Telerheumatology--diagnostic accuracy and acceptability to patient, specialist, and general practitioner

This study examines the diagnostic accuracy and acceptability of telemedicine in the field of rheumatology. One hundred patients had a telephone and televisual consultation and the results were compared with a face-to-face consultation. While the telephone consultations were often unsatisfactory, the televisual consultations were highly accurate (97%) and acceptable to patients, general practitioners, and specialists.

General practice out-of-hours service, variations in use and equality in access to a doctor: a cross-sectional study

BACKGROUND

There is increasing dissatisfaction among general practitioners (GPs) with their 24 hour commitment despite the demand for GP services outside ordinary working hours. The creation of out-of-hours co-operatives has been welcomed by participating GPs and their families and patient satisfaction is generally high. However, there have been concerns about the lack of patient consultation in their development and on the quality of care provided.

OBJECTIVES

To examine geographical variation in the rates of out-of-hours calls and to see if there is any systematic variation in how the co-operative that covers the area responds to calls.

DESIGN OF STUDY

A secondary data analysis of 110,357 calls received by the co-operative during the second year of its operation.

SETTING

A co-operative with four centres providing out-of-hours care for one mostly rural Health Board in Northern Ireland.

METHOD

Deprivation score and mortality and long-term illness ratios provided indicators of need at an area level. Proximity to the four co-operative centres was measured as the distance in kilometres and estimated travel time (in minutes) along the road network.

RESULTS

Out-of-hours call ratios were proportional to the area deprivation score and proximity to the co-operative centres, though not to area indicators of ill health. Older patients were more likely to be seen by the GP and females over the age of 15 years were more likely to receive telephone advice only (adjusted odds ratio [OR] = 0.785, 95% confidence intervals [CI] 0.756-0.816, P < 0.001). Each kilometre from the centres reduced the likelihood of seeing the GP (OR = 0.978, 95% CI = 0.976-0.979, P < 0.001). Even after controlling for potential confounders a large difference remained in how centres responded to calls.

CONCLUSIONS

It is not certain whether these inequalities in services delivery represent inequity as the apposite level or type of response cannot be determined until more is known about the appropriateness of the demand for out-of-hours medical care.

Community participation in road safety: barriers and enablers

The objectives of the paper were to identify barriers to community participation in road safety activities and to recommend strategies to reduce those barriers. Information was obtained from: a review of relevant literature, from the authors' extensive community-based experiences, from undertaking community-based research, and from interviews with key stakeholders in road safety in Western Australia. Ten significant barriers to community participation were identified. These are classified into two groups: personnel and planning issues. The former includes: reasons why people are often reluctant to become involved in projects in their communities, a lack of leadership, and a lack of skills. The latter includes: inappropriate program foci, inappropriate program evaluation, lack of resources, and a lack of sustainability. It was concluded that the barriers to community involvement in road safety initiatives are similar in many parts of Australia and overseas and apply to a wide range of health promotion interventions besides road safety. Awareness of the barriers and knowledge of their solutions can ensure that appropriate steps are taken to maximise the likelihood of community participation.

Intraoperative motor evoked potentials to transcranial electrical stimulation during two anaesthetic regimens

OBJECTIVES

To study motor evoked potentials (MEPs) to multi-pulse transcranial electrical stimulation (MP-TES) during orthopaedic spinal surgery under different anaesthetic regimens.

METHODS

MEPs to MP-TES were recorded from tibialis anterior and abductor hallucis bilaterally in 50 operations. Anaesthesia was maintained with propofol and nitrous oxide in 29 operations and isoflurane (0.78+/-0.17% end-tidal) and nitrous oxide in 23 (two patients received both regimens). Analgesia was provided with fentanyl or remifentanil.

RESULTS

Motor stimulation caused neither EEG changes nor seizures. MEPs were obtained in 97% of patients during propofol anaesthesia. The median amplitude and coefficient of variation (CV) at baseline (across all muscles) were 198 microV and 22%, respectively. Amplitudes throughout the operation paralleled the degree of neuromuscular block and were reduced after fentanyl bolus, isoflurane or morphine. Loss of MEPs or persistent amplitude decrements were associated with neurological complications in one patient and severe blood loss in another two patients. MEPs were obtainable in 61% of patients during isoflurane anaesthesia and became inconsistent for end-tidal concentrations >0.87+/-0.08%. Amplitudes were smaller (85 microV) and baseline variability higher (coefficient of variation 29%) than in the propofol group. The decrease in the number of recordings was greater for isoflurane than propofol when the number of pulses/train decreased from 4 to 2.

