Patients' Knowledge of Female Pelvic Health and Related Educational Preferences

Many patients have a rudimentary knowledge of their body's anatomy and functioning. In a clinical setting, deficits in patient understanding can lead to miscommunication affecting patient care and satisfaction. Hence, this study aims to estimate a baseline of patient knowledge regarding pelvic anatomy and to assess their educational preferences in learning about related topics. For this cross-sectional study, we developed a 24-item assessment with questions related to pelvic anatomy, health, and function. The questionnaire was validated using feedback from anonymous community focus groups, and then distributed to English-speaking female patients at the Women's Clinic of LAC + USC Medical Center (Los Angeles). The participant performance as a percentage-correct score on the anatomy assessment constituted our primary outcome. As secondary outcomes, educational preferences were inquired. Statistical analysis was conducted using two-sample t tests. The majority of our total sample of 269 were Hispanic (65.4 %) with a mean age of 35.3 years. We documented deficits in patient knowledge with a mean score of 66.1 % correct on anatomy assessment. Statistically significant lower scores were associated with less education and with Hispanic/Latino origin. Additionally, we found that while physicians have played a role in health education, women prefer to receive more education from their providers in the future. The deficits we identified indicate the pressing need to improve the pelvic health literacy of our patients. Understanding what our patients know and want to know is critical to effective communication and is fundamental to providing better clinical care in the future.

Black box towards glass box: 'Mapaloguing' a typology of public health CPD activities in UK in 2011/12

Background

The 1996 Faculty of Public Health study of specialists continuing professional development (CPD) diaries indicated forward-looking approaches. There has been little substantive research on public health CPD records since.

Methods

Mixed methods research assessed 795 CPD records/reflective notes from 2011/12. The quantitative methods aimed to analyse types of new learning; a qualitative sub-sample analysis of reflective standards will be reported elsewhere. Many current CPD categories were non-specific and situational, including conferences/workshops and learning as part of the job. These were later classified to a new CPD typology of 13 learning-orientated categories with sub-types.

Results

Most (572 = 71.9%) activities fell into current FPH CPD categories that did not identify the learning topic. The new categorization identified four most common CPD learning types: about health protection topics, key specialist knowledge/skills, experiences handling new public health systems and educator/trainer requirements.

Conclusions

This new typology illustrates wide-ranging CPD activities, including work-based opportunities from shifts in organizations and policies. A CPD 'Mapalogue' is proposed, with 'Mapaloguing' as an analytical research process, combining mapping of influences and direction of CPD alongside cataloguing actual CPD undertaken. This could inform individual professionals' choice menu for CPD and personal development and increase the profession's transparency and understanding of long-term trends.

Decreased Antioxidant Vitamin Concentration May Be a Risk Factor for Recurrent Carotid Stenosis

Carotid endarterectomy has been found to be associated with a transient increase in systemic oxidative stress, and this has been shown to be a predictor of restenosis. The aim of this study was to determine the incidence of early recurrent stenosis and investigate a possible role of oxidative stress in its development by measuring the concentration of antioxidant vitamins. Patients undergoing carotid endarterectomy between August 2001 and February 2003 were included in the study. A preoperative blood sample was analyzed for antioxidant vitamin concentrations. All patients were followed up by duplex scans 3 and 12 months postoperatively. Ninety-three patients (101 carotid endarterectomies) were recruited. Nine arteries had developed restenosis by 12 months. Those patients who developed recurrent stenosis had significantly lower vitamin C concentrations (19.10 ± 3.69 vs 30.11 ± 19.10, P = .02) than those who did not. This study suggests that low antioxidant vitamin levels may predispose to early restenosis after carotid endarterectomy.

