PrÉvalence Et DÉterminants De La Non-Vaccination Contre L’hÉpatite B Chez Les Adolescents Au Canada, 2013

HISTORIQUE: Le Comité consultatif national de l’immunisation (CCNI) recommande depuis 1993 la mise en place de programmes de vaccination universelle contre l’hépatite B au Canada. Depuis 1998, des programmes de vaccination universelle contre l’hépatite B sont place partout au pays. Les calendriers de vaccination systématique ne sont toutefois pas harmonisés.

OBJECTIFS: Mesurer la couverture vaccinale pour l’hépatite B rapportés et identifier les facteurs de risques associés à la non-vaccination.

MATÉRIALS/MÉTHODE: Nous avons analysé les données de 6805 adolescents de 17 ans inclus dans l’enquête nationale sur la couverture vaccinale des enfants (ENCVE) de 2013 pour identifier les facteurs socio-démographiques associés à la non-vaccination, c’est-à-dire n’avoir reçu aucune dose du vaccin contre l’hépatite B. Les variables indépendantes incluses dans l’analyse étaient les provinces et territoires, le fait que les adolescents ou les parents soient nés à l’extérieur du Canada ou non, le statut matrimonial des parents et le niveau d’éducation de ces derniers en plus du revenu familial moyen. Les rapports de cotes ont été calculés au moyen de regressions logistiques simples et multiples. Les intervalles de confiance ont été estimés par la méthode bootstrap.

RÉSULTATS: En tout, 87.9% des adolescents avaient reçu au moins une dose du vaccin. Il n’y avait pas d’association significative entre le statut socioéconomique et le statut vaccinal des enfants pour l’hépatite B. Il existe cependant des différences au niveau de couverture vaccinale pour ce vaccin entre les différentes provinces et territoires du Canada. De plus, à 17 ans le fait d’être né à l’extérieur du Canada était associé à un risque plus élevé d’être non-vacciné comparativement aux enfants nés au Canada, et ce à la limite du seuil de signification (p=0.556).

CONCLUSION: Il existe des différences entre les taux de couvertures des provinces et territoires malgré des programmes de vaccination systéma-tique contre l’hépatite B dans toutes les juridictions. Par contre, il ne semble pas y avoir d’inégalité socioéconomique en lien avec le statut vac-cinal de l’hépatite B des adolescents. Ceci est un fait encourageant pour les programmes de promotion en place dans le pays.

Diffusion-weighted imaging in uterine artery embolisation: do findings correlate with contrast enhancement and volume reduction?

OBJECTIVES

The objective of this study was to determine the role of diffusion-weighted imaging (DWI) in uterine artery embolisation (UAE), and to assess the apparent diffusion coefficient (ADC) of the dominant fibroid and its relationship to contrast enhancement and fibroid volume reduction.

METHODS

We carried out a retrospective study of 15 patients who underwent UAE. Calculations were performed at baseline and 6 months post-embolisation. Fibroid ADC (expressed in 10(-3) mm(2) s(-1)) was calculated using b=0 and b=1000 DWI values. Fibroid enhancement was compared with background myometrium by measuring signal-difference-to-noise ratio (SDNR). Fibroid volume was calculated using a prolate ellipse formula.

RESULTS

There was a significant reduction (p<0.001) in fibroid ADC at 6 months (0.48; standard deviation, SD=0.26) as compared with baseline (1.01; SD=0.39). No significant change (p=0.07) was identified in 6-month myometrial ADC (1.09; SD=0.28) as compared with baseline (1.24; SD=0.20). Moderately strong and significant positive correlation was identified between baseline ADC and 6-month percentage volume reduction of the fibroid (correlation=0.66, p=0.007). No correlation was identified between SDNR and ADC at baseline or 6 months (r=0.01, p=0.97 and r=-0.13, p=0.64, respectively) or SDNR and percentage volume reduction at 6 months (correlation r=0.18, p=0.51).

