Computer-assisted instruction in Australian medical schools

OBJECTIVE

To survey the use of computer-assisted instruction (CAI) in undergraduate medical student education in Australia.

SETTING AND DESIGN

A postal questionnaire survey of medical school deans, and department heads, in all Australian medical schools.

RESULTS

90% of deans, and 88% of department heads responded to the questionnaires. There were considerable variations between departments and faculties in the use of CAI. Overall, 36% of departments were using CAI and 65% of those not currently using it were either developing CAI or would like to introduce it into their teaching programs. Some medical faculties had well-developed policies for CAI, and provided considerable resources, while others did not. Some departments had large numbers of student work stations (up to 64), and multiple teaching packages (up to 200). CAI packages were generally thought to be popular with students, and to have improved the standard of learning.

CONCLUSION

This form of teaching is currently undergoing rapid expansion, but in an uncoordinated manner that is likely to lead to greatly increased overall development costs.

Community-based study of mortality in children with epilepsy

We used the records of a statewide pediatric mortality surveillance system to determine mortality rates and causes of death in children with epilepsy. Of the 1,095 children aged 1-14 years who died in the state of Victoria during the study period 1985-1989, 93 had a history of epilepsy. Six children (6%) had primary epilepsy, and 87 (94%) had secondary epilepsy. Death was (a) directly attributable to epilepsy in 20 (22%), including 11 with sudden unexplained death, (b) not directly attributable to epilepsy in 59 (63%), and (c) of undetermined cause in 14 (15%). No classifiable death occurred as a direct result of status epilepticus. The average annual mortality rates for children with epilepsy were (a) death from all causes, 30.6 in 10,000 [95% confidence interval (CI) 19.7, 47.5], and (b) death attributable to epilepsy, 6.6 in 10,000 (95% CI 3.7, 11.8). Relative to the all-cause mortality rate in children without epilepsy, the all-cause mortality rate ratios were (a) all children with epilepsy, 13.2 (95% CI 8.5, 20.7); (b) primary epilepsy, 1.1 (95% CI 0.5, 2.6); and (c) secondary epilepsy, 49.7 (95% CI 31.7, 77.9). The mortality rate ratios for secondary epilepsy relative to primary epilepsy were (a) death from all causes, 43.5 (95% CI 19.0, 99.5); and (b) death attributable to epilepsy, 9.0 (95% CI 3.3, 24.8). Epilepsy appeared on the death certificate of only 11 of 20 (55%) children whose deaths were attributable to epilepsy.(ABSTRACT TRUNCATED AT 250 WORDS)

Role of a children's hospital safety centre in injury control

Over the past 13 years, child safety centres have been established at several Australian Children's hospitals. In a short time, they have developed an important role in community injury control programmes. These centres provide an efficient conduit for transferring up-to-date injury surveillance and prevention information to families, industry, health and education professionals, and government. The activities of the Child Safety Centre at the Royal Children's Hospital in Melbourne are described, together with ways in which a degree of self-funding can be achieved.

Epidemiology of non-intentional injuries in an Australian urban region: results from injury surveillance

Injury surveillance provides an opportunity to determine non-intentional injury rates for those injuries which are treated in hospital accident and emergency departments. The first full calendar year of injury surveillance in north-western greater Melbourne was used to calculate incidence rates of a wide range of injury types and causes for 1989. In a population at risk estimated to number 150,604 children aged 0-14 years, the all-cause injury mortality was 10.5/100,000 per year (95% confidence interval [Cl], 5.4-15.8). There were 8207 attendances by children from the denominator area for non-intentional injury at the three hospitals participating in surveillance, representing rates of 6437/100,000 per year (95% Cl, 6258-6616) and 4406/100,000 per year (95% Cl, 4254-4558) for boys and girls respectively, while the rates for admission to hospital were 957/100,000 per year (95% Cl, 888-1025) and 649/100,000 per year (95% Cl, 590-707). The leading causes of hospital attendance were related to injuries involving sports, play equipment, bicycles and poisoning. These rates are substantially lower than those reported from other countries. The possible reasons for this include differences in health care utilization, under-ascertainment of cases, and a real difference in injury risk. Injury Surveillance Information System codes are defined for a standard set of injuries and injury causes which may be used for future comparative studies. Problems related to assessing the reliability of injury ascertainment are discussed, and the importance of integrating injury surveillance into routine hospital information systems is emphasized.