CONCLUSIONS

Muscle MEPs to MP-TES are a safe, sensitive and reliable method for monitoring motor pathways during propofol/nitrous oxide and fentanyl or remifentanil anaesthesia. MEPs are also obtainable in the majority of patients during isoflurane/nitrous oxide anaesthesia, but quantitative monitoring is not always possible with this regimen.

Professional perceptions of the benefits of orthodontic treatment

The aim of this study was to assess general dental practitioners' and orthodontists' perceptions of the benefits of orthodontic treatment. A specially designed questionnaire was sent to a random sample of 150 general dental practitioners (GDPs) and all orthodontists in Northern Ireland (excluding hospital practitioners) with a postgraduate qualification (n = 29). There was a 93 per cent response rate by the general dental practitioners and all but one specialist practitioner returned the questionnaire. The questionnaire comprised 14 visual analogue scales (VAS) whereby participants were asked to rate the importance of various possible dental health and psychosocial benefits of orthodontic treatment. In addition to the VAS, the influence of dentist variables such as number of years since qualification, orthodontic cases completed, referral rates and attendance at postgraduate lectures were examined. When ratings on the 14 dental health and psychosocial scales were examined overall, GDPs rated an improvement in self-esteem while orthodontists considered an improvement in physical attractiveness as the most important benefit of orthodontic treatment. Even though psychosocial variables received the highest ratings, examination of the mean ratings (and 95 per cent confidence intervals) revealed that some dental health factors were also rated highly by both groups. While the results do indicate an encouraging awareness of the psychosocial benefits of orthodontic treatment, they also suggest that both GDPs and orthodontists have an unrealistic expectation of the dental health gain likely to result from orthodontic treatment.

Sequence-specific interaction between HIV-1 matrix protein and viral genomic RNA revealed by in vitro genetic selection

The human immunodeficiency virus type-1 matrix protein (HIV-1 MA) is a multifunctional structural protein synthesized as part of the Pr55 gag polyprotein. We have used in vitro genetic selection to identify an RNA consensus sequence that specifically interacts with MA (Kd = 5 x 10(-7) M). This 13-nt MA binding consensus sequence bears a high degree of homology (77%) to a region (nt 1433-1446) within the POL open reading frame of the HIV-1 genome (consensus sequence from 38 HIV-1 strains). Chemical interference experiments identified the nucleotides within the MA binding consensus sequence involved in direct contact with MA. We further demonstrate that this RNA-protein interaction is mediated through a stretch of basic amino acids within MA. Mutations that disrupt the interaction between MA and its RNA binding site within the HIV-1 genome resulted in a measurable decrease in viral replication.

Clinical decision support systems for intensive care units: using artificial neural networks

The paper provides an overview of applications of artificial neural networks (ANNs) to various medical problems, with a particular focus on the intensive care unit environment (ICU). Several technical approaches were tested to see whether they improve the ANN performance in estimating medical outcomes and resource utilization in adult ICUs. These experiments include: (1) use of the weight-elimination cost function; (2) use of 'high' and 'low' nodes for input variables; (3) verifying the effect of the total number of input variables on the results; (4) testing the impact of the value of the constant predictor on the performance of the ANNs. The developments presented intend to help medical and nursing personnel to assess patient status, assist in making a diagnosis, and facilitate the selection of a course of therapy.

An overview of the injury severity score and the new injury severity score

OBJECTIVE

The research was undertaken to describe the injury severity score (ISS) and the new injury severity score (NISS) and to illustrate their statistical properties.

DESIGN

Descriptive analysis and assessment of the distribution of these scales.

METHODS

Three data sources--the National Pediatric Trauma Registry; the Massachusetts Uniform Hospital Discharge Data Set; and a trauma registry from an urban level I trauma center in Massachusetts--were used to describe the distribution of the ISS and NISS among injured patients.

RESULTS

The ISS/NISS was found to have a positively skewed distribution and transformation did not improve their skewness.

