Informing Rift Valley Fever preparedness by mapping seasonally varying environmental suitability

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Database of Rift Valley Fever occurrences from 46 countries over 22 years.

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Predictions of Rift Valley Fever suitability for every month over 1995–2016.

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Identifies areas at-risk by synthesizing time-series of environmental predictions.

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We use human and livestock data to identify possible hotspots of disease spillover.

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We identify places where long-term and routine preparation efforts should be focused.

Background

Rift Valley Fever (RVF) poses a threat to human and animal health throughout much of Africa and the Middle East and has been recognized as a global health security priority and a key preparedness target.

Methods

We combined RVF occurrence data from a systematic literature review with animal notification data from an online database. Using boosted regression trees, we made monthly environmental suitability predictions from January 1995 to December 2016 at a 5 × 5-km resolution throughout regions of Africa, Europe, and the Middle East. We calculated the average number of months per year suitable for transmission, the mean suitability for each calendar month, and the “spillover potential,” a measure incorporating suitability with human and livestock populations.

Results

Several countries where cases have not yet been reported are suitable for RVF. Areas across the region of interest are suitable for transmission at different times of the year, and some areas are suitable for multiple seasons each year. Spillover potential results show areas within countries where high populations of humans and livestock are at risk for much of the year.

Conclusions

The widespread environmental suitability of RVF highlights the need for increased preparedness, even in countries that have not previously experienced cases. These maps can aid in prioritizing long-term RVF preparedness activities and determining optimal times for recurring preparedness activities. Given an outbreak, our results can highlight areas often at risk for subsequent transmission that month, enabling decision-makers to target responses effectively.

Epidemiological data from the COVID-19 outbreak, real-time case information

Cases of a novel coronavirus were first reported in Wuhan, Hubei province, China, in December 2019 and have since spread across the world. Epidemiological studies have indicated human-to-human transmission in China and elsewhere. To aid the analysis and tracking of the COVID-19 epidemic we collected and curated individual-level data from national, provincial, and municipal health reports, as well as additional information from online reports. All data are geo-coded and, where available, include symptoms, key dates (date of onset, admission, and confirmation), and travel history. The generation of detailed, real-time, and robust data for emerging disease outbreaks is important and can help to generate robust evidence that will support and inform public health decision making.

Epidemiological data from the COVID-19 outbreak, real-time case information

Cases of a novel coronavirus were first reported in Wuhan, Hubei province, China, in December 2019 and have since spread across the world. Epidemiological studies have indicated human-to-human transmission in China and elsewhere. To aid the analysis and tracking of the COVID-19 epidemic we collected and curated individual-level data from national, provincial, and municipal health reports, as well as additional information from online reports. All data are geo-coded and, where available, include symptoms, key dates (date of onset, admission, and confirmation), and travel history. The generation of detailed, real-time, and robust data for emerging disease outbreaks is important and can help to generate robust evidence that will support and inform public health decision making.

Travel time to health facilities in areas of outbreak potential: maps for guiding local preparedness and response

BACKGROUND

Repeated outbreaks of emerging pathogens underscore the need for preparedness plans to prevent, detect, and respond. As countries develop and improve National Action Plans for Health Security, addressing subnational variation in preparedness is increasingly important. One facet of preparedness and mitigating disease transmission is health facility accessibility, linking infected persons with health systems and vice versa. Where potential patients can access care, local facilities must ensure they can appropriately diagnose, treat, and contain disease spread to prevent secondary transmission; where patients cannot readily access facilities, alternate plans must be developed. Here, we use travel time to link facilities and populations at risk of viral hemorrhagic fevers (VHFs) and identify spatial variation in these respective preparedness demands.

METHODS AND FINDINGS

We used geospatial resources of travel friction, pathogen environmental suitability, and health facilities to determine facility accessibility of any at-risk location within a country. We considered in-country and cross-border movements of exposed populations and highlighted vulnerable populations where current facilities are inaccessible and new infrastructure would reduce travel times. We developed profiles for 43 African countries. Resulting maps demonstrate gaps in health facility accessibility and highlight facilities closest to areas at risk for VHF spillover. For instance, in the Central African Republic, we identified travel times of over 24 h to access a health facility. Some countries had more uniformly short travel times, such as Nigeria, although regional disparities exist. For some populations, including many in Botswana, access to areas at risk for VHF nationally was low but proximity to suitable spillover areas in bordering countries was high. Additional analyses provide insights for considering future resource allocation. We provide a contemporary use case for these analyses for the ongoing Ebola outbreak.

