Vetting of medical imaging referrals: A scoping review of the radiographers' role

INTRODUCTION

Vetting and treatment verification, are now an expectation of threshold radiography competencies at qualification. Radiographer-led vetting contributes to the expedition of patients' treatment and management. However, the current state and the role of the radiographer in vetting medical imaging referrals remains unclear. This review aims to explore the current state and associated challenges to a radiographer-led vetting and offer directions for future research by addressing knowledge gaps.

METHOD

The Arksey and O'Malley methodological framework was employed for this review. This includes a comprehensive search using key terms relating to radiographer-led vetting across relevant databases: Medline, PubMed, AMED and Cumulative Index to Nursing and Allied Health Literature (CINAHL). Articles were screened for eligibility and information extracted and analysed descriptively to map the available evidence.

RESULTS

1149 studies were identified with 12 articles included for this review after duplicates were removed. The findings indicate existence of some radiographer-led vetting activities in practice; however, the scope of this practice is associated with a large variance across settings. Key challenges relating to radiographer-led vetting include referral selectivity, medical professional dominance, and lack of clinical indication on referrals.

CONCLUSION

Radiographers vet various categories of referrals depending on jurisdictional policies and more clarity in regulation, advanced practice training and change in workplace culture is needed to support radiographer-led vetting.

IMPLICATION FOR PRACTICE

Radiographer-led vetting should be championed across settings through formalised training to widen the scope of advance practice and career progression pathways for radiographers as a means of ensuring optimal use of resources.

Dialects in North American elk bugle calls: comparisons between source and translocated elk populations

Identifying the factors shaping dialects can reveal selective pressures and cultural influences on acoustic signals. Translocations of species have been considered the “gold standard” for identifying population differences in vocalizations, including dialects. The North American elk (Cervus canadensis) is a species that has experienced numerous translocations, but no published studies exist on dialects in elk or any other ungulate species. Adult male North American elk utter an iconic vocalization during the breeding season, which is termed the bugle call due to the power, duration, and pitch of the sound. We investigated if dialect differences existed between three populations: a source population in Wyoming (N = 10 bulls, 132 calls) and translocated populations in Colorado (N = 13 bulls, 92 calls) and Pennsylvania (N = 20 bulls, 160 calls). Dialect differences existed between the populations in 9 of 10 measured variables, in both the frequency domain and time domain. Habitat factors (acoustic adaptation hypothesis) affecting sound transmission were inconsistently related to dialects in the populations. Genetic factors may be related to dialects, as the historically bottlenecked Pennsylvania population, with low heterozygosity and low allelic richness, exhibited the least variability in acoustic measures. Cultural transmission and vocal learning may also contribute to dialect development in this highly vocal, social ungulate species.

Short-wavelength free-electron laser sources and science: a review

This review is focused on free-electron lasers (FELs) in the hard to soft x-ray regime. The aim is to provide newcomers to the area with insights into: the basic physics of FELs, the qualities of the radiation they produce, the challenges of transmitting that radiation to end users and the diversity of current scientific applications. Initial consideration is given to FEL theory in order to provide the foundation for discussion of FEL output properties and the technical challenges of short-wavelength FELs. This is followed by an overview of existing x-ray FEL facilities, future facilities and FEL frontiers. To provide a context for information in the above sections, a detailed comparison of the photon pulse characteristics of FEL sources with those of other sources of high brightness x-rays is made. A brief summary of FEL beamline design and photon diagnostics then precedes an overview of FEL scientific applications. Recent highlights are covered in sections on structural biology, atomic and molecular physics, photochemistry, non-linear spectroscopy, shock physics, solid density plasmas. A short industrial perspective is also included to emphasise potential in this area.

Concatenation of 'alert' and 'identity' segments in dingoes' alarm calls

Multicomponent signals can be formed by the uninterrupted concatenation of multiple call types. One such signal is found in dingoes, Canis familiaris dingo. This stereotyped, multicomponent ‘bark-howl’ vocalisation is formed by the concatenation of a noisy bark segment and a tonal howl segment. Both segments are structurally similar to bark and howl vocalisations produced independently in other contexts (e.g. intra- and inter-pack communication). Bark-howls are mainly uttered in response to human presence and were hypothesized to serve as alarm calls. We investigated the function of bark-howls and the respective roles of the bark and howl segments. We found that dingoes could discriminate between familiar and unfamiliar howl segments, after having only heard familiar howl vocalisations (i.e. different calls). We propose that howl segments could function as ‘identity signals’ and allow receivers to modulate their responses according to the caller’s characteristics. The bark segment increased receivers’ attention levels, providing support for earlier observational claims that barks have an ‘alerting’ function. Lastly, dingoes were more likely to display vigilance behaviours upon hearing bark-howl vocalisations, lending support to the alarm function hypothesis. Canid vocalisations, such as the dingo bark-howl, may provide a model system to investigate the selective pressures shaping complex communication systems.