CONCLUSION

The findings suggest that for statistical or analytical purposes the ISS/ NISS should not be considered a continuous variable, particularly if ISS/NISS is treated as a continuous variable for correlation with an outcome measure.

Two long terminal repeat circles and persistent HIV-1 replication

Building on the success of combination antiretroviral drug therapy will require a better understanding of the underlying basis for viral persistence. Characterization of the therapeutic, viral, and immunological factors that influence the size and stability of viral reservoirs will foster the development of strategies to control or eliminate HIV-1 from infected individuals. Here we review recent work aimed at delineating the complex interplay between viral replication, the immune system, and viral reservoirs. Finally, we address the implications and clinical significance of the residual replication that persists in infected individuals on potent antiretroviral therapy to evaluate both the possible risks and benefits of ongoing HIV-1 replication.

Relation between macular morphology and visual function in patients with choroidal neovascularisation of age related macular degeneration

AIM

To examine the relation between three measures of visual function (distance acuity, near acuity, and contrast sensitivity) and specific fluorescein angiographic characteristics of the macular lesion in patients with subfoveal choroidal neovascularisation (CNV) due to age related macular degeneration (AMD).

METHODS

Visual evaluation and digital fundus fluorescein angiography were performed in 93 patients with subfoveal CNV. Standard morphometric techniques were used on two frames from the angiographic series closest to 30 seconds and 60 seconds respectively, to ascertain total lesion size (defined as the entire area of abnormal fluorescence), the size of the classic component, and the distance from the fovea to the closest point of healthy retina. Correlations were sought using Pearson's correlation coefficients. Stepwise regression was used to minimise multiple colinearity.

RESULTS

When the study eye was the better eye of a patient's pair of eyes, the strongest correlation was between the size of the classic component and contrast sensitivity (r= 0.48, p <0.001) and was highly significant. When the study eye was the worse eye, significant correlations were observed between total lesion size and all three measures of visual function. The strongest correlation was observed between overall lesion size and contrast sensitivity (r = 0.52, p <0.001).

CONCLUSIONS

This study has shown that the status of the study eye (that is, better or worse eye of a pair of eyes) influences the impact of macular pathology in AMD on visual function. The distance of the fovea from healthy retina was found to be an important factor in predicting visual function.

Where do patients with cancer die in Belfast?

BACKGROUND

Most patients with cancer prefer to die at home but the majority die in institutions.

AIM

To determine place of death for patients with cancer in Belfast, to examine changes over time and identify factors associated with place of death.

METHODS

A survey of deaths registered in Belfast over a six-month period for 1977, 1987 and 1997 identified patients dying from cancer. Epidemiological data included age, gender, malignancy, social class, marital status, area of residence and place of death.

RESULTS

Home deaths fell from 35% in 1977 to 28% in 1997. Hospital deaths fell from 50% in 1977 to 40% in 1987 rising to 42% in 1997. Hospice deaths rose from 13% in 1977 to 25% in 1987 falling to 23% in 1997. There was an association between place of death and age, marital status, type of cancer and area of residence, but not with social class or gender.

CONCLUSION

The majority of people fail to achieve a home death. Resources need to be targeted to those most at risk of an institutional death; females, the elderly, the unmarried, those with haematological malignancies and residents of South Belfast.

Intestinal disappearance and mesenteric and portal appearance of amino acids in dairy cows fed ruminally protected methionine

An experiment was conducted to compare the rates of disappearance of amino acids (AA) from the small intestine and their net appearance in the blood draining only the small intestine (mesenteric-drained viscera) and the whole gastrointestinal tract (portal-drained viscera) of cows fed a silage-based diet supplemented or not with ruminally protected Met. Five lactating dairy cows (118+/-4 DIM) equipped with duodenal and ileal cannulae (n = 2) or a duodenal cannula only (n = 3), two of which were multicatheterized, were fed a TMR top dressed with 0 or 72 g of ruminally protected Met per day. The addition of ruminally protected Met to the diet increased the duodenal flux of Met leading to a higher apparent digestibility of Met in the small intestine. Sixty-six percent of Met from ruminally protected Met bypassed the rumen and 82% of that Met disappeared from the small intestine. Arterial plasma Met concentrations numerically increased with ruminally protected Met (45 vs. 18 microM), while total AA concentration decreased. Feeding ruminally protected Met resulted in higher concentrations of urea-N and glucose in arterial plasma. Milk production and milk composition were unaffected. The disappearance of essential AA across the small intestine was equivalent (101%) to their flux through the mesenteric-drained viscera while the portal:mesenteric-drained viscera flux ratio for each essential AA varied from 38% for Thr to 76% for Phe. The portal:mesenteric-drained viscera flux ratio for Met was 66%. These results confirm observations made with pigs and sheep.