CONCLUSION

Baseline ADC of dominant fibroids shows a moderately strong correlation with subsequent volume reduction at 6 months following UAE. No correlation was identified between ADC values and contrast enhancement on the baseline or 6-month scans. Further prospective evaluation is needed before DWI can be utilised in clinical practice. Advances in knowledge DWI imaging may provide additional information about UAE and possibly help to predict uterine volume reduction.

Developing and validating a predictive model for stroke progression

BACKGROUND

Progression is believed to be a common and important complication in acute stroke, and has been associated with increased mortality and morbidity. Reliable identification of predictors of early neurological deterioration could potentially benefit routine clinical care. The aim of this study was to identify predictors of early stroke progression using two independent patient cohorts.

METHODS

Two patient cohorts were used for this study - the first cohort formed the training data set, which included consecutive patients admitted to an urban teaching hospital between 2000 and 2002, and the second cohort formed the test data set, which included patients admitted to the same hospital between 2003 and 2004. A standard definition of stroke progression was used. The first cohort (n = 863) was used to develop the model. Variables that were statistically significant (p < 0.1) on univariate analysis were included in the multivariate model. Logistic regression was the technique employed using backward stepwise regression to drop the least significant variables (p > 0.1) in turn. The second cohort (n = 216) was used to test the performance of the model. The performance of the predictive model was assessed in terms of both calibration and discrimination. Multiple imputation methods were used for dealing with the missing values.

RESULTS

Variables shown to be significant predictors of stroke progression were conscious level, history of coronary heart disease, presence of hyperosmolarity, CT lesion, living alone on admission, Oxfordshire Community Stroke Project classification, presence of pyrexia and smoking status. The model appears to have reasonable discriminative properties [the median receiver-operating characteristic curve value was 0.72 (range 0.72-0.73)] and to fit well with the observed data, which is indicated by the high goodness-of-fit p value [the median p value from the Hosmer-Lemeshow test was 0.90 (range 0.50-0.92)].

CONCLUSION

The predictive model developed in this study contains variables that can be easily collected in practice therefore increasing its usability in clinical practice. Using this analysis approach, the discrimination and calibration of the predictive model appear sufficiently high to provide accurate predictions. This study also offers some discussion around the validation of predictive models for wider use in clinical practice.

Public health on-call in Scotland: how much experience is sufficient?

OBJECTIVES

To quantify the out-of-hours experience obtained by public health trainees in Scotland and to assess whether this is sufficient to meet the Faculty of Public Health guidelines.

STUDY DESIGN

Prospective survey.

METHODS

All public health trainees in Scotland were invited to participate in a prospective survey of out-of-hours experience. Data were collected from March 2009 to March 2010. The variation in the experience between trainees was compared according to the size, urban/rural mix, and deprivation of the population for which they were responsible. The variation in the experiences gained were then compared to the requirements of the Faculty of Public Health.

RESULTS

18 trainees participated from 6 areas, collecting data on 391 shifts and a total of 276 calls. For every 50 shifts the median number of notifications of probable meningococcus was 3.7 and the median number of chemical incidents and Escherichia coli O157 notifications was 0.0. This variation is difficult to interpret because some trainees collected data for only a short period. The variation between trainees was not significantly related to population size, deprivation or rurality. Pooling the data from all trainees, there was a mean of 2.9 probable meningococcus notifications, 2.4 E coli O157 calls, and 0.3 chemical incident calls per 50 shifts.

CONCLUSIONS

There is a large and unpredictable degree of variation in the on-call experience of Scottish trainees. The minimum recommended number of on-call shifts may not be adequate to ensure a high proportion of trainees are prepared for unsupervised on-call.