Evaluation of the properties and reliability of a clinical severity scale for acute asthma in children

The inter-observer agreement (reliability) and validity of a clinical asthma severity scale (ASS) derived from separate scores of wheeze, heart rate and accessory muscle use (each on a 4-point scale) were studied in 60 children aged between 6 months and 17 years (mean 5.4 years). Independent assessments of these clinical parameters were made by two paediatricians, and they also rated patients as having a mild, moderate, severe or very severe acute episode (clinical judgement rating, CJR). Oxygen saturation (SaO2) was measured concurrently by a Biox 3700 pulse oximeter and readings were categorized as mild (SaO2 greater than or equal to 94%), moderate (91-93%) and severe (less than 91%). Agreement between clinicians was assessed by the weighted kappa statistic (kappa W). Agreement for the ASS score compared to the severity grade obtained from SaO2 was slight (kappa W = 0.34) and compared to CJR the kappa W was 0.55. An ASS score of moderate or worse (greater than 3) had sensitivity of 97% and specificity of 50% for prediction of admission. The maximum frequency and duration of nebulizer therapy following admission were significantly greater for severe patients than for moderate patients. Length of hospital stay did not reflect the ASS score in the emergency department but total duration of functional disability increased with ASS score. The substitution of an adjusted heart rate score for the raw heart rate score used in ASS detracted from scale performance. The ASS is an imprecise but reasonable quantitative measure of the severity of an acute episode of asthma.(ABSTRACT TRUNCATED AT 250 WORDS)

Spontaneous seminoma in an owl monkey in captivity

An adult male Aotus nancymae maintained for breeding purposes was submitted for surgery and the left testicle was removed. The surgically removed mass was about two to three times the size of a normal adult owl monkey testicle. Grossly, on cut surface, the mass was soft, white to pale gray, and bulged above the adjacent tissue. Microscopically, the morphology of the tumor cells was consistent with a seminoma.

Randomised trial of laxatives in treatment of childhood encopresis

Primary faecal incontinence (encopresis) in children is usually treated with laxative medication and a behaviour modification programme aimed at promoting regular toileting, but the effectiveness of laxatives has never been adequately investigated. 169 children with encopresis and evidence of stool on plain abdominal radiograph were randomly allocated to receive multimodal (MM) therapy (laxatives plus behaviour modification; n = 83) or behaviour modification alone (BM; n = 86). Mean (SD) follow-up was 55.1 (27.0) weeks and 56.7 (32.0) weeks, respectively. By 12 months' follow-up 42 (51%) of the MM group and 31 (36%) of the BM group (p = 0.079) had achieved remission (at least one 4 week period with no soiling episodes) and 52 (63%) vs 37 (43%) (p = 0.016) had achieved at least partial remission (soiling no more than once a week). MM subjects achieved remission significantly sooner than BM subjects, and the difference in the Kaplan-Meier remission curves was most striking in the first 30 weeks of follow-up (p = 0.012). The patterns of compliance with toileting in the treatment groups were almost identical, although about 1 in 8 children overall did not comply with the sitting programme. After exclusion of the 24 poor compliers, there was no significant difference between BM and MM groups. This study shows a clear advantage overall for the use of laxative medication, although the benefit may not be as great for children who are able to maintain regular toileting.