The bark, the howl and the bark-howl: Identity cues in dingoes' multicomponent calls

Dingoes (genus Canis) produce a stereotyped bark-howl vocalisation, which is a unimodal complex signal formed by the concatenation of two call types (a bark and a howl). Bark-howls may function as alarm signals, although there has been no empirical investigation of this vocalisation's structure or function. We quantified the content and efficacy of the bark and howl segments separately and when combined, using 140 calls from 10 individuals. We found that both segments are individually distinctive, although howl segments are more accurately classified, suggesting a higher level of individuality. Furthermore, howls convey signature characteristics that are conserved across different contexts of production, and thus may act as 'identity signals'. The individual distinctiveness of full bark-howls increases above that of isolated segments, which may be a result of selection on improved signal discriminability. Propagation tests revealed that bark-howls are best described as medium-range signals, with both segments potentially allowing for individual discrimination up to 200m regardless of environmental conditions. We discuss our findings regarding the fitness benefits of encoding identity cues in a potential alarm call and propose additional hypotheses for the function(s) of bark and howl segments.

Aggressive Bimodal Communication in Domestic Dogs, Canis familiaris

Evidence of animal multimodal signalling is widespread and compelling. Dogs’ aggressive vocalisations (growls and barks) have been extensively studied, but without any consideration of the simultaneously produced visual displays. In this study we aimed to categorize dogs’ bimodal aggressive signals according to the redundant/non-redundant classification framework. We presented dogs with unimodal (audio or visual) or bimodal (audio-visual) stimuli and measured their gazing and motor behaviours. Responses did not qualitatively differ between the bimodal and two unimodal contexts, indicating that acoustic and visual signals provide redundant information. We could not further classify the signal as ‘equivalent’ or ‘enhancing’ as we found evidence for both subcategories. We discuss our findings in relation to the complex signal framework, and propose several hypotheses for this signal’s function.

Demonstration of a high-field short-period superconducting helical undulator suitable for future TeV-scale linear collider positron sources

The first demonstration of a full-scale working undulator module suitable for future TeV-scale positron-electron linear collider positron sources is presented. Generating sufficient positrons is an important challenge for these colliders, and using polarized e(+) would enhance the machine's capabilities. In an undulator-based source polarized positrons are generated in a metallic target via pair production initiated by circularly polarized photons produced in a helical undulator. We show how the undulator design is developed by considering impedance effects on the electron beam, modeling and constructing short prototypes before the successful fabrication, and testing of a final module.

Using membrane stress to our advantage

The nature of the bilayer motif coupled with the ability of lipids and proteins to diffuse freely through this structure is crucial to the viability of cells and their ability to compartmentalize domains contained therein. It seems surprising to find then that biological as well as model membranes exist in a dynamic state of mechanical stress. The stresses within such membranes are surprisingly large, typically reaching up to 50 atm (1 atm=101.325 kPa) at the core of the membrane and vary as a function of depth. The uneven distribution of lateral pressures within monolayer leaflets causes them to bend away from or towards the water interface. This can result in the formation of complex, self-assembled mesophases, many of which occur in vivo. Our knowledge of the principles underlying membrane mechanics has reached the point where we are now able to manipulate them and create nano-structures with reasonable predictability. In addition, they can be used both to explain and control the partitioning of amphipathic proteins on to membranes. The dependence of the dynamics of membrane-bound proteins and the chemical reactivity of amphipathic drug molecules on membrane stresses suggests that Nature itself takes advantage of this. Understanding and manipulating these internal forces will be a key element in creating self-assembled, biocompatible, nanoscale cell-like systems.

Traction for low-back pain with or without sciatica

BACKGROUND

Traction is used to treat low-back pain (LBP), often with other treatments.

OBJECTIVES

To determine traction's effectiveness, compared to reference treatments, placebo, sham traction or no treatment for LBP.

SEARCH STRATEGY

We searched CENTRAL (The Cochrane Library 2006, issue 4), MEDLINE, EMBASE, and CINAHL to October 2006, references in relevant reviews and personal files.

SELECTION CRITERIA

Randomized controlled trials (RCTs) involving traction to treat acute (less than four weeks duration), sub-acute (four to 12 weeks) or chronic (more than 12 weeks) non-specific LBP with or without sciatica.

DATA COLLECTION AND ANALYSIS

Study selection, methodological quality assessment and data extraction were done independently by two authors. As there were insufficient data for statistical pooling, we performed a qualitative analysis.

MAIN RESULTS

We included 25 RCTs (2206 patients; 1045 receiving traction). Five trials were considered high quality. For patients with mixed symptom patterns (acute, sub-acute and chronic LBP with and without sciatica) there is: strong evidence of no statistically significant difference in outcomes between traction as a single treatment and placebo, sham or no treatment; moderate evidence that traction as a single treatment is no more effective than other treatments; limited evidence of no significant difference in outcomes between a standard physical therapy program with or without continuous traction. For LBP patients with sciatica (with acute, sub-acute or chronic pain), there is conflicting evidence in several comparisons: autotraction compared to placebo, sham or no treatment; other forms of traction compared to other treatments; different forms of traction. In other comparisons, there were no statistically significant differences; the evidence is moderate for continuous or intermittent traction compared to placebo, sham or no treatment, and limited for light versus normal force traction.