The effect of bipolar I disorder and major depressive disorder on workforce function

This investigation was undertaken to explore and compare the effect of bipolar I disorder (BD) and major depressive disorder (MDD) on workforce function. The data for this analysis were procured from the Canadian Community Health Survey (CCHS 1.2). The sample consisted of 20 747 individuals (≥ 18 years old and currently working); the proportions screening positive for lifetime BD and MDD were 2.4% and 11.2%, respectively. Individuals with BD or MDD had a signifi cantly lower mean annual income, compared to people without these disorders. Individuals with BD had a signifi cantly lower annual income when compared to MDD (p $lt; 0.05). Results from a multiple logistic regression also indicate that employed individuals with BD had greater odds of reporting one or more mental health disability days in the past two weeks, compared with those with MDD (OR = 1.6; 95% CI = 1.0 to 2.6). Currently employed individuals with BD had lower odds of “good job security” relative to those with MDD (OR = 0.6 95% CI = 0.5 to 0.9). The data herein underscore the pernicious effect of BD on workforce function, and suggest that opportunistic screening for BD in all individuals utilizing employment assistance programs for depression might be warranted.

The effect of bipolar I disorder and major depressive disorder on workforce function

This investigation was undertaken to explore and compare the effect of bipolar I disorder (BD) and major depressive disorder (MDD) on workforce function. The data for this analysis were procured from the Canadian Community Health Survey (CCHS 1.2). The sample consisted of 20,747 individuals (>or=18 years or older and currently working); the proportions screening positive for lifetime BD and MDD were 2.4% and 11.2%, respectively. Individuals with BD or MDD had a significantly lower mean annual income, compared to people without these disorders. Individuals with BD had a significantly lower annual income when compared to MDD (p < 0.05). Results from a multiple logistic regression also indicate that employed individuals with BD had greater odds of reporting one or more mental health disability days in the past two weeks, compared with those with MDD (OR = 1.6; 95% CI = 1.0 to 2.6). Currently employed individuals with BD had lower odds of "good job security" relative to those with MDD (OR = 0.6 95% CI = 0.5 to 0.9). The data herein underscore the pernicious effect of BD on workforce function, and suggest that opportunistic screening for BD in all individuals utilizing employment assistance programs for depression might be warranted.

Dental caries in 5-year-old children attending multi-ethnic schools in Greater Glasgow--the impact of ethnic background and levels of deprivation

OBJECTIVE

To examine levels of dental caries of 5-year-olds attending multi-ethnic schools in Greater Glasgow and to explore the effects of deprived backgrounds and ethnic identity on their dental health.

DESIGN

Between October 2001 and February 2002 a cross-sectional dental epidemiology survey of a sample of 721 5-year-olds was undertaken in schools having at least 25 per cent of pupils from black or minority ethnic groups. Background data on participating children were obtained from school records, including: ethnic origin, mothers' ability to speak English, religion, and demographics. Statistical analyses included two way analysis of variance to determine the effect of ethnicity after adjusting for socio-economic factors.

RESULTS

Complete data were available for 649 (90%) children. The sample broadly divided into white (52%), Pakistani (33%), and other minority ethnic groups (15%). Based on repeat observations, diagnosis reliability was good (Kappa = 0.77). The caries experience of Pakistani children (d3mft = 4.1; 95% CI 3.6 to 4.6) was significantly higher (p < 0.001) than the white children (d3mft = 2.3; 95% CI 1.9 to 2.6). Only 25% (95% C1 17 to 34) of the Pakistani children had no obvious decay, significantly lower (p < 0.001) than their white contemporaries (48%, 95% CI 39 to 58). Pakistani ethnic origin was associated with significantly higher levels of dental caries (p < 0.001), after adjusting for socio-economic deprivation.

CONCLUSION

Children from deprived backgrounds have worse dental caries levels than their affluent counterparts and, over and above this effect, minority ethnic children of Pakistani background have higher levels than their white peers.