CONCLUSIONS

These maps demonstrate the use of geospatial analytics for subnational preparedness, identifying facilities close to at-risk populations for prioritizing readiness to detect, treat, and respond to cases and highlighting where gaps in health facility accessibility exist. We identified cross-border threats for VHF exposure and demonstrate an opportunity to improve preparedness activities through the use of precision public health methods and data-driven insights for resource allocation as part of a country's preparedness plans.

A database of geopositioned Middle East Respiratory Syndrome Coronavirus occurrences

As a World Health Organization Research and Development Blueprint priority pathogen, there is a need to better understand the geographic distribution of Middle East Respiratory Syndrome Coronavirus (MERS-CoV) and its potential to infect mammals and humans. This database documents cases of MERS-CoV globally, with specific attention paid to zoonotic transmission. An initial literature search was conducted in PubMed, Web of Science, and Scopus; after screening articles according to the inclusion/exclusion criteria, a total of 208 sources were selected for extraction and geo-positioning. Each MERS-CoV occurrence was assigned one of the following classifications based upon published contextual information: index, unspecified, secondary, mammal, environmental, or imported. In total, this database is comprised of 861 unique geo-positioned MERS-CoV occurrences. The purpose of this article is to share a collated MERS-CoV database and extraction protocol that can be utilized in future mapping efforts for both MERS-CoV and other infectious diseases. More broadly, it may also provide useful data for the development of targeted MERS-CoV surveillance, which would prove invaluable in preventing future zoonotic spillover.

Measurement(s)	Middle East Respiratory Syndrome • geographic location
Technology Type(s)	digital curation
Factor Type(s)	geographic distribution of Middle East Respiratory Syndrome Coronavirus (MERS-CoV) • year
Sample Characteristic - Organism	Middle East respiratory syndrome-related coronavirus
Sample Characteristic - Location	Earth (planet)

Machine-accessible metadata file describing the reported data: 10.6084/m9.figshare.11108801

Implementation of statin prescribing guidelines: a cost effectiveness analysis

Focal points

Total parathyroidectomy without autotransplantation for renal hyperparathyroidism

Background

Parathyroidectomy is the standard treatment for renal hyperparathyroidism although controversy exists about the optimal surgical procedure. Total parathyroidectomy without either autotransplantation or thymectomy is one suggested approach. This study reviewed the medium- to long-term results of this procedure.

Methods

A retrospective review was undertaken of patients undergoing total parathyroidectomy between August 2000 and March 2009. The procedure was performed by a single surgeon and median follow-up was 31 (range 1–120) months.

Results

Data were obtained on 115 patients with no re-explorations for bleeding or clinical recurrent laryngeal nerve injuries. The rate of postoperative hypocalcaemia on the day after surgery was 15·7 per cent. Thirty-three patients (28·7 per cent) had an undetectable parathyroid hormone level at the end of follow-up. Fourteen patients (12·2 per cent) developed recurrent hyperparathyroidism with a median parathyroid hormone level of 35·4 (range 5·4–200·0) pmol/l. The reoperation rate was 3·5 per cent. Thymectomy tissue, taken if all four glands could not be identified, revealed no parathyroid glands.

Conclusion

Total parathyroidectomy alone has minimal associated morbidity or mortality, and a good medium- to long-term clinical outcome with a low recurrence rate.