Efficacy of glove combinations in reducing cell culture infection after glove puncture with needles contaminated with human immunodeficiency virus type 1

OBJECTIVE

To study the effect of various latex and treated glove combinations in reducing the frequency of human immunodeficiency virus (HIV) infection of tissue culture cells after puncture by surgical needles contaminated with infectious human immunodeficiency virus type 1 (HIV-1).

DESIGN

One, two, or three layers of sterile latex glove material, or two latex layers with intermediate cotton or Kevlar (with or without the virucidal compound nonoxynol-9) were used to cover 24-well cell culture dishes containing MT2 cells in cell culture medium. Surgical needles wet with cell culture medium containing HIV-1 (HTLV IIIA strain) were passed through the glove materials into the culture medium in the wells of the culture dishes. The culture medium in each well was then assayed biweekly for HIV-1 p24 antigen as a test for infection of cells in the well.

RESULTS

The rate of HIV-1 infection of cell cultures after glove puncture was greater than 90% with a single latex surgical glove barrier, 23% to 60% with double or triple layers of latex gloves, less than 8% with an intermediate cotton glove impregnated with 4% nonoxynol-9, 6% with an intermediate Kevlar glove, and 0% with an intermediate Kevlar glove impregnated with nonoxynol-9.

CONCLUSIONS

An intermediate glove of Kevlar or of Kevlar or cotton impregnated with virucidal compound nonoxynol-9 between standard latex gloves may improve surgical glove safety, compared with latex gloves alone with respect to needlestick transmission of HIV-1. The experimental model used may permit rapid investigation of other glove systems as barriers to the transfer of infectious agents through gloves by needlestick.

Determination of femtomole/milliliter concentrations of enprostil acid in human plasma using high-performance liquid chromatography-laser-induced fluorescence detection

This paper describes the use of multiple-column high-performance liquid chromatography (HPLC) combined with laser-induced fluorescence for the determination of femtomole/milliliter concentrations of enprostil acid, a prostaglandin analogue, in human plasma. The drug is isolated from plasma by phenyl solid-phase extraction and fluorescently labeled at its carboxyl functional group with a large excess of 2-bromoacetyl-6-methoxynaphthalene. A multi-column method using both normal- and reversed-phase chromatography is necessary to separate the labeled drug from the unreacted reagent. Post-column dilution of the mobile phase with water after the reversed-phase chromatography allows on-line concentration of the labeled analyte onto a guard column prior to the microbore HPLC. A loop guard column device provides a simple way to inject up to 1.0 ml of sample solution onto a microbore column without significantly reducing the column efficiency. A 325-nm He-Cd laser is used to excite the labeled drug, and fluorescence emission is monitored at 450 nm. Using this system, we are able to derivatize, detect, and quantify 5 pg of the prostaglandin analogue in 1.0 ml of plasma.

Principles behind practice. 4. Natural history

The busy clinician is confronted daily with a wide range of decisions about patient diagnosis and management. The sharpness and scepticism to constantly ask fundamental questions about the natural history of a patient's disease is a talent that a few lucky individuals have. For the rest of us, it is an acquired skill which must be developed and maintained. We suggest the following questions to guide the clinician in taking account of the natural history of disease in everyday clinical practice. How strong is the evidence that the putative consequence of this illness is or is not attributable to some external factor? Can I be sure that this exposure (drug, surgery, social or behavioural therapy, toxic or environmental agent) does not have a long latency and that subsequent development of illness will not ensue? What do I know from long-term prospective studies about the life history of this disease? Does lead time explain the apparent benefit of this diagnostic test or other screening procedure? Does the evidence of the natural history of this disease specifically relate to the characteristics of my patient--age, sex, set of prognostic factors, selected or unselected referral? Is there good evidence from at least one good randomised controlled trial with a "no treatment" control group that this intervention is efficacious (and not hazardous)?

Pulse oximetry in acute asthma

The predictive value of pulse oximetry was evaluated in 100 patients who attended the emergency department with acute asthma. Oximetry after treatment with a cut off point of less than 91% had a sensitivity of 42% and specificity of 78% for unfavourable outcome, and oximetry before treatment had a sensitivity of 36% and a specificity of 57%. Despite its low sensitivity, oximetry after treatment does seem to have a role in minimising diagnostic errors in the emergency department, but only when used in conjunction with clinical assessment.