Inferior vena cava thrombosis: a review of current practice

Inferior vena cava (IVC) thrombosis remains under-recognised as it is often not pursued as a primary diagnosis. The aetiology of IVC thrombosis can be divided into congenital versus acquired, with all aetiological factors found among Virchow's triad of stasis, injury and hypercoagulability. Signs and symptoms are related to aetiology and range from no symptoms to cardiovascular collapse. Painful lower limb swelling combined with lower back pain, pyrexia, dilatation of cutaneous abdominal wall veins and a concurrent rise in inflammatory markers are suggestive of IVC thrombosis. Following initial lower limb venous duplex, magnetic resonance imaging (MRI) is the optimal non-invasive imaging tool. Aetiology directs treatment, which ranges from anticoagulation and lower limb compression to open surgery, with endovascular therapies increasingly favoured. The objective of this review is to assess current literature on the aetiology, presentation, investigation, treatment, prognosis and other factors pertaining to IVC thrombosis.

Fatty Hypertrophy Cause Obstructive Sleep Apnea after Fat Injection for Velopharyngeal Incompetence

Intervention

Soft tissue augmentation of the posterior pharyngeal wall and the soft palate is reported to reduce velopharyngeal incompetence, and fat grafting in selected patients has shown effective and lasting results for restoring normal resonance. Potential complications of soft tissue augmentation for velopharyngeal incompetence include obstructive sleep apnea.

Patient

An 8-year-old boy with velopharyngeal incompetence and a small velopharyngeal gap underwent a fat injection procedure and subsequently developed obstructive sleep apnea concomitant with a significant weight gain. Videofluoroscopy and nasendoscopy showed a remarkable enlargement of the grafted fat areas that required a soft palate debulking procedure, significantly improving obstructive sleep apnea.

Conclusion

This is an unusual case where alteration in volume of grafted fat at the recipient site is suspected of causing obstructive sleep apnea. It is also an example of long-term fat graft survival and fat graft overgrowth.

Optimal management of peripheral arterial disease for the non-specialist

Peripheral arterial disease (PAD) now affects approximately 20% of adults older than 55 years to an estimated total of 27 million people in the Western World. The aim of this paper is to describe the medical management of PAD for the non-vascular specialist, particularly general practitioners, where PAD has now been included in the Northern Ireland Department of Health's Primary Care Service Framework (Directed Enhanced Service).

Laparoscopic adrenalectomy versus open adrenalectomy: results from a retrospective comparative study

The relatively new operation of laparoscopic adrenalectomy has now become the procedure of choice for the management of most benign adrenal tumours. We have reviewed the data relating to the first 25 patients on whom we performed laparoscopic adrenalectomy and have made comparison with a group of 25 diagnosis-matched individuals on whom we had previously carried out open adrenalectomy. The patients who underwent laparoscopic adrenalectomy had a significantly shorter hospital stay and experienced significantly less postoperative morbidity than those who had an open operation, but the operation time was significantly longer for the laparoscopic group of patients. There is now good potential and sound evidence base for extending the indications for laparoscopic adrenalectomy.

The Effect of Pravastatin on Intima Media Thickness of the Carotid Artery in Patients with Normal Cholesterol

OBJECTIVE

Carotid intima media thickness (IMT) is a good indicator of the severity of atherosclerotic disease. Statins have been found to reduce carotid IMT in patients with hypercholesterolaemia. The aim of this study was to investigate if pravastatin is effective in reducing IMT in normocholesterolaemic patients with carotid artery disease.

METHODS

Patients with carotid artery stenosis and normal cholesterol levels who were not on a statin, were recruited. Patients were randomised to receive pravastatin or placebo daily. Serum concentration of cholesterol and IMT of common carotid arteries were measured before randomisation and at 3 monthly intervals thereafter, for 9 months. IMT was analysed to give the mean of a standardised 2 cm of the common carotid artery (CCA). Results are expressed as median (IQR) and comparison made using the Wilcoxon signed ranks test.

RESULTS

Fifty-four patients were examined. Twenty-eight patients were randomised to active treatment. There was no difference in demographic details and co-morbid states between the two groups. A significant reduction in cholesterol concentration was observed from 3 months in patients randomised to the pravastatin group [5.14(4.72-5.88) vs. 4.11(3.44-5.33), p < 0.05], while there was also a significant decrease in combined IMT form 6 months [1.53(1.36-1.87) vs. 1.41 (1.33-1.78), p < 0.05].

CONCLUSIONS

The results demonstrate that pravastatin reduces intima media thickness of the common carotid artery in normocholesterolaemic patients with moderate carotid stenosis.