IMPLICATIONS FOR PRACTICE

The results of the available studies involving mixed groups of acute, sub-acute and chronic patients with LBP with and without sciatica were quite consistent, indicating that continuous or intermittent traction as a single treatment for LBP is not likely effective for this group. Traction for patients with sciatica cannot be judged effective at present either, due to inconsistent results and methodological problems in most studies. We conclude that traction as a single treatment for LBP is probably not effective.

IMPLICATIONS FOR RESEARCH

Any future research on traction for patients with LBP should distinguish between symptom pattern and duration, and should be carried out according to the highest methodological standards.

Traction for low-back pain with or without sciatica

BACKGROUND

Various types of traction are used in the treatment of low-back pain (LBP), often in conjunction with other treatments.

OBJECTIVES

To determine the effectiveness of traction in the management of LBP.

SEARCH STRATEGY

We searched The Cochrane Library 2004, Issue 4, MEDLINE, EMBASE, and CINAHL to November 2004, references in relevant reviews, and our personal files.

SELECTION CRITERIA

Randomized controlled trials (RCTs) examining any type of traction for the treatment of acute (less than four weeks duration), sub-acute (four to 12 weeks) or chronic (more than 12 weeks) non-specific LBP with or without sciatica.

DATA COLLECTION AND ANALYSIS

Study selection, methodological quality assessment and data extraction were done independently by sets of two reviewers. As available studies did not provide sufficient data for statistical pooling, a qualitative analysis was performed.

MAIN RESULTS

Twenty-four RCTs, involving 2177 patients (1016 receiving traction) were included in the review. Five trials were considered high quality. There is strong evidence that there is no significant difference in short or long-term outcomes between either continuous or intermittent traction and placebo, sham, or other treatments for patients with a mixed duration of LBP, with or without sciatica. There is moderate evidence that: autotraction is more effective other forms of traction are no more effective than placebo, sham or no treatment for patients with a mixed duration of LBP with sciatica. There is limited evidence that: there is no significant difference in outcomes between a standard physical therapy program with continuous traction and the same program without traction, for patients with a mixed duration of LBP, with or without sciatica autotraction on its own is more effective than a physical therapy program that includes Tru-Trac traction for patients with a mixed duration of LBP with sciatica. There is conflicting evidence regarding the short-term effectiveness of either continuous or intermittent traction compared to placebo, sham or other treatments, in the management of patients who have either chronic LBP or a mixed duration of LBP with sciatica.

AUTHORS' CONCLUSIONS

The evidence suggests that traction is probably not effective. Neither continuous nor intermittent traction by itself was more effective in improving pain, disability or work absence than placebo, sham or other treatments for patients with a mixed duration of LBP, with or without sciatica. Although trials studying patients with sciatica had methodological limitations and inconsistent results, there was moderate evidence that autotraction was more effective than mechanical traction for global improvement in this population.

A reappraisal of the role of cerium in burn wound management

A rare earth element, cerium, was introduced as an antibacterial agent in 1976 but has rarely been used due to the emphasis on wound excision. Used in combination with silver sulphadiazine, it may improve patient survival when excision is not possible.

The distribution of presumptive thoracic paraganglionic tissue in the common marmoset (Callithrix jacchus)

The aortic-pulmonary regions (APR) of seven adult marmosets (Callithrix jacchus) and the region of the right subclavian artery of a further three marmosets were diffusion-fixed with 10% buffered formol-saline solution. In both regions serial 5 microm sections were cut and stained by the Martius yellow, brilliant crystal scarlet and soluble blue method. Presumptive thoracic paraganglionic (PTP) tissue was only observed in the APR. PTP tissue was composed of small groups of cells that varied in size and number. The distribution of the groups of cells was extremely variable, so much so that it would be misleading to attempt to classify their position; they were not circumscribed by a connective tissue capsule, but were always related to the thoracic branches of the left vagus nerve. The cells lay in loose areolar tissue characteristic of this part of the mediastinum and received their blood supply from small adjacent connective tissue arterioles. Unlike the paraganglionic tissue found in the carotid body the cells in the thorax did not appear to have a profuse capillary blood supply. There was, however, a close cellular-neural relationship. The cells, 10-15 microm in diameter, were oval or rounded in appearance and possessed a central nucleus and clear cytoplasm. No evidence was found that these cells possessed a 'companion' cell reminiscent of the arrangement of type 1 and type 2 cells in the carotid body. In conclusion, we found evidence of presumed paraganglionic tissue in the APR of the marmoset which, however, did not show the characteristic histological features of the aortic body chemoreceptors that have been described in some non-primate mammals. A survey of the mediastina of other non-human primates is required to establish whether this finding is atypical for these animals.

Contrast echocardiography for detection of pulmonary arteriovenous malformations

BACKGROUND

Pulmonary arteriovenous malformations (PAVMs) lead to stroke, brain abscess, and hemorrhage in hereditary hemorrhagic telangiectasia (HHT). The current screening approach for PAVMs in HHT patients with chest radiograph (CXR) and oxygen shunt study has not been validated and is thought to be insensitive. We hypothesized that agitated saline contrast echocardiography (ECHO) would be a useful screening test for PAVMs.