Complete intracellular pH protection during extracellular pH depression is associated with hypercarbia tolerance in white sturgeon, Acipenser transmontanus

Sturgeons are among the most CO2 tolerant of fishes investigated to date. However, the basis of this exceptional CO2 tolerance is unknown. Here, white sturgeon, Acipenser transmontanus, were exposed to elevated CO2 to investigate the mechanisms associated with short-term hypercarbia tolerance. During exposure to 1.5 kPa Pco2, transient blood pH [extracellular pH (pHe)] depression was compensated within 24 h and associated with net plasma HCO3- accumulation and equimolar Cl- loss, and changes in gill morphology, such as a decrease in apical surface area of mitochondrial-rich cells. These findings indicate that pHe recovery at this level of hypercarbia is accomplished in a manner similar to most freshwater teleost species studied to date, although branchial mechanisms involved may differ. White sturgeon exposed to more severe hypercarbia (3 and 6 kPa Pco2) for 48 h exhibited incomplete pH compensation in blood and red blood cells. Despite pHe depression, intracellular pH (pHi) of white muscle, heart, brain, and liver did not decrease during a transient (6 h of 1.5 kPa Pco2) or prolonged (48 h at 3 and 6 kPa Pco2 blood acidosis. This pHi protection was not due to high intrinsic buffering in tissues. Such tight active cellular regulation of pHi in the absence of pHe compensation represents a unique pattern for non-air-breathing fishes, and we hypothesize that it is the basis for the exceptional CO2 tolerance of white sturgeon and, likely, other CO2 tolerant fishes. Further research to elucidate the specific mechanisms responsible for this tremendous pH regulatory capacity in tissues of white sturgeon is warranted.

Informed consent in renal transplantation

PURPOSE

This study was performed to assess how well completed the new consent forms are for patients undergoing renal transplantation.

METHODOLOGY

100 patients were randomly selected from the 160 who had a renal transplantation, at a single centre in the UK, over an 18 month period. The notes were located and the consent forms scrutinised.

FINDINGS

Seven sets of notes could not be traced and 10 did not contain a relevant consent form. Forty eight per cent of completed forms mentioned the source of organ while 8% mentioned on which side the operation was to be performed. Twelve risks and complications were identified as being relevant to this procedure but no single form mentioned all 12. In most cases a senior member of the surgical team obtained consent.

IMPLICATIONS

The demonstrated variability in the amount of detail on consent forms lends weight to the call for the use of procedure specific forms. While such variability does not necessarily equate with not gaining valid, informed consent, this form, at present, serves as the only record of what has been discussed with the patient. These findings should encourage all surgeons to complete the forms themselves, be as detailed as possible, and ensure that the form is filed in the patients' notes.

Ictal stuttering: a sign suggestive of psychogenic nonepileptic seizures

OBJECTIVE

To determine if ictal stuttering (IS) is more common among patients with psychogenic nonepileptic seizures (PNES) than patients with epileptic seizures (ES).

METHODS

The authors prospectively reviewed the medical records, EEG-video recordings, and Minnesota Multiphasic Personality Inventory-2 (MMPI-2) scores of consecutive adults of normal intelligence diagnosed with either PNES or ES.

RESULTS

A total of 230 (117 PNES and 113 ES) patients were studied. PNES patients were older (p = 0.029), more likely to be female (p < 0.001), and had a shorter duration of seizure disorder (p < 0.001) than ES cases. Ten (8.5%) PNES subjects and no ES cases demonstrated IS. The proportion of patients with IS in these two groups was significantly different (p = 0.004). PNES patients with IS were of similar age as but had an even shorter (p = 0.010) duration of seizure disorder (mean = 3.0 years) than those without IS. Scores on the hypochondriasis, depression (D), and hysteria scales of the MMPI-2 were significantly higher among PNES subjects than in ES patients (p < or = 0.002). However, seven PNES patients with IS had a lower mean score on the D scale than did 98 PNES cases without stuttering (p = 0.005). This produced a more sharply defined "conversion V" appearance on the MMPI-2 graph in the stutterers.

CONCLUSIONS

Ictal stuttering was present in 8.5% of 117 consecutive patients with psychogenic nonepileptic seizures, but was not observed in a consecutive series of 113 adults with epileptic seizures. Patients with psychogenic nonepileptic seizures with ictal stuttering had a shorter duration of seizure disorder and a more prominent conversion profile on the Minnesota Multiphasic Personality Inventory than either patients with psychogenic nonepileptic seizures without stuttering or subjects with epileptic seizures.