Intra-mucosal acidosis as a predictor of cardiac outcome following abdominal aortic aneurysm surgery

OBJECTIVE

To assess if sigmoid ischaemia is a prognostic indicator of early and late post-operative cardiac morbidity and mortality.

MATERIALS AND METHODS

Patients undergoing elective abdominal aortic aneurysm repair (AAAR) were included in the study. Demographic details and risk factors for heart disease were recorded. Sigmoid pHi was measured at the time of surgery using a silicone tonometer and perioperative morbidity and mortality were recorded in all patients. Seven years following surgery the patients and their general practitioners were contacted to determine the patient's health.

RESULTS

Thirty-eight patients were included in the study. Within the follow-up period, 22 (58%) had died. Eight patients died of cardiac failure or myocardial infarction. The pHi in patients with cardiac related deaths [6.99 (6.84-7.10)] was significantly lower than those with non-cardiac related deaths [7.11 (7.04-7.21), p<0.05]. Similarly, patients who suffered acute cardiac events (within 30 days following AAA repair) had lower pHi [7.01 (6.88-7.12)] compared to those who did not [7.09 (6.90-7.19), p<0.05].

CONCLUSION

The results show that sigmoid ischaemia is more frequent amongst patients that develop cardiac events after AAAR and is associated with a worse long term outcome. This suggests that global hypoperfusion as a result of an under performing heart may be partly responsible for the sigmoid ischaemia in patients following AAAR. Therefore, low sigmoid pHi may predict an increased risk of cardiac complications in these patients.

Delayed paraplegia after endovascular repair of abdominal aortic aneurysm

Paraplegia is rare after open repair of infrarenal abdominal aortic aneurysm, and only two cases have been reported after endovascular repair, both due to atheroembolism. Incidence of renal failure after endovascular repair of abdominal aortic aneurysm (EVAR) in patients with normal preoperative renal function is about 8.7%, but is much higher in those with preexisting renal impairment, possibly because of administration of nephrotoxic contrast media during EVAR. We report a case in which contrast medium-induced acute renal failure is believed to have led to delayed paraplegia after EVAR.

Aneurysm of the inferior vena cava

Aneurysms of the inferior vena cava (IVC) are extremely rare, with a range of reported presentations including deep venous thrombosis. Computerised Tomography (CT) and Magnetic Resonance Imaging (MRI) scans are suggested appropriate diagnostic imaging modalities, but even then it may not be possible to differentiate between an IVC aneurysm and a retroperitoneal tumour. This case illustrates that an IVC aneurysm should be considered in the differential diagnosis of a retroperitoneal tumour.

Synergism between radiotherapy and vascular risk factors in the accelerated development of atherosclerosis: a report of three cases

Radiotherapy is commonly used in the management of testicular tumors. However, to date the risk of radiation-induced vascular occlusive disease in men following radiotherapy for testicular cancer has not been regarded as a major factor in their long-term care. Several animal studies have shown the importance of established vascular risk factors such as hypercholesterolemia and hypertension in the pathogenesis of radiation-induced atherosclerosis. This report presents three cases of premature chronic iliofemoral arterial disease presenting 5,13, and 16 years following exposure to therapeutic irradiation for the treatment of testicular cancer. The patients were in the age group of 40-45 years and all demonstrated associated known atherosclerotic risk factors. The patients had received radiotherapy in the dose of 3,500-4,000 rads in a standard "dog-leg" fashion to the ipsilateral aortoiliac lymphatic chain. Our results showed that young men treated with radiotherapy for testicular cancer may be targeted from the outset for atherosclerotic risk factor reduction to minimize the risk of development of late chronic occlusive arterial disease. It may be that a cohort of men so treated with historical regimes of radiotherapy and now entering middle age should be screened for arterial disease and risk factor reduction.

Introduction of an automated service for the laboratory confirmation of meningococcal disease in Scotland

The Scottish Meningococcus and Pneumococcus Reference Laboratory provides a national service for the laboratory confirmation of meningococcal and pneumococcal disease in Scotland. The main tests used for the laboratory confirmation of meningococcal disease are culture, the polymerase chain reaction (PCR), antibody testing, and more recently DNA sequencing. This paper describes the automation of PCR for the laboratory confirmation of meningococcal disease and the typing of meningococcal isolates using DNA sequencing. Both methods have been automated using a robotic liquid handler and automated DNA sequencer. These methods, along with standard culture phenotyping and antibody testing, provide Scotland with an excellent service for the confirmation of meningococcal disease.