The multidisciplinary team meeting improves staging accuracy and treatment selection for gastro-esophageal cancer

The object of this article is to assess current staging accuracies for individual modalities and to investigate the influence of the multidisciplinary team (MDT) on clinical staging accuracies and treatment selection for patients with gastro-esophageal cancer. Patients newly diagnosed with gastric or esophageal cancer and who were deemed suitable for surgical resection by the MDT were studied. Patients were staged with a combination of computerized tomography (CT), endoscopic ultrasound (EUS) and laparoscopic ultrasound (LUS). Additionally, the MDT determined an overall clinical stage for each patient after discussion at the MDT meeting. Treatments were selected according to this final clinical stage. Final histopathological staging (pTNM) was available for all patients and was used as the gold standard for determining staging accuracy. Suitability of treatment selection was assessed once final pTNM was available. One hundred and eighteen patients were studied. Endoscopic ultrasound was the most accurate individual staging modality for the loco-regional assessment of esophageal tumors (T stage accuracy 78%, N stage accuracy 70%). Laparoscopic ultrasound was the most accurate modality in T staging of gastric cancers (91%). The MDT stage was more accurate than each individual staging modality for T and N staging for both gastric and esophageal cancers (accuracy range: 88-89%) and was better for the assessment of nodal disease than each individual modality (CT P < 0.001, EUS P < 0.01, LUS P < 0.01). Overall staging accuracy as determined at the MDT meeting was increased and resulted in only 2/118 (2%) patients being under-treated. The MDT significantly improves staging accuracy for gastro-esophageal cancer and ensures that correct management decisions are made for the highest number of individual patients.

Elevated tumour interleukin-1beta is associated with systemic inflammation: A marker of reduced survival in gastro-oesophageal cancer

Systemic inflammation is associated with adverse prognosis cancer but its aetiology remains unclear. We investigated the expression of proinflammatory cytokines within normal mucosa from healthy controls and tumour tissue in cancer patients and related these levels with markers of systemic inflammation and with the presence of a tumour inflammatory infiltrate. Tissue was collected from 56 patients with gastro-oesophageal cancer and from 12 healthy controls. Tissue cytokine mRNA concentrations were measured by real-time PCR and tissue protein concentrations by cytometric bead array. The degree of chronic inflammatory cell infiltrate was recorded. Serum cytokine and acute phase protein concentrations (including C-reactive protein (CRP)) were measured by enzyme-linked immunosorbent assay. Proinflammatory cytokines were significantly overexpressed (interleukin (IL)-1β, IL-6, IL-8 and tumour necrosis factor-α) both at mRNA and protein levels in the cancer specimens compared with mucosa from controls. Interleukin-1β was expressed in greatest (10–100-fold) concentration and protein levels correlated significantly with systemic inflammation (CRP) (P=0.05, r=0.31). A chronic inflammatory infiltrate was observed in 75% of the cancer specimens and was associated with systemic inflammation (CRP: P=0.01). However, the presence of chronic inflammation per se was not associated with altered cytokine expression within the tumour. Both a chronic inflammatory infiltrate and systemic inflammation (CRP) were associated with reduced survival (P=0.05 and P=0.03, respectively). Tumour chronic inflammatory infiltrate and tumour tissue IL-1β overexpression are potential independent factors influencing systemic inflammation in oesophagogastric cancer patients.

Expression of the proteolysis-inducing factor core peptide mRNA is upregulated in both tumour and adjacent normal tissue in gastro-oesophageal malignancy

Gastro-oesophageal cancer is associated with a high incidence of cachexia. Proteolysis-inducing factor (PIF) has been identified as a possible cachectic factor and studies suggest that PIF is produced exclusively by tumour cells. We investigated PIF core peptide (PIF-CP) mRNA expression in tumour and benign tissue from patients with gastro-oesophageal cancer and in gastro-oesophageal biopsies for healthy volunteers. Tumour tissue and adjacent benign tissue were collected from patients with gastric and oesophageal cancer (n=46) and from benign tissue only in healthy controls (n=11). Expression of PIF-CP mRNA was quantified by real-time PCR. Clinical and pathological information along with nutritional status was collected prospectively. In the cancer patients, PIF-CP mRNA was detected in 27 (59%) tumour samples and 31 (67%) adjacent benign tissue samples. Four (36%) gastro-oesophageal biopsies from healthy controls also expressed PIF-CP mRNA. Expression was higher in tumour tissue (P=0.031) and benign tissue (P=0.022) from cancer patients compared with healthy controls. In the cancer patients, tumour and adjacent benign tissue PIF-CP mRNA concentrations were correlated with each other (P<0.0001, r=0.73) but did not correlate with weight loss or prognosis. Although PIF-CP mRNA expression is upregulated in both tumour and adjacent normal tissue in gastro-oesophageal malignancy, expression does not relate to prognosis or cachexia. Post-translational modification of PIF may be a key step in determining the biological role of PIF in the patient with advanced cancer and cachexia.