How much interest is the Internet to patients?

OBJECTIVES

To assess the accessibility of the internet, the level of interest from patients attending genitourinary (GU) medicine clinics, and explore potential concerns about confidentiality.

METHODS

Questionnaire based survey of patients attending five GU medicine clinics in England.

RESULTS

41% of GU medicine clinic patients in 1999 had access to the internet (range 31%-52%) with access more common in younger age groups, and less common in women and black Caribbean patients. One in 10 patients (with internet access) had used the internet to find out more about the problem with which they had come to the clinic. 60% of patients replied that information on sexual health on the internet was of interest to them and a high proportion of patients said they would use the internet to access information about GU clinics (64%), book an appointment (64%) or get test results (63%). Almost a quarter of patients who made additional suggestions wanted an interactive website.

CONCLUSIONS

A high proportion of patients attending GU clinics have access to the internet with potential uses for health education and service delivery.

New targets for inhibitors of HIV-1 replication

Despite the success of protease and reverse transcriptase inhibitors, new drugs to suppress HIV-1 replication are still needed. Several other early events in the viral life cycle (stages before the viral genome is inserted into host cell DNA) are susceptible to drugs, including virus attachment to target cells, membrane fusion and post-entry events such as integration, accessory-gene function and assembly of viral particles. Among these, inhibitors of virus-cell fusion and integration are the most promising candidates.

Comparison of the in situ and in vivo intestinal disappearance of ruminally protected methionine

We designed a switchback expriment to compare the intestinal disappearance of ruminally protected Met determined in situ or in vivo over three consecutive periods. Four nonlactating Holstein heifers (477+/-36 kg) with cannulae in the rumen, duodenum, and ileum were fed a diet based on timothy silage to meet requirements for maintenance (dry matter intake = 8.72+/-0.15 kg). A total of 16 bags, containing 1.5 g of ruminally protected Met, were incubated in the rumen (4.5 h) of each cow and transferred to an acid-pepsin solution to simulate the abomasum (2.5 h). Following each incubation, bags were recovered and three bags were dried at 55 degrees C and analyzed for Met. Remaining bags were introduced directly into the duodenal or ileal cannula for the in situ method, while for the in vivo method, the content of remaining bags was transferred into gelatin capsules before their introduction in the duodenal or ileal cannula. Spot samples of digesta were collected during a 96-h period, with Co-EDTA and Cr-mordanted fiber used as indigestible markers to estimate in vivo digestibility. The disappearance of Met in the small intestine determined in vivo tended to be higher than in situ (74.45 vs. 43.65+/-1.79%). Our results indicate that when used to assess intestinal availability of ruminally protected Met, the mobile nylon bag technique can underestimate the true bioavailability of Met.

Early therapy of vertical human immunodeficiency virus type 1 (HIV-1) infection: control of viral replication and absence of persistent HIV-1-specific immune responses

Studies of potent antiretroviral combination regimens were undertaken in young infants to evaluate the potential for long-term suppression of viral replication and to evaluate the immune consequences of such therapies. Early combination antiretroviral therapy led to a loss of plasma viremia, cultivable virus, and labile extrachromosomal replication intermediates. Despite preservation of immune function, persistent human immunodeficiency type 1 (HIV-1)-specific immune responses were not detected in most infants. The absence of detectable, persisting immune responses in most HIV-1-infected infants treated early contrasts with what is typically seen in adults who are treated early. These results are consistent with the notion that early combination antiretroviral therapy of HIV-1-infected infants allows the long-term suppression of viral replication.