Desensitization of the gag reflex in an adult with cerebral palsy: a case report

Severe oral hypersensitivity and aversive oral behaviors present a significant barrier to dental treatment and compromise oral health status. Although several authors have addressed the reduction of oral hypersensitivity and aversive behaviors (such as gagging, retching, and vomiting) in the otherwise well dental patient, treatment for patients with severe disability has not been explored. The successful management of oral hypersensitivity and aversive behavior can have significant health benefits. These can be described via an outcomes paradigm as physical and social benefits for the patient, psychological benefits for the patient, carer, and practitioner, and organizational benefits for the institutions providing dental care and medical management. This paper summarizes the management of a severely disabled patient whose aversive behaviors were eliminated with non-invasive therapy techniques. Oral hygiene was facilitated and health benefits were identified across a number of domains following successful multi-disciplinary management.

Neonatal examination and screening trial (NEST): a randomised, controlled, switchback trial of alternative policies for low risk infants

OBJECTIVE

To evaluate the effectiveness of one rather than two hospital neonatal examinations in detection of abnormalities.

DESIGN

Randomised controlled switchback trial.

SETTING

Postnatal wards in a teaching hospital in north east Scotland.

PARTICIPANTS

All infants delivered at the hospital between March 1993 and February 1995.

INTERVENTION

A policy of one neonatal screening examination compared with a policy of two.

MAIN OUTCOME MEASURES

Congenital conditions diagnosed in hospital; results of community health assessments at 8 weeks and 8 months; outpatient referrals; inpatient admissions; use of general practioner services; focused analysis of outcomes for suspected hip and heart abnormalities.

RESULTS

4835 babies were allocated to receive one screening examination (one screen policy) and 4877 to receive two (two screen policy). More congenital conditions were suspected at discharge among babies examined twice (9.9 v 8.3 diagnoses per 100 babies; 95% confidence interval for difference 0.3 to 2.7). There was no overall significant difference between the groups in use of community, outpatient, or inpatient resources or in health care received. Although more babies who were examined twice attended orthopaedic outpatient clinics (340 (7%) v 289 (6%)), particularly for suspected congenital dislocation of the hip (176 (3.6/100 babies) v 137 (2.8/100 babies); difference -0.8; -1.5 to 0.1), there was no significant difference in the number of babies who required active management (12 (0.2%) v 15 (0.3%)).

CONCLUSIONS

Despite more suspected abnormalities, there was no evidence of net health gain from a policy of two hospital neonatal examinations. Adoption of a single examination policy would save resources both during the postnatal hospital stay and through fewer outpatient consultations.

Determination of neomycin in animal tissues by liquid chromatography

Tissue samples are digested under hot alkaline conditions after initial conditioning at room temperature with phosphate-buffered saline. The cooled digest is deproteinated with concentrated perchloric acid. After centrifugation and pH adjustment, the clear supernatant is applied to an ion-exchange cartridge, and after the cartridge is washed, the neomycin is eluted with dilute perchloric acid. This eluate is derivatized with 9-fluorenylmethyl chloroformate prior to liquid chromatography using a wide-pore spherical silica C4 column and fluorescence detection. Recovery and repeatability are calculated from tissue extract standard calibration curves produced from the same assay. Recoveries ranged from 80 to 120% for fortifications of 0.25-1.00 mg/kg for muscle tissue and from 80 to 100% for fortifications of 0.50-10.0 mg/kg for kidney tissue. Limits of quantitation were 0.25 and 0.50 mg/kg, respectively, for muscle and kidney tissues. Limits of detection were 0.125 and 0.20 mg/kg, respectively, for muscle and kidney tissues.