Gastric adenocarcinoma missed at endoscopy

BACKGROUND AND PURPOSE

The diagnosis of gastric cancer is based on histological confirmation at endoscopy with the emphasis on early detection to improve prognosis. The aims of this study were to identify the proportion of patients with gastric adenocarcinoma in whom the diagnosis was missed at first endoscopy and the subsequent delay which occurred before the histological diagnosis was established.

METHODS

Retrospective review of 137 consecutive patients with biopsy-proven gastric adenocarcinoma presenting to one surgical unit over a five-year period.

RESULTS

Two patients with a biopsy diagnosis at laparotomy and 6 patients in whom case notes could not be traced were excluded from the study. Of the remaining 129 patients, the diagnosis of gastric adenocarcinoma was missed at first endoscopy in 18 (14%). The median delay to histological diagnosis in this subgroup of patients was 13 weeks (range 3-102).

CONCLUSION

Delays in establishing the diagnosis of gastric adenocarcinoma following initial endoscopy occur in a number of patients. Greater suspicion and a more rigorous protocol for repeat endoscopy and biopsy must be implemented in order to reduce the number of missed diagnoses after initial endoscopy.

Mortality in metropolitan areas

OBJECTIVES

This article examines differences in all causes mortality rates and rates for the leading causes of death (heart disease, cancer and cerebrovascular disease) by census metropolitan area (CMA).

DATA SOURCE

The data are from the Canadian Vital Statistics Data Base maintained by Statistics Canada.

ANALYTICAL TECHNIQUES

Annualized age-standardized mortality rates were calculated for Canada and for each CMA for the three-year period from 1994 to 1996. Differences between the CMA rates and the national rate were examined.

MAIN RESULTS

Mortality rates tend to be high in CMAs in the Atlantic provinces and Québec and low in CMAs in the Prairies and British Columbia. Ontario contains CMAs with some of the highest mortality rates in Canada, as well as others whose rates are among the lowest. The pattern of mortality for specific causes also differs within CMAs: a CMA may have a high death rate for one cause, but a low rate for another.

The epidemiology of infantile hypertrophic pyloric stenosis in Greater Glasgow area, 1980-96

The annual incidence of infantile hypertrophic pyloric stenosis (IHPS) in Greater Glasgow area from 1980 to 1996 was calculated. An increasing incidence was observed between 1980 and 1988 but not thereafter. There is a suggestion that environmental factors may play a role in the aetiology of this condition.

Gender and survival: a population-based study of 201,114 men and women following a first acute myocardial infarction

OBJECTIVES

We tested the hypotheses that the effect of gender on short-term case fatality following a first admission for acute myocardial infarction (AMI) varies with age, and that this effect is offset by differences in the proportion of men and women who survive to reach hospital.

BACKGROUND

Evidence is conflicting regarding the effect of gender on prognosis after AMI.

METHODS

All 201,114 first AMIs between 1986 and 1995 were studied. Both 30-day and 1-year case fatality were analyzed for the 117,749 patients hospitalized and for all first AMIs, including deaths before hospitalization. The effect of gender and its interaction with age on survival was examined using multivariate modeling.