Giant cell tumor and the skeletally immature patient

Conventional wisdom suggests that giant cell tumor (GCT) does not occur in the skeletally immature individual; however, we believe that GCTs of bone, though rare, do occur in children. We are reporting the occurrence of GCT of bone in three patients who were skeletally immature at the time of their initial presentation. In our review of the reports since 1954 that document this condition, we were also able to find a total of 318 patients, of whom 130 were skeletally immature at the time of their tumor presentation. From the data compiled, we found a 7.5% incidence of GCT of bone in skeletally immature individuals at a mean age of 10.5 years. Based on our review and the experience with our three patients, we believe the diagnosis of GCT of bone should be considered in the differential diagnosis of a destructive lesion of bone in skeletally immature individuals. Giant cell tumor in the skeletally immature is being reported here to better define its incidence and increase awareness of its occurrence. Management options will also be discussed.

Cyclosporin, nifedipine and gingival hyperplasia: a randomized controlled study

Nifedipine increases the frequency and severity of gingival hyperplasia associated with CyA therapy in renal transplant recipients and this effect appears to be independent of whole-blood CyA levels. De novo malignancies have been reported arising in areas of gingival hyperplasia, in a group already at high risk of malignancy. Patients receiving CyA and nifedipine should receive advice regarding the need for strict oral hygiene to control the initial development of gingival hyperplasia, with severe cases being promptly referred for gingivectomy and histological examination.

A prospective randomized trial of three different sizes of core-cutting needle for renal transplant biopsy

BACKGROUND

Needle-core biopsy remains one of the most important investigations in cases of renal allograft dysfunction. The size and quality of the biopsy material are likely to be important factors in achieving an accurate diagnosis. The aim of this study was to compare the success and complication rates of renal transplant biopsy procedures using three differently sized needles.

METHODS

One hundred renal allograft recipients undergoing transplant biopsy using an automated needle core method were randomized to a 14, 16, or 18 gauge (G) needle. The size of each biopsy core was measured, and the presence or absence of renal cortical and medullary tissue and the number of glomeruli were recorded. Assessments of the ease with which the procedure was performed, the diagnostic usefulness of the biopsy material, and the discomfort associated with the procedure were made using verbal response and linear analog scales.

RESULTS

Fourteen G biopsy cores (N = 33) were larger than both 16G (N = 33) and 18G (N = 34) cores and contained more gomeruli (mean number for 14G, 16G, and 18G = 15, 11 and 9, respectively). There were no differences in the ease of use of the three needle types, but scores for diagnostic usefulness were higher for 14G versus 18G and 16G versus 18G. The 14G needle was associated with significantly more pain than the two smaller needles when this was assessed using a linear analog score. Macroscopic hematuria occurred in eight patients, but there were no differences in complications rates between the three groups.

CONCLUSIONS

All three needle sizes are safe for use in renal allograft biopsy using a semiautomated biopsy gun. The larger needles provide more tissue and glomeruli and, thus, are more diagnostically useful. Use of a 14G needle may be associated with more pain, and the 16G needle appears to offer the best compromise between diagnostic usefulness and patient acceptability.

Energy cost of NaCl transport in isolated gills of cutthroat trout

Few studies have made direct estimates of the energy required for ion transport in gills of freshwater (FW) and seawater (SW) fish. Oxygen consumption was measured in excised gill tissue of FW-adapted cutthroat trout (Oncorhynchus clarki clarki) to estimate the energy cost of NaCl transport in that osmoregulatory organ. Ouabain (0.5 mM) and bafilomycin A1 (1 microM) were used to inhibit the Na+-K+ and H+ pumps, respectively. Both inhibitors significantly decreased gill tissue oxygen consumption, accounting for 37% of total tissue respiration. On a whole mass basis, the cost of NaCl uptake in the FW trout gill was estimated to be 1.8% of whole animal oxygen uptake. An isolated, saline-perfused gill arch preparation was also used to compare gill energetics in FW- and SW-adapted trout. The oxygen consumption of FW gills was significantly (33%) higher than SW gills. On a whole animal basis, total gill oxygen consumption in FW and SW trout accounted for 3.9 and 2.4% of resting metabolic rate, respectively. The results of both experiments suggest that the energy cost of NaCl transport in FW and SW trout gills represents a relatively small (<4%) portion of the animal's total energy budget.