Inverse relationship between the expression of the human papillomavirus type 16 transcription factor E2 and virus DNA copy number during the progression of cervical intraepithelial neoplasia

The human papillomavirus type 16 (HPV-16) status of 43 cervical biopsies, which had been characterized histologically as normal, various grades of cervical intraepithelial neoplasia (CIN) and invasive squamous cell carcinoma, was examined by using (i) a novel antibody against the HPV-16 E2 protein, (ii) sensitive HPV-16 DNA in situ hybridization and (iii) microdissection/PCR for the E2 ORF. The data indicate that E2 protein expression is highest in koilocytes in lower-grade CIN (I), but decreases with increasing grade, whereas the detection of HPV DNA is delayed until CIN I/II, rising to the highest levels in carcinoma cells. Co-localization of E2 with HPV-16 DNA-positive cells was most commonly observed in koilocytes in CIN II lesions. PCR analyses of microdissected epithelium from the same or serial sections indicated that E2 ORFs were retained in an intact form in a number of higher-grade CIN lesions and invasive carcinomas.

Could a low-cost audio-visual link be useful in rheumatology?

We have investigated prospectively the diagnostic accuracy, specialist satisfaction and patient-specialist rapport of a low-cost audio-visual link between a junior doctor with a patient and a consultant rheumatologist. Using a telephone link and subsequently a video-phone link, 20 patients, with various rheumatological problems, were presented by a junior doctor to the consultant rheumatologist for provisional diagnosis. All patients were then seen face to face by the consultant, when a final diagnosis was made. An independent consultant rheumatologist made a 'gold standard' diagnosis. Thirty-five per cent of diagnoses were made correctly over the telephone and 40% over the video-phone--there was no significant difference in the diagnostic accuracy between these two methods of communication. Rapport over the video-phone was universally poor. Where it was important, clinical signs could not be visualized over the video-phone and in more than 85% of cases small joint swellings could not be seen clearly.

Distribution of atrophy in Helicobacter pylori-infected subjects taking proton pump inhibitors

BACKGROUND

Gastric atrophy is associated with Helicobacter pylori infection. Conflicting results have been obtained as to whether acid suppressant therapy hastens the development or changes the distribution of atrophy in the stomach. The aim of this study was to investigate whether concomitant proton pump inhibitor (PPI) therapy in H. pylori-infected individuals resulted in an increase or an alteration in atrophy distribution and whether this was reflected by the plasma gastrin.

METHODS

Multiple gastric biopsy specimens were taken from the antrum and corpus from 46 H. pylori-infected subjects, 18 of whom were taking PPIs, and assessed histologically by the updated Sydney System. The control group was age- and sex-matched to the index group. Fasting gastrin levels were measured.

RESULTS

In the control group there was no significant tendency for either antral or corpus atrophy to predominate (P = 0.44). In the treatment group there was a significant tendency for corpus as opposed to antral atrophy to develop (P < 0.001). There was no significant difference in the overall atrophy score between the treated and untreated groups (P = 0.76). Fasting gastrin levels were significantly higher in the treated group (P < 0.001).

CONCLUSIONS

Treatment with PPIs in H. pylori-infected subjects does not lead to an overall increase in gastric atrophy. It does, however, result in an increased prevalence of corpus as opposed to antral atrophy. This is associated with a significantly higher gastrin level.

Child pedestrian injury prevention project: student results

BACKGROUND

Few comprehensive pedestrian safety interventions for primary-school-age children have been developed and evaluated. This paper reports the impact of the 3-year (1995-1997) Child Pedestrian In jury Prevention Project (CPIPP) on a cohort of 1603 children followed from age 6 to 9 years. This multicomponent project comprised an educational intervention for students, their parents and teachers, and the local community, as well as several environmental interventions. The primary aim of CPIPP was to improve children's road-related behavior and to enhance the safety of their road environment.

METHODS

Three communities were assigned to the treatment conditions: (1) high-education, community, and environmental interventions; (2) moderate-education intervention only; and (3) comparison (usual road safety education). Children's pedestrian knowledge and road crossing and playing behaviors were assessed using a pre- and posttest self-report questionnaire. Their self-reported road crossing behaviors were validated using an observational schedule and brief interview.

RESULTS

Children in the high and moderate intervention groups were significantly more likely to cross the road with adult supervision (P = 0.013) and play away from the road (P = 0.000) than the comparison group. No differences were detected in children's pedestrian safety knowledge between the intervention and comparison groups.

CONCLUSIONS

While several methodological limitations may have influenced the study outcomes, these data nonetheless indicate that in the study sample the CPIPP educational intervention deaccelerated the natural increase in children's pedestrian-related risk behavior.