RESULTS

Gender-based differences in survival varied according to age in hospitalized patients, with younger women having higher 30-day case fatality than men (e.g., <55 years, women 6.5% vs. 4.8% men, p < 0.0001). When deaths from first AMI before hospitalization were included in 30-day case fatality, women were less likely to die (adjusted odds ratio 0.9, confidence interval 0.89 to 0.93). Gender was not an independent predictor of one-year survival (p = 0.16).

CONCLUSIONS

Female gender increases the probability of surviving to reach hospital, and this outweighs the excess risk of death occurring in younger women following hospitalization. Overall, men have a higher 30-day case fatality than women. Women do not fare worse than men after AMI when age and other factors are taken into account. However, men are more likely to die before hospitalization.

Migraine

OBJECTIVES

This article provides prevalence and incidence estimates of migraine among Canadians aged 12 or older. Associations with selected socio-demographic factors and health characteristics are also examined. Selected health indicators and medication use, as well as health care use and attitudes, are discussed, comparing migraineurs with non-migraineurs.

DATA SOURCES

The findings are based on the cross-sectional and longitudinal household components of the first three cycles (1994/95, 1996/97 and 1998/99) of Statistics Canada's National Population Health Survey. Information on hospital stays is from the 1997/98 Hospital Morbidity Database, maintained by the Canadian Institute for Health Information.

ANALYTICAL TECHNIQUES

Cross-tabulations were used to estimate the prevalence and incidence of migraine. Associations of migraine with selected factors were examined using generalized logistic regression.

MAIN RESULTS

In 1998/99, migraine was most prevalent among women, 25- to 54-year-olds, Whites, and individuals in low-income households. The odds of being diagnosed with migraine were higher for women with pre-existing sinusitis, bronchitis or emphysema, compared with women without these conditions. The odds of this disorder for men were associated with previously diagnosed arthritis or rheumatism.

Multi-centre research surveillance project to reduce infections/phlebitis associated with peripheral vascular catheters

A surveillance project was undertaken on 37 surgical wards by infection control nurses with the aim of reducing phlebitis/infections associated with peripheral vascular catheters, and to identify risk factors. Data on 2934 catheters in situ longer than 24h was collected in two separate surveillance periods and results were fed back after each surveillance period. Four significant risk factors were identified; what the catheters were used for, the duration the catheters were in situ, the surveillance period (the first surveillance period had a higher phlebitis rate than the second) and whether an infusion pump was used. Logistic regression analysis showed that each of these had a significant effect after adjusting for the effects of the other three factors.

Do health checks cause stress?

Data are reported concerning social responses to health checks in an occupational setting. Previous research has suggested that screening may be a stressful experience. This, in turn, has contributed to a degree of scepticism about the value of health checking. No evidence was found in the present study to support the proposition that health checks cause such responses. It is shown that health checks prompt recipients to try to engage in health promoting behavioural changes. The study was a randomized controlled trial of 1,371 persons employed in a large engineering factory in the West of Scotland.

The accessibility of information systems for patients: use of touchscreen information systems by 345 patients with cancer in Scotland

AIM

To examine cancer patients' use, and satisfaction with touchscreen information systems. By examining the experience of subgroups, to address issues of equality of access.

PATIENTS

345 patients starting radiotherapy at the Beatson Oncology Centre (BOC), Glasgow.

METHODS

Patients were invited to use a touchscreen computer at the start of treatment. They were sent a printout of what they saw on screen. Patients had open access to the system. Data were collected at recruitment, intervention, 3 weeks and 3 months. Predictor variables included: patients' demographics, information preferences, technology use, and psychological state. Outcome variables included: use and views of the computer and printout.

RESULTS

Younger, broadsheet readers with previous computer use were more likely to find the system easy to use. Older, tabloid readers were more likely to find the content new and relevant.

DISCUSSION

We need to make systems adapt to users' different needs. More effort should be made to provide affordable information for older, generally less literate and technologically less literate groups in suitable locations.