METHODS AND RESULTS

A total of 106 sequential HHT patients underwent screening for PAVMs with ECHO in a prospective study. If the test was positive, or if the CXR or shunt study suggested PAVMs, pulmonary angiography was performed. A positive ECHO was defined as appearance of bubbles in the left atrium after injection of agitated saline solution. A positive shunt study was defined as a partial pressure of oxygen in arterial blood <500 mm Hg while breathing 100% oxygen. The mean age was 41 years (range 15-80 years); 66% were female. Forty-four patients had positive ECHO. Forty-one of the 44 patients underwent angiography. Three patients declined further testing. Thirty-three of the 41 patients who underwent angiography were diagnosed with PAVMs. Of the 62 patients with a negative ECHO, 18 underwent angiography because of either a shunt study or CXR that was suggestive of PAVMs. Of these 18 patients, 2 had PAVMs. In the total population of 106 patients, 35 (33%) had PAVMs. ECHO was the only positive screening test in 11 of 35 (31%) patients. The diagnosis of PAVMs in these 11 patients would have otherwise been missed.

CONCLUSIONS

ECHO is a useful screening tool for PAVMs in HHT.

Fossil that fills a critical gap in avian evolution

Despite the discoveries of well-preserved Mesozoic birds, a key part of avian evolution, close to the radiation of all living birds (Aves), remains poorly represented. Here we report on a new taxon from the Late Cretaceous locality of Ukhaa Tolgod, Mongolia, that offers insight into this critically unsampled period. Apsaravis and the controversial alvarezsaurids are the only avialan taxa known from the continental deposits at Ukhaa Tolgod, which have produced hundreds of fossil mammals, lizards and other small dinosaurs. The new taxon, Apsaravis ukhaana, is the best-preserved specimen of a Mesozoic ornithurine bird discovered in over a century. It provides data important for assessing morphological evolution across Avialae, with implications for, first, the monophyly of Enantiornithes and Sauriurae; second, the proposition that the Mesozoic sister taxa of extant birds, as part of an 'ecological bottleneck', inhabited exclusively near-shore and marine environments; and third, the evolution of flight after its origin.

Assessment of adherence to renal dosing guidelines in long-term care facilities

OBJECTIVE

We determined whether dosing guidelines based on creatinine clearance (Ccr) for renally excreted drugs are being applied when prescribing to long-term care residents

DESIGN

A cross sectional chart review for the month of May 1999.

PARTICIPANTS

Long-term care residents more than 65 years of age from four long-term care facilities in Southern Ontario who were prescribed a medication from a list of renally excreted drugs commonly prescribed in long-term care facilities.

RESULTS

Approximately one in three prescriptions (34.1%) were considered inappropriate for the calculated Ccr of the residents. Overall, 42.3% of the residents who were prescribed a drug under review received at least one inappropriate prescription based on creatinine clearance. Logistic regression found that age (odds ratio (OR) = 1.06 per year; 95% confidence interval (CI) 1.03-1.09, P = .001), weight (OR = 0.96 per kg; 95% CI 0.94-0.98, P < .001), the total number of prescribed medications (OR = 1.10; 95% CI 1.04-1.17, P = .001), and the number of physicians prescribing in the facility (OR 1.02; 95% CI, 1.003-1.044, P = .03) were predictive for receiving an inappropriate prescription based on Ccr.

CONCLUSIONS

Renal function is often overlooked when prescribing renally excreted drugs to older long-term care residents. These findings emphasize the need for consideration of Ccr when prescribing such drugs in this population.

Quantitative studies of the vasculature of the carotid body in the chronically hypoxic rat

The carotid bodies of rats made chronically hypoxic by breathing 12% O2 in a normobaric chamber (inspired PO2 91 mmHg) were compared with those of controls. Serial 5-microm sections of the organs were examined using an interactive image analysis system. The total volume of the carotid bodies was increased by 64%. The total vascular volume rose by 103% and was likely due to an increase in size of the large vessels (>12 microm lumen diameter) because the small vessel (5-12 microm lumen diameter) volume did not increase significantly while the small vessel density tended to decrease. The extravascular volume was increased by 57%. Expressed as a percentage of the total volume of the organ, the total vascular volume did not change, but the small vessel volume was significantly decreased from 7.83 to 6.06%. The large vessel volume must therefore have been increased. The proportion occupied by the extravascular volume was virtually unchanged (84 vs 82%). In accordance with these findings, the small vessel endothelial surface area per unit carotid body volume was diminished from 95.2 to 76.5 mm-1, while the extravascular area per small vessel was increased from 493 to 641 microm(2) or by 30%. In conclusion, the enlargement of the carotid body in chronic hypoxia is most likely due to an increase in total vascular volume, mainly involving the "large" vessels, and to an increase in extravascular volume. This is in contrast to our previously published findings indicating that in the spontaneous insulin-dependent diabetic rat the enlargement of the carotid body is due solely to an increase in extravascular volume.