Synthesis and properties of 2-(naphthosultamyl)methyl-carbapenems with potent anti-MRSA activity: discovery of L-786,392

A series of 1beta-methyl-2-(naphthosultamyl)methyl-carbapenems bearing dicationic groups on the naphthosultamyl moiety was prepared and evaluated for activity against resistant gram-positive bacteria. Based on a combination of excellent in vitro antibacterial activity, acceptable mouse acute toxicity, and a desirable fragmentation pattern on beta-lactam ring opening, the analog 2g (L-786,392) was selected for extended evaluation.

Cortisol-induced changes in oxygen consumption and ionic regulation in coastal cutthroat trout (Oncorhynchus clarki clarki) parr

The influence of cortisol on oxygen consumption and osmoregulatory variables was examined in coastal cutthroat trout (Oncorhynchus clarki clarki) parr kept in fresh water (FW) and transferred to seawater (SW). Intraperitoneal implants containing cortisol (50 μg g(-1)) in vegetable oil resulted in elevated plasma cortisol titres similar to those observed in fish following a 24h SW exposure. Cortisol treatment significantly increased the oxygen consumption and plasma glucose levels of trout in FW, consistent with the glucocorticoid role of cortisol. Cortisol treatment did not cause any changes in plasma ion concentrations or gill Na(+),K(+)-ATPase activity in FW after 10 days. Cortisol-implanted fish exposed to SW for 24h showed slightly improved ion regulatory ability compare to non-implanted controls. The results of this study suggest that during SW transfer in juvenile salmonids, increases in cortisol may act as both a mineralocorticoid and a glucocorticoid, depending on the developmental state of the fish (e.g., smolt versus parr). Furthermore, the relative energetic costs of osmoregulation and that of the stress associated SW transfer cannot be discerned using whole-animal oxygen consumption rates.

Lack of correlation of soluble E-selectin level with renal transplant rejection

E-Selectin is a 115-kDa cell surface glycoprotein transiently expressed on vascular endothelium in response to interleukin-1 and tumour necrosis factor-alpha with a peak in expression at four hours. Its distribution in transplant biopsies has been associated with inflammatory events such as allograft rejection. Recently, a soluble isoform of E-selectin has been detected in the culture medium of cytokine activated endothelial cells by an ELISA method. In this study soluble E-selectin levels in renal allograft recipients were compared with the incidence of rejection, acute tubular necrosis (ATN), cyclosporin A (CyA) toxicity, and use of orthoclone OKT3 (muromonab-CD3) to establish whether early endothelial activation and inflammatory damage could be detected. The mean soluble E-selectin level in normal volunteers was 89 ng/ml serum compared to 120 ng/ml for a group of chronic renal failure patients. Soluble E-selectin levels declined upon transplantation but this was not significant, nor was the difference in samples from patients experiencing rejection, ATN or CyA toxicity. A dramatic and sustained rise in soluble E-selectin levels was found within 24 hours of the first dose of OKT3 treatment. This study shows that soluble E-selectin does not provide early unequivocal indication of pathological sequelae in renal transplantation, although extensive endothelial activation can be demonstrated with OKT3 treatment.

The importance of E-selectin as a marker for renal transplant rejection

Vascular endothelial cells express membrane bound adhesion molecules which play a direct role in the localization and subsequent movement of leucocytes from the blood into sites of inflammation. E-Selectin is a cytokine induced adhesion molecule, known to be expressed by endothelial cells in inflammatory conditions, which binds to various leucocyte subpopulations. In a prospective study we have investigated the expression and distribution of E-selectin on renal allograft needle biopsies taken from 16 pretransplant kidneys and 119 post-transplant kidneys. Post-transplant biopsies were taken at times of graft dysfunction and at times of normal graft function. Formal histology was also performed and assessed independently. E-Selectin was found predominantly on the intertubular endothelium and on the endothelium of larger vessels. E-Selectin was present, at low intensity, in some pretransplant biopsies and also some post-transplant biopsies which were reported histologically as normal. In post-transplant biopsies taken for dysfunction E-selectin was present in the majority of cases. Expression was strong in biopsies showing acute cellular rejection and this was associated with a CD4 positive cellular infiltrate. Biopsies showing other causes of dysfunction, in particular acute tubular necrosis, also were E-selectin and CD4 positive with lower intensity than those with acute cellular rejection. These results suggest that E-selectin is a good marker for endothelial activation in renal transplant biopsies. Its presence in histologically apparently normal biopsies suggests that its in vivo kinetics may differ from previously reported in vitro kinetics. E-Selectin may be a potential target for therapeutic intervention.