Health checks and coronary risk: further evidence from a randomised controlled trial

OBJECTIVE

To determine the effectiveness of a health check and assess any particular benefits resulting from feedback of plasma cholesterol concentration or coronary risk score, or both.

DESIGN

Randomised controlled trial in two Glasgow work sites.

SUBJECTS

1,632 employees (89% male) aged 20 to 65 years.

INTERVENTIONS

At the larger work site, (a) health education; (b) health education and feedback on cholesterol concentration; (c) health education and feedback on risk score; (d) health education with feedback on cholesterol concentration and risk score (full health check); (e) no health intervention (internal control). At the other work site there was no health intervention (external control).

MAIN OUTCOME MEASURES

Changes in Dundee risk score, plasma cholesterol concentration, diastolic blood pressure, body mass index and self-reported behaviours (smoking, exercise, alcohol intake, and diet) in comparison with internal and external control groups.

RESULTS

Comparisons between the full health check and the internal control groups showed a small difference (0.13 mmol/l) in the change in mean cholesterol concentration (95% confidence interval 0.02 to 0.22, P = 0.02) but no significant differences for changes in Dundee risk score (P = 0.21), diastolic blood pressure (P = 0.71), body mass index (P = 0.16), smoking (P = 1.00) or exercise (P = 0.41). Significant differences between the two groups were detected for changes in self-reported consumption of alcohol (41% in group with full health check v 17% in internal control group, P = 0.001) fruit and vegetables (24% v 12%, P < 0.001), and fat (30% v 9%, P < 0.001). Comparison of all groups showed no advantage from feedback of cholesterol concentration or risk score, or both.

CONCLUSIONS

The health check only had a small effect on reversible coronary risk. It was effective in influencing self reported alcohol consumption and diet. Feedback on cholesterol concentration and on risk score did not provide additional motivation for a change in behaviour.

Epidemiology of Down's syndrome in a Scottish city

The aim of the study was to investigate aspects of the epidemiology of Down's syndrome (DS) in a population subjected to continuous surveillance. Data were obtained from the Glasgow Register of Congenital Anomalies. Over the period 1980-90, 173 cases of DS were identified (1.2 per 1000 births), of which 135 (78.1%) were livebirths, five (2.9%) were stillbirths and 33 (19.1%) were terminations following prenatal diagnosis. The increasing risk of DS with advancing maternal age was confirmed, although most DS pregnancies occurred in women aged under 35. While the birth prevalence of DS did not vary significantly over time, there was a significant increase in DS pregnancy prevalence. The proportion of all DS pregnancies terminated showed a statistically significant rise from 14% in 1980-87 to 31% in 1988-90 following the introduction of a new screening marker for DS risk. Almost half of DS pregnancies in women aged 35 and over ended in termination following prenatal diagnosis compared with only 7% in women under 35. There was a statistically significant excess risk of DS pregnancy in the more prosperous areas of the city; this excess persisted, but was not statistically significant, after standardising the rates for maternal age. These findings suggest that there is no scope for reducing service provision for DS children on the basis of the epidemiological trends, that the antenatal screening programme, while benefiting from the recent introduction of serum markers of risk, continues to have a greater impact on older women, and that further aetiological research using population based registries is required.

Outpatient clinic referrals and their outcome

A cohort of 392 patients referred to six outpatient clinics by general practitioners during 1987 with diagnoses of rheumatoid arthritis, osteoarthritis, peripheral vascular disease, psoriasis or eczema, were studied from the time of their first attendance until up to two years later. Six consultant clinics were studied in the three specialties: rheumatology, vascular surgery and dermatology. For each specialty a clinic in both a teaching hospital and a district general hospital were included. The cohort members were predominantly middle-aged or elderly people, with a greater proportion of women, except at the vascular surgery clinic where 65% of patients were men. The 392 patients made a total of 936 visits (median two, range one-eight) during the study period; 91 patients were still attending up to two years after the first visit. Patients referred by their general practitioner for therapy were less likely to be discharged than those referred for other reasons. The principal reason for continuing attendance as perceived by patients, general practitioners and hospital doctors was the necessity for consultant supervision, although agreement was far from complete in individual cases. Junior staff tended to see a higher proportion of patients at follow-up visits than did consultants, and were found to have lower discharge rates than consultants. Analyses of data showed that at the first visit, diagnosis, disease severity and the grade of doctor seeing the patient in the clinic was significantly associated with patient discharge at the P < 0.05 level of significance. Patients considered that their visits had produced improvement in their condition in 38% of cases.(ABSTRACT TRUNCATED AT 250 WORDS)