Prediction of toxigenic fungal growth in buildings by using a novel modelling system

There is growing concern about the adverse effects of fungal bioaerosols on the occupants of damp dwellings. Based on an extensive analysis of previously published data and on experiments carried out within this study, critical limits for the growth of the indoor fungi Eurotium herbariorum, Aspergillus versicolor, and Stachybotrys chartarum were mathematically described in terms of growth limit curves (isopleths) which define the minimum combination of temperature (T) and relative humidity (RH) at which growth will occur. Each growth limit curve was generated from a series of data points on a T-RH plot and mathematically fitted by using a third-order polynomial equation of the form RH = a(3)T(3) + a(2)T(2) + a(1)T + a(0). This fungal growth prediction model was incorporated within the ESP-r (Environmental Systems Performance [r stands for "research"]) computer-based program for transient simulation of the energy and environmental performance of buildings. For any specified location, the ESP-r system is able to predict the time series evolution of local surface temperature and relative humidity, taking explicit account of constructional moisture flow, moisture generation sources, and air movement. This allows the predicted local conditions to be superimposed directly onto fungal growth curves. The concentration of plotted points relative to the curves allows an assessment of the risk of fungal growth. The system's predictive capability was tested via laboratory experiments and by comparison with monitored data from a fungus-contaminated house.

The carotid body of the spontaneous insulin-dependent diabetic rat

The carotid bodies from adult spontaneous insulin-dependent diabetic rats (strain BB/S) were perfusion-fixed at normal arterial blood pressure with 3% phosphate-buffered glutaraldehyde and compared with the organs from control rats (strain BB/Sc) prepared in the same way. Serial 5-micron sections were cut, stained, and using an interactive image analysis system, were analysed to determine the volumes of the carotid body and its vascular and extravascular compartments. There was no evidence of systemic arterial disease in the carotid stem arteries in either group of animals, and the microvasculature of the organs appeared normal by light microscopy. The volume of the carotid body was unchanged 3 months after the onset of diabetes but was increased at 6 months. The total vascular volume of the organ was unchanged, but the volume of the small vessels (5-12 microns) was increased. In the control group the small vessels comprised 5% of the total volume of the carotid body, or about 44% of the vascular compartment. The percentage of small vessels increased at 3 months in the diabetic group, but had returned to normal at 6 months. The extravascular volume followed the same pattern as the total carotid body volume and so did not change appreciably when expressed as a percentage of the total volume of the organ. The increase in size of the carotid body in diabetic rats is due, therefore, to an augmented extravascular volume. In one diabetic specimen the carotid sinus nerve showed signs of diabetic neuropathy, axonal swelling and intramyelinic oedema. The clinical implications of these results are discussed.

Design of a 2 T multipole wiggler insertion device for the SRS

Two new identical insertion devices have been designed for the Daresbury SRS. They are 2 T permanent-magnet multipole wigglers that will provide high flux in the X-ray region. This paper describes the magnetic and mechanical design of the arrays of steel pole pieces and permanent-magnet blocks. Also given is the engineering design of the support structure that will cope with the very large forces present while maintaining high levels of precision in gap setting and parallelism. The engineering design has been fully assessed using finite-element techniques to predict the deflections of critical parts of the structure. These two devices are due to be installed into the SRS by the end of 1998.

Beamline 14: a new multipole wiggler beamline for protein crystallography on the SRS

A new multipole wiggler device has been designed for the 2.0 GeV Synchrotron Radiation Source at Daresbury Laboratory in the UK. The nine-pole 2.0 T device will provide radiation for two beamlines dedicated to protein crystallography, one of which will be of high intensity. This article provides details of the design of the two stations and outlines methods being developed to combine dealing with the high heat load from the radiation while allowing both stations to be built as close to the centre of the fan as possible.

Severe skin loss after meningococcal septicaemia: complications in treatment

Meningococcal septicaemia can lead to purpura fulminans with subsequent full thickness skin loss and deep muscle damage. The case reports on two infants who recovered from such a severe episode are used to describe post-septicaemic procedures and complications encountered in nursing care, psychological support and rehabilitation, with the main focus on surgery. Skin grafting is complicated by contaminated and contracting wound areas. Extensive tissue necrosis required leg amputations. Cultured keratinocytes in one of the patients were found to be too vulnerable. It has still to be proven whether more radical early-stage fasciotomies can limit skin and muscle necrosis. Patients with meningococcal septicaemia are subject to a high number of complications that are optimally treated in a burns unit. These patients require up-to-date knowledge of constantly evolving treatment possibilities and a high-level collaboration of all medical fields involved.

The regulatory situation in central and eastern Europe

The countries of central and eastern Europe, as part of their integration into the European Community, are required to adopt Community regulatory systems for medical devices. This article discusses the challenges faced by these countries during the transition, and support the Community itself can provide to assist their integration. The views expressed in this article are those of the author and do not necessarily represent those of the European Commission.

Monokine products as predictors of AIDS dementia

OBJECTIVE

To determine whether or not soluble factors produced by peripheral blood mononuclear cells (PBMC) can predict AIDS dementia.

DESIGN AND METHODS

PBMC were isolated from individuals with and without AIDS dementia complex (ADC) to determine if the levels of cytokines tumour necrosis factor (TNF)-alpha and interleukin (IL)-6, or the production of a neurotoxic substance, were significantly different. PBMC were studied after determining that the numbers of monocyte-derived macrophages isolated by adherence were highly variable from patients with ADC compared with individuals without ADC. We prospectively studied 16 AIDS dementia patients, 13 healthy HIV-seropositive individuals, and eight sero-negative controls. Supernatants from PBMC were assayed for TNF-alpha, IL-6 and alone for neurotoxicity on human neural cells in vitro.

