenesis; and (b) in scattered cells of the endolymphatic sac, as is Serrate1.

Behaviour of Lutzomyia longipalpis in an area of southern Honduras endemic for visceral/atypical cutaneous leishmaniasis

The predominant sandfly in Las Maria de Pavana, Choluteca, Honduras, was found to be Lutzomyia longipalpis, most (69%) of the 791 specimens of this species caught being male. When local Lu. longipalpis were studied over 1 year (1986-1987) using CDC traps, peaks in the size of the adult population were observed in December and July, each after a period of rain. Most [51% (24/47)-67% (97/144)] of the flies caught inside houses were female whereas most [55% (6/11)-56% (37/66)] of those caught outside were male. Far more Lu. longipalpis of both sexes were collected, per h of collection, from cattle and horses than from dogs or pigs, the vast majority (83%-93%) of the flies caught on each type of animal being male. The males may benefit from resting on the mammals because the females with which they mate come to the same animals for blood. The females may benefit by the presence of the males, not only by the increased chance of finding a mate but also because pheremones from the males may attract the females both to the males and to a bloodmeal source. The adult Lu. longipalpis only appeared to be active during the hours of darkness, none alighting in the twilight of dawn (04.00-06.00 hours) or dusk (18.00-20.00 hours) on the large mammals investigated.