Children seen frequently out of hours in one general practice

OBJECTIVE

To identify reasons why some children receive more out of hours visits than most.

DESIGN

A one year prospective study to identify the study group. This was followed by a case-control study involving a record search and personal interviews.

SETTING

One three doctor urban general practice in West Lothian with 4812 patients.

SUBJECTS

40 children aged under 10 years identified as high users of the out of hours service (more than two visits a year) and 40 age and sex matched controls.

MAIN OUTCOME MEASURES

Numbers of visits; social factors such as lone motherhood, low educational attainment; score for management response to clinical vignette.

RESULTS

147/756 (19%) out of hours visits in the study year were to children aged under 10 years; 109 (74%) to 41 children (6%). Problems seen were mainly minor, and little active management was required. Family and social factors which were significantly more common for the cases than for the controls included a lone mother (15 v 4), low educational attainment by the mother (25 v 14), receipt of income support (22 v 7), and non-ownership of the home (45 v 22) or a car (19 v 9). Mothers of the cases were more likely to choose to contact a doctor when presented with vignettes describing common childhood illnesses (median score for 16 vignettes 16.5 for cases v 14.5 for controls, Wilcoxon signed rank test, p = 0.01).

CONCLUSIONS

Children seen more frequently than expected out of hours came from more socially disadvantaged families and their mothers were more likely to seek medical advice about minor childhood illness. Maternal education, to promote confidence in managing minor illness, may reduce their use of the out of hours service.

Silastic foam dressing for healing exenteration cavities

Dressing the exenterated orbital cavity is difficult and time consuming for staff, traumatic to the healing wound, and painful for the patient, particularly when the wound is being left to granulate. We report the use of a silastic foam dressing which offers a number of advantages in this clinical situation.

Goblet cell carcinoid of the appendix

We have reviewed all cases of goblet cell carcinoid in the Department of Pathology, Edinburgh University. Of the 10 cases identified, two had died as a result of the tumour. This would suggest a poorer prognosis than is generally recognized. Those patients who subsequently had progression of their disease were not predicted by histological criteria. Because of the unpredictable behaviour of these tumours we recommend that such patients should correctly be treated by a right hemicolectomy.

Pethidine compared with meptazinol during labour. A prospective randomised double-blind study in 1100 patients

A randomised double-blind comparison of pethidine and meptazinol used as analgesics in labour was carried out in 1,100 consecutive women who would normally have received intramuscular pethidine. Pain assessments at 30-minute intervals were made independently by patients and midwives. Maternal and neonatal side effects were noted. The babies' requirements for resuscitation and weight changes in the first 5 days were studied. There was no difference in the analgesia provided by the two drugs; the pattern of side effects was similar, but the incidence of vomiting was greater following meptazinol administration. The babies in the two groups were similar with respect to resuscitation received, weight gains or losses and the incidence of clinical neonatal jaundice. The most striking findings were the poor quality of pain relief experienced by both groups following parenteral analgesics and the high incidence of side effects.

Effectiveness of screening for hypertension in Scotland

1. Data from long-term follow-up of subjects screened for hypertension indicate that the elevation of blood pressure represents a major contribution to community-attributable risk of death. 2. Attendance rates at screening, and drop-out rates from follow-up, have been assessed in studies in Glasgow. 3. Screening and follow-up are probably best conducted from general practice, and should be regarded as an extension of good primary care.