RESULTS

We observed a trend towards worse cognitive and motor performance in patients suffering from ADC but who had no opportunistic infections ('pure dementia'; n = 8). Levels of PBMC IL-6 were significantly higher in 'pure dementia' patients. There was a trend towards lower levels of PBMC TNF-alpha in the group of patients who had both dementia and opportunistic infections compared with "pure dementia' patients. Supernatant from PBMC of ADC patients was significantly more neurotoxic than that from healthy HIV-seropositive individuals.

CONCLUSIONS

Macrophage isolation from PBMC of patients with ADC was altered. Soluble factors produced from PBMC were significantly more neurotoxic than soluble factors from PBMC of healthy HIV-seropositive individuals. PBMC production of TNF-alpha and IL-6 was not a significant predictor of ADC.

European migration report

"This report uses available statistics to describe the contemporary trends and patterns of international migration involving Central and Eastern Europe. It focuses on the former Warsaw Pact countries, excluding the former Soviet Union..., and also omits former Yugoslavia." The authors conclude that "substantial emigration to the West continues, much of it unrecorded. What is perhaps more surprising is that the region has emerged as one of substantial immigration. This reflects two main forces. First, the countries of Central and Eastern Europe have become stepping stones on the way to the lotus lands of Western Europe....Second, some of the countries of Central and Eastern Europe...have become honeypots in their own right."

Dermasorb versus Jelonet in patients with burns skin graft donor sites

A prospective and randomized trial that compares Jelonet (Smith & Nephew PLC, London, England) with a new hydrocolloid dressing, Dermasorb (Convatec Ltd., Clwyd, United Kingdom), is presented. The dressings were applied on contiguous donor sites in 21 patients that required skin grafting for burn wounds. Pain experienced with the dressing in situ was assessed on days 2, 4, 7, and on two subsequent occasions. During dressing changes, pain experienced was again assessed, bacteriologic swabs were taken, and the percentage of epithelialization was recorded. Questionnaires completed by investigators and patients were used to assess the perceived performances of both dressings. The results showed that Dermasorb is a less painful dressing than Jelonet, in which wounds heal faster. Dermasorb was preferred by both investigators and patients. No clinical or laboratory evidence of any differences of colonization or infection were found. All results were statistically significant. We would strongly recommend the use of Dermasorb as a split-thickness skin graft donor site dressing for a patient with burns.

Mortality after transurethral and open prostatectomy in Scotland

OBJECTIVE

To use the linked medical and death records in Scotland to investigate the possible increased mortality that has been reported after transurethral prostatectomy (TURP) compared with open prostatectomy.

PATIENTS AND METHODS

Scotland has maintained linkable hospital, cancer and death records for more than 20 years, representing one of the largest such databases in the world. From these computerized records, data on various cohorts of men aged 55-84 years selected from 81,997 men who underwent prostatectomy in Scotland between 1968 and 1989 were analysed. The risk of late mortality was calculated for each type of operation, whether there was prior comorbidity and for a range of specific causes (cancer, respiratory and circulatory conditions) after prostatectomy.

RESULTS

Among the largest cohort, consisting of 65,519 men who underwent prostatectomy between 1968 and June 1989, the relative risk of late mortality after TURP compared with open prostatectomy was 1.13 (95% CI, 1.10-1.16), after controlling for age and the presence of a diagnosis of cancer. A more restricted cohort of 18,732 men who underwent prostatectomy between 1974 and 1979 allowed adjustment for prior hospitalization with, or concurrent diagnosis of, circulatory and respiratory conditions. In this cohort, the relative risk of late mortality after TURP as compared with open prostatectomy was 1.15 (95% CI, 1.11-1.19) after adjusting for prior and comorbidity and age. Finally, a cohort of 'healthy patients' restricted to the 6932 men who underwent prostatectomy from 1974 to 1979 and with no evidence of hospitalization in the previous 5 years or any current diagnosis other than benign hypertrophy of the prostate, showed a relative risk of 1.14 (95% CI, 1.07-1.21). There was no evidence of an increased risk of dying from circulatory disease in general, ischaemic heart disease or acute myocardial infarction after TURP as opposed to open prostatectomy. However, there was an increased risk of dying from respiratory conditions and from cancer, especially of the prostate and bladder. The analysis suggested the possibility that open prostatectomy may have cured some patients with early prostatic cancer, because the late death rate from prostatic cancer was greater in patients who underwent TURP than open prostatectomy.

CONCLUSION

The present analysis confirmed the increased risk of late mortality after TURP compared with open prostatectomy, as shown in previous studies based on administrative records. However, limitations in the coding of comorbidities and the absence of coding of more subtle aspects of the condition of the patient which may influence the choice between the forms of prostatectomy mean that the differential mortality after the two procedures could still be a reflection of the pre-operative selection of patients rather than the effects of the surgical procedure.