Triple therapy and incidence of de novo cancer in renal transplant recipients

Some 27 (5.5 per cent) of 492 renal transplant recipients developed de novo cancer between January 1975 and December 1991. Patients administered triple therapy of prednisolone, cyclosporin A and azathioprine had a significantly higher incidence of cancer (seven of 40 patients; 17.5 per cent) than those given prednisolone with cyclosporin (14 of 319; 4.4 per cent) and azathioprine with prednisolone (six of 133; 4.5 per cent) (P = 0.005). In a prospective study between January 1989 and December 1992, 110 renal transplant patients were randomized into three immunosuppressive regimens at the time of transplantation. The incidence of cancer in patients receiving low-dose cyclosporin, azathioprine and prednisolone was three of 45, in those given high-dose cyclosporin and prednisolone none of 23 and in those administered high-dose cyclosporin, nifedipine and prednisolone one of 29. The addition of azathioprine to ongoing maintenance cyclosporin and prednisolone therapy is useful in a subgroup of patients with graft dysfunction, but there are possibly higher risks in the development of de novo carcinoma.

Point of care and patient privacy: who is in control?

Public and patient access to medical records has been severely limited through policies limiting physical and timely access and intellectual understanding of content. New expectations of patient/public access and control have arisen accompanying the new paradigms of health care delivery and health information (computer-based patient records). Examples from these new paradigms are personalized and presented in information system contexts from bedside to community settings. Patient and family involvement in care delivery, education, assessment, and control of privacy are explored. A personalized confidentiality/security/privacy module of the computer-based patient record is suggested.

Isolated vaginal recurrences of endometrial carcinoma

PURPOSE

The authors undertook this study to evaluate the results of radiation therapy (RT) for vaginal recurrence in early stage endometrial carcinoma.

MATERIALS AND METHODS

Between 1964 and 1987, 34 patients with isolated vaginal recurrences of endometrial carcinoma were treated with RT. The records were reviewed for outcome and prognostic factors, such as location of tumor recurrence, time to recurrence, size of tumor at recurrence, tumor differentiation, and total radiation dose delivered at RT.

RESULTS

With a median follow-up of 48 months, the 5-year actuarial survival and disease-free survival rates were 68% +/- 4 and 60% +/- 3, respectively. Results were statistically significant for some prognostic factors, including time to tumor recurrence and total radiation dose delivered at RT to the recurring tumor.

CONCLUSION

Long-term survival can be obtained for patients with an isolated vaginal recurrence of endometrial cancer treated with aggressive local-regional radiation therapy.

The histopathology of infrainguinal vein graft stenoses

The precise histopathological nature of vein graft stenoses is unclear. Some authors have suggested that these lesions are due to intimal hyperplasia and others have claimed that they are fibrous strictures. The aim of this study was to determine the histological nature of infrainguinal vein graft stenoses by examining sections of vein grafts that had developed stenoses and had been surgically revised. This was performed using a combined anti-smooth muscle actin/Millers elastin stain. The results show that vein graft stenoses are due to intimal hyperplasia whereby smooth muscle cells proliferate and cause thickening of the intimal layer.