Prevalence of asthma in Melbourne schoolchildren: changes over 26 years

OBJECTIVES

To determine the prevalence of asthma in the past 12 months in Melbourne schoolchildren aged 7, 12, and 15 years and to compare the prevalence of a history of asthma with that of 26 years ago.

DESIGN

A questionnaire on respiratory symptoms was distributed to children for completion by parents and return to the school. Subjects were selected by a stratified cluster design.

SETTING

Government and non-government schools in the greater Melbourne area, Australia.

SUBJECTS

10,981 children. Parents completed questionnaires for 3324 children aged 7, 2899 aged 12, and 2968 aged 15. The overall response rate was 90%.

MAIN OUTCOME MEASURES

History of wheeze or asthma in the past 12 months and in lifetime.

RESULTS

The prevalences of wheeze in the past 12 months were 23.1%, 21.7%, and 18.6% for 7, 12, and 15 year olds respectively. A history of wheeze was more common in boys than in girls at age 7 (443/1711 v 324/1614) and 12 (418/1767 v 322/1718) but not at age 15. Overall, 78% (1548) of those reporting wheeze also reported a history of asthma and 83% (1611) had used a bronchodilator. The prevalence of a history of asthma among 7 year olds was 46% compared with 19.1% in the 1964 survey, an increase of 141%.

CONCLUSIONS

The current prevalence of asthma in Melbourne schoolchildren is high and has risen substantially over the past 26 years.

Revision, replication and neglect--research on maladjustment in chronic illness

Children with chronic physical disorders have twice the risk of psychosocial maladjustment compared with healthy children. This "second handicap" poses a significant mental health problem. This review examines factors related to the child, family, and clinical condition that affect the risk of maladjustment, as well as the manner in which this knowledge has influenced intervention strategies. Much of the research reviewed represents replication of what is already known and important areas of enquiry have been neglected. Investigators are urged to work towards the further identification of high risk characteristics and to apply these to the development and evaluation of new preventive and therapeutic approaches for these children and their families.

Role of IFN-gamma in lethal and nonlethal malaria in susceptible and resistant murine hosts

IFN-gamma plays an important role in host defense against microbial disease. Here, we studied the role of IFN-gamma in lethal and nonlethal murine malaria. Administration of recombinant murine IFN-gamma resulted in a dose-dependent protection of SW, BALB/cByJ, and CBA/J mice from the lethal variant of Plasmodium yoelii 17x (PyL) but had little effect on the course of the nonlethal variant of this parasite (PyNL). Administration of recombinant IFN-gamma also resulted in the activation of peritoneal macrophages for increased phagocytosis of malaria-infected erythrocytes and release of H2O2, as measured in vitro. The ability of spleen cells from infected mice to produce endogenous IFN-gamma and release H2O2 during the course of malaria was also studied. In BALB/cByJ mice, which are relatively susceptible to PyL and PyNL, there was an initial burst of IFN-gamma only in response to PyNL whereas in CBA/J mice, which are relatively resistant to these parasites, there was an initial burst of IFN-gamma in response to both PyL and PyNL. The kinetics of H2O2 release corresponded to that of IFN-gamma. In all infections, levels of IFN-gamma declined as parasitemia increased; however, nonlethal infections were characterized by a recovery of both IFN-gamma activity and H2O2 release as parasitemia declined. These data suggest that IFN-gamma may play an important role in modulating the course of malaria infections by activating macrophages for both intracellular and extracellular parasite destruction.