Disablement resulting from motorcycle crashes

This retrospective study describes the nature and severity of disablement resulting from motorcycle crashes (both traffic and non-traffic). Two hundred and fifty motorcycle crash victims were randomly selected from the total population of motorcycle crash victims (n = 1510) who had received compensation for disablement in the year ending 31 March 1990. Information on the nature and extent of disablement was obtained from official accident compensation files and coded according to the International Classification of Impairments, Disabilities, and Handicaps. Extremity injuries predominated, especially to the lower limb. The majority of these were fractures. Most commonly impairments occurred in the areas of 'skeletal', 'disfiguring' and 'generalized' impairment. Mechanical impairment of a limb was reported in 68% of cases, often with associated disfigurement. Disability mostly involved problems with locomotion and problems coping with physical stresses at work. Occupational handicap was the most common handicap reported, with mobility handicap the next most common. The shortcomings of this study included its retrospective design and the variable quality of the information on disablement. It was most likely, though, that these factors contributed to an underestimation of disablement in the study group.

Changing patterns of prostatectomy in Scotland: 1971-1989

Analysis of 81,374 prostatectomies performed in Scotland between 1971 and 1989 showed that the annual prostatectomy rate (per 100,000 men) increased 3-fold for procedures performed by urologists, but remained static for general surgeons. In 1971, transurethral prostatectomy comprised 16% of all prostatectomies performed by general surgeons and 55% of those performed by urologists, but by 1989 it comprised 93% of prostatectomies performed by general surgeons and 96.5% of those performed by urologists. The relative increase in the annual number of prostatectomies was greatest (2.61) in the older age group (80-89 years) and smallest (1.76) in the younger age group (60-69 years). The relative increase in the age-specific prostatectomy rate was greatest (1.79) in the youngest age group (50-59 years) and smallest (1.54) in the oldest age group (80-89 years). This indicates that the increase in the annual number of prostatectomies performed in the older age groups is largely the result of an increase in the number of elderly men in the population, but this is compounded by an expansion of the indications for prostatectomy in all age groups.

Firework related injury in New Zealand

AIMS

In March 1992 a private members Bill was introduced into parliament which sought to place tighter restrictions on the sale of fireworks. The primary purpose of this research was to document the nature and extent of firework related injury in New Zealand for the purpose of preparing a submission on this Bill.

METHODS

Firework related injuries were examined in relation to the legislative history of fireworks control in New Zealand to ascertain if existing regulations had been effective in reducing firework injuries and whether there was justification for greater control.

RESULTS

Between 1979 and 1992 (inclusive) 237 persons were admitted to hospital for treatment of injuries related to fireworks. The overall incidence rate for this period was 0.52 per 100,000 persons per year. Eighty five percent of all events involved males. Children (< 15 years) comprised 68% of the victims with the 10-14 year age group having the highest rate of injury, at 2.5 per 100,000 persons per year.

CONCLUSIONS

The authors concluded that, on the basis of morbidity, it may be premature to impose a complete ban on the public sale of fireworks (as is proposed in the Bill). The current legislation could well be supported though, by extending the ban on the types of fireworks publicly available to include skyrockets.

Audit of emergency throughput in a regional plastic surgery unit

A prospective study of emergency admissions to a regional plastic surgery unit was performed to investigate the extent and causes of delay between injury and operation. Details of 52 consecutive admissions, excluding those to the burns unit, were collected over a 50-day period. The mean delay between the injury and start of operation was 16.9 h (range 4.33-52.75 h). For patients referred from other hospitals in the region (n = 35) the mean delay between referral and admission was 3.64 h (range 0.5-17 h). This delay was 1.06 h (range 0-4.0 h) for those referred from the on-site accident and emergency department (n = 17). These results show that there is an excessive delay in treating these patients, but that transfer times to a regional centre contribute relatively little to the overall delay. The cause of this delay in the majority of cases was identified as lack of theatre availability. As a consequence of this 38% of operations took place after 2300 hours. If late-night operating was reduced, delay would worsen unless a second emergency theatre was made available between 1700 and 2300 hours, or emergency cases replaced elective ones on routine operating lists.

Investigation of HIV-infected macrophage neurotoxin production from patients with AIDS dementia

The mechanism for AIDS dementia may involve the production of toxic cytokines. Since macrophage/microglia are the infected cells in the brain, we were interested in the production of some of the same cytokines by HIV-infected macrophages from patients with AIDS dementia. HIV-infected macrophages from 11 patients with AIDS dementia were cultured and evaluated for p24, cytomegalovirus (CMV) DNA, and the production of interleukin 6 (IL-6), tumor necrosis factor alpha (TNF alpha) and other neurotoxic factors. The percentage of HIV macrophage infectivity did not correlate with the severity of dementia nor did the presence of CMV. The production of IL-6 and an unidentified neurotoxin did not correlate with HIV macrophage infectivity suggesting that these soluble factors are strain specific. Production of TNF alpha by HIV-infected macrophages was relatively low (< 1-35 pg/ml) and may not be a significant factor in toxicity.