Marketing dentistry: a pilot study in Dudley

This study was an attempt to persuade non-users or irregular users of dental services to change their behaviour and visit the dentist more regularly. The task was divided into two main parts. One was a promotion campaign undertaken in the Borough of Dudley in the West Midlands and the other a professional development programme for the dentists practising in the same area. The professional development campaign was designed to make the practitioners aware of the barriers to dental care which are perceived by patients. It was undertaken through a series of workshops on various aspects of practice development and promotion to which the staff of all the dental practices in Dudley were invited. Thirty-nine out of a total of forty-one accepted the invitation and attended some or all of the programme. In addition to the workshops members of the research team visited each of the participating practices regularly to discuss aspects of the programme and to record progress. The practitioners had varied attitudes to marketing and varied learning styles, and therefore they had different expectations of the nature and purpose of professional development. The majority attended solely to learn about the promotion campaign. There were also varying perceptions of patient recruitment and retention. None saw this as a serious problem. However, even before the new National Health Service contract for general dental practitioners there was the growing realisation that in the future there would be competition between practices and that this could be a reason for considering recruitment and the retention of patients more carefully. This was considered by many of the dentists, but not all, to be a problem of patient behaviour, linked with a degree of fatalism, and that nothing much could be done about it. There was a reluctance to change and the fear of the risks involved led a number of the general dental practitioners to identify and emphasise the difficulties in making new developments rather than their benefits. Only one quarter of the practices made any changes and they tended to prefer quick solutions rather than basic development. The experience gained in this part of the study indicated that in the future professional development should be considered in terms of the dentist's perception of the costs and the benefits; direct costs, opportunity costs, and the prospect of effecting change.(ABSTRACT TRUNCATED AT 400 WORDS)

Rationalisation of follow-up in patients with non-invasive bladder tumours. A preliminary report

The risk of recurrence and progression in 170 patients presenting with pTa urothelial tumours of the bladder has been estimated so that follow-up can be rationalised. Patients were followed up for between 1 and 15 years, the original pathology reviewed and those with carcinoma in situ (CIS) or dysplasia of the background urothelium excluded. Only 5 patients progressed over the whole follow-up period, giving an overall progression rate of 3%. Solitary tumours had an annual initial recurrence risk (AIR) of 0.23 in the first year; after the first year the AIR fell to approximately 0.1 but did not fall significantly in subsequent years up to 8 years. Of the 45 patients with multiple tumours, 32 suffered recurrences within the first year (AIR 0.71). Tumour grade did not influence either recurrence or progression. The results indicate that for solitary pTa tumours, less frequent endoscopic follow-up is justified but some continued surveillance after 5 disease-free years is necessary. The estimated risk of recurrence is a useful factor to consider when planning follow-up.

Artificial urinary sphincters around intestinal segments--are they safe?

Artificial urinary sphincters (AUS) were implanted around intestinal segments to achieve urinary continence in 8 patients and faecal continence in 1. In 6 patients the cuff was placed around the lower end of the cystoplasty following bladder neck (5) or urethral (1) erosion. Four are completely dry, 1 on self-intermittent catheterisation (SIC). One has mild stress incontinence. In 1 patient the cuff eroded at 8 months. Two patients had cuffs implanted parastomally to create continent diversion. One is satisfactory on SIC and the other had her AUS explanted because of life-threatening metabolic acidosis. The rectal cuff was explanted because of faecal impaction above the cuff. As an absolute last resort, placing an AUS round a cystoplasty appears little more hazardous than round bladder neck. The use of the AUS for continent diversion has not been pursued because of reliable techniques of non-prosthetic continent diversion. The current model of the AUS is unsuitable for the treatment of faecal incontinence.

Understanding non-attendance in outpatient paediatric clinics

Outpatient clinic appointments are often not kept. There has been little study of the reasons for this, but failure to attend may affect future health. Our study was based on the children's outpatient department of a large inner city district general hospital. The parents of 34 children who had failed to keep appointments and of 12 who did attend were interviewed in depth and the appointment systems of the hospital and of a nearby regional referral centre for children were reviewed. At the district general hospital 23% of first appointments and 35% of subsequent appointments were not kept. We found that parents usually made a conscious decision about attending, balancing the perceived advantages and disadvantages of doing so. Their assessment of the severity of the child's illness was crucial in this. Twenty one of the 34 children who had not attended were assessed at the time of interview as still needing to attend. Of these, 16 subsequently kept an appointment and 11 underwent further investigation or treatment. We conclude that children who are not brought for outpatient appointments may be at risk of avoidable ill health and that ways of either ensuring attendance at outpatient clinics or providing alternative means of health supervision are needed.