Role of IFN-gamma in lethal and nonlethal malaria in susceptible and resistant murine hosts

IFN-gamma plays an important role in host defense against microbial disease. Here, we studied the role of IFN-gamma in lethal and nonlethal murine malaria. Administration of recombinant murine IFN-gamma resulted in a dose-dependent protection of SW, BALB/cByJ, and CBA/J mice from the lethal variant of Plasmodium yoelii 17x (PyL) but had little effect on the course of the nonlethal variant of this parasite (PyNL). Administration of recombinant IFN-gamma also resulted in the activation of peritoneal macrophages for increased phagocytosis of malaria-infected erythrocytes and release of H2O2, as measured in vitro. The ability of spleen cells from infected mice to produce endogenous IFN-gamma and release H2O2 during the course of malaria was also studied. In BALB/cByJ mice, which are relatively susceptible to PyL and PyNL, there was an initial burst of IFN-gamma only in response to PyNL whereas in CBA/J mice, which are relatively resistant to these parasites, there was an initial burst of IFN-gamma in response to both PyL and PyNL. The kinetics of H2O2 release corresponded to that of IFN-gamma. In all infections, levels of IFN-gamma declined as parasitemia increased; however, nonlethal infections were characterized by a recovery of both IFN-gamma activity and H2O2 release as parasitemia declined. These data suggest that IFN-gamma may play an important role in modulating the course of malaria infections by activating macrophages for both intracellular and extracellular parasite destruction.

Evaluation of a children's hospital medical peer review programme

The records of medical peer review meetings at the Royal Children's Hospital, Melbourne, were audited for the period 1983-87. This investigation focused on the peer review process, but also evaluated the extent to which recommended changes in medical practice were carried out. The results showed that few recommendations arose from the meetings despite the clear recognition of a number of problem areas. In the instances where firm recommendations were made, few appeared to have been implemented. The main reasons for this failure were: (i) the review was not an integrated part of the medical management structure of the hospital; (ii) recommendations were frequently not made despite clear expressions of the need for action; (iii) the absence of a designated individual to ensure that recommended actions were implemented, together with the lack of a feedback or internal review process to monitor effectiveness; and (iv) a relatively low profile of the peer review. Despite these shortcomings, the peer review is widely perceived to be a valuable exercise, especially as a general educational tool. However, its potential is far greater, and a model is proposed for a more effective medical peer review programme.

Single dose trimethoprim for urinary tract infection

A randomised clinical trial of single dose trimethoprim against a seven day course of co-trimoxazole (trimethoprim/sulphamethoxazole) for the treatment of uncomplicated urinary tract infection was carried out in 106 children aged between 2 and 16 years. Of the 50 children with confirmed urinary tract infections who were followed up 48 hours after treatment with a single dose of trimethoprim all were free of infection, whereas two of the 56 who received the course of co-trimoxazole (4%) had persisting infections. At follow up after 10 days, however, significantly more of the group treated with trimethoprim had evidence of recurrent urinary tract infection compared with those who had received co-trimoxazole (10 of 44, 23%, compared with one of 46, 2%). Of the recurrences in the trimethoprim group, six were asymptomatic. We conclude that single dose trimethoprim is effective in clearing the urine of bacteria, but the risk of asymptomatic bacteriuria soon after treatment is high.

Controlled trial of social work in childhood chronic illness

Children with chronic illnesses have a doubled risk of becoming psychosocially maladjusted, and social-work support and counselling are commonly used to reduce this secondary morbidity. A randomised controlled trial of this type of intervention was conducted in 345 children with chronic physical disorders cared for in eleven specialty clinics at a children's hospital. Four months after a six-month period of social-work services, no significant difference was found between social-work and control groups in overall prevalence of maladjustment. There was no evidence to support a preventive or therapeutic effect of social work on child behaviour disorder or social dysfunction on the principal outcome measure, the Child Behaviour Checklist. Nor was there any detectable effect on child self-esteem, on maternal psychological function, or on the impact of the child's illness on the family. Furthermore, no patient subgroup could be shown to benefit from the intervention, and restriction of the analysis to individuals who received the intervention did not alter the results.