The use of cerium nitrate-silver sulphadiazine as a topical burns dressing

Infection remains the major cause of morbidity and mortality following the shock phase in the burn patient. Measures to reduce the risk of wound infection and subsequent sepsis include early excision where possible, and the use of topical antimicrobial creams such as silver sulphadiazine. Studies from the USA and Europe suggest the addition of cerium nitrate to this commonly used agent may improve its efficacy. We present the findings of a pilot study which investigated the action of a commercial preparation of cerium nitrate/silver sulphadiazine mixture (Flammacerium, Duphar B. V. Holland) on 20 patients considered unsuitable for surgery. There were no episodes of cellulitis or septicaemia. Flammacerium was noted to produce an adherent eschar that was easy to shave and which received split skin grafts well.

Ecstasy and Whizz at a rave resulting in a major burn plus complications

A patient who sustained a major burn following abuse with Ecstasy and Whizz is described. His progress was complicated by hyperpyrexia, acute renal failure and convulsions, all of which have been recently recognized as potential side-effects of Ecstasy abuse. This report further highlights the dangers of substance abuse.

An evaluation of a program to reduce home hot tap water temperatures

Children are more likely to be hospitalised because of burns from hot liquids than from contact with fire and flames. Many of these hot liquid burns are from contact with hot tap water, usually in the home. Hot tap water burns to young children can be prevented completely by lowering the delivery temperature of the hot tap water. This study reports on the evaluation of a program designed to lower the temperature of home hot tap water in Dunedin, New Zealand. In conjunction with a national media campaign, the program provided an educational intervention to households with young children. Before and after measures were made and comparison groups were used to determine the effect of the intervention on tap water temperatures. Mean tap water temperature was 64.2 degrees C at baseline and 61.2 degrees C at follow-up. The proportion of households with water temperatures above 70 degrees C decreased by 50 per cent between baseline and follow-up while the proportion below 60 degrees C increased from 33 per cent to 47 per cent. The group receiving the intervention did not differ significantly from the comparison groups. There were significant decreases in tap water temperature across all groups, but the majority of households still had temperatures above 55 degrees C at the end of the study.

Utility of Scottish morbidity and mortality data for epidemiological studies of motor neuron disease

OBJECTIVES

To determine the accuracy of (1) hospital discharge data and (2) death certificates, coded as motor neuron disease (MND).

DESIGN

Comparison of data from The Scottish Motor Neuron Disease Register (SMNDR) with routinely collected Scottish Hospital In-Patient Statistics (SHIPS) and death certificate coding.

SETTING

Scotland UK.

PATIENTS

1) 379 adults (> 15 years) discharged for the first time from a Scottish hospital in 1989-90 and (2) 281 deaths in the same period assigned to the International Classification of Diseases (ICD)-9, category 335 (MND).

MAIN OUTCOME MEASURES

The sensitivity and positive predictive value of a diagnosis of MND as retrieved by (1) the Information and Statistics Division of the Common Services Agency for the Scottish Health Service for morbidity data and (2) the Registrar General's office for mortality data, using the SMNDR as the 'gold standard'.

RESULTS

(1) Thirty per cent of adult patients identified as having MND by SHIPS did not have this disease and 23% of patients with MND did not appear on SHIPS. The sensitivity of a diagnosis of MND, as retrieved by SHIPS, was 84% and the positive predictive value was 70% overall. Miscoding of patients with pseudobulbar palsy caused by cerebrovascular disease was the major source of false positive error. The incidence of adult onset sporadic MND was over estimated by SHIPS by a factor of 1.6. (2) Mortality data were more accurate, with a false negative rate of 6% and a positive predictive value of 90%.

CONCLUSIONS

Coded hospital discharge data are an inaccurate record of a diagnosis of MND and cannot, in their present form, be used as a reliable measure of disease incidence in Scotland. Greater care is required in the preparation of discharge summaries and coding if these data are to be useful for health care planning and epidemiological research. SHIPS is, however, an important source of information to achieve a complete sample of patients with MND. There is also a problematic false positive rate for mortality data but this source more closely approximates true incidence.

A morphological study of the size of the vascular compartment of the carotid body in a non-human primate (Cercopithecus ethiopus), and a comparison with the cat and rat

The carotid bodies from 5 adult non-human primates (mean body weight 2.9 kg) were perfusion-fixed at normal arterial blood pressure with 3% phosphate-buffered glutaraldehyde. Serial 5-microns sections were cut, stained, and, using an interactive image analysis system, determinations were made of the volumes of the carotid body and of its vascular and extravascular compartments. The total volume of the carotid body was, on average 0.21 mm3, the total vascular volume contributing 9.7%. The small vessels (5-12 microns diameter) comprised 5.4% of the total volume of the carotid body, or about 56% of the vascular compartment; these estimates were similar to values obtained for the cat and rat. The mean small vessel endothelial area, per unit of extravascular volume (which is assumed to consist largely of type 1 and 2 cells) was 61.8 mm-1 in the primate and 69.7 mm-1 in the cat. A value was not available for the rat. Estimates of the carotid body tissue specific blood flow were 31, 61 and 104 ml/min/100 g organ tissue in the primate, cat and rat, respectively. It was emphasised that these values were not to be confused with estimates of carotid body specific blood flow based on values for total organ blood flow and the dissected weight of the organ.