Appraisal: purpose, pitfalls and good practice

This article is based on the proceedings of the conference 'Appraisal: purpose, pitfalls and good practice,' held at the Royal College of Physicians of London in May 1996. The conference brought together not only doctors but also representatives of other professions, to review the role of appraisal in education and industry, and to discuss how it might be applied in the medical field.

Clinical significance of cough and wheeze in the diagnosis of asthma

OBJECTIVES

(1) To determine the prevalence of cough, wheeze, and breathlessness, both as single symptoms and in combination, in primary schoolchildren and their relation to doctor diagnosed asthma. (2) To identify in areas with different levels of dust pollution whether questionnaire reported 'cough alone' (without wheeze or breathlessness) had similar risk factors to the questionnaire reported triad of 'cough, wheeze, and breathlessness'.

SUBJECTS AND METHODS

Two cross sectional community surveys of primary schoolchildren (5-11 years) were performed in 1991 and 1993. Parent completed questionnaires related to socioeconomic and respiratory factors were distributed through 15 schools in three areas of Merseyside, one of which had a relatively high level of dust pollution. Data were analysed to determine the prevalence of different respiratory symptom patterns. Univariate and multiple logistic regressions were used to investigate the associations between respiratory symptom profiles and potential risk factors.

RESULTS

The proportions of completed questionnaires that were returned were similarly high in both surveys, 92% in 1991 (1872 of 2035) and 87% in 1993 (3746 of 4288). The proportions of children with different respiratory symptom patterns were similar in the two surveys: in 1991, asymptomatic children 70.1% (1109 of 1583), those with cough alone 8.9% (141 of 1583), and children with the symptom triad of cough, wheeze, and breathlessness 8.3% (132 of 1583); the figures for 1993 were 69.5% (2144 of 3083), 9.2% (284 of 3083), and 7.3% (224 of 3083) respectively. The prevalence of doctor diagnosed asthma increased from 17.4% in 1991 to 22.1% in 1993. The symptom of cough alone was associated with going to school in an area of increased air pollution. The symptom triad of cough, wheeze, and breathlessness was associated with reported allergies, familial history of atopy and preterm birth. In 1991, of children with the symptom of cough alone one in eight were diagnosed asthmatic; twice as many doctors made the diagnosis on this basis in 1993.

CONCLUSION

The respiratory symptom of cough alone and cough, wheeze, and breathlessness represent clinical responses to different specific risk factors. Cough alone was associated with the environmental factors of school in the dust exposed zone and dampness in the home, whereas cough, wheeze, and breathlessness related to allergic history and preterm birth, and may be the best surrogate of asthma. Diagnosis of asthma on the basis of cough alone partly explains the increased prevalence of doctor diagnosed asthma, especially in dust polluted areas.

CDC WONDER on the Web

CDC WONDER, an information system developed at the Centers for Disease Control and Prevention (CDC), provides access to 26 text and numeric databases, and special facilities for surveillance, through an architecture developed for public health. We report extensions of the original architecture that allowed us to create a Web version (http:@wonder.cdc.gov).

Volume preloading is not essential to prevent spinal-induced hypotension at caesarean section

We have compared the protective effect of 1000 ml preload with 200 ml preload of crystalloid solution, administered during the 10 min before spinal anaesthesia was induced, in 60 healthy women with no fetal compromise undergoing elective Caesarean section. The spinal anaesthetic was managed identically in both groups by an anaesthetist who was unaware of the volume of fluid administered. A prophylactic infusion of ephedrine 60 mg in Hartmann's solution 500 ml was given according to maternal arterial pressure. Hypotension was defined as > or = 30% reduction from baseline or < 90 mm Hg, and was treated by i.v. ephedrine bolus doses. There was no significant difference in ephedrine requirements between the two groups or in the incidence, severity or duration of hypotension: 10 women in the 1000-ml group, five episodes lasting > or = 3 min compared with nine women in the 200-ml group, four lasting > or = 3 min. There was no difference between neonates in each group. We have now abandoned the routine of preloading before regional anaesthesia.

Effects of air pollution on symptoms and peak expiratory flow measurements in subjects with obstructive airways disease

BACKGROUND

Evidence from laboratory studies suggests that air pollution can produce bronchoconstriction and respiratory symptoms in selected subjects, but the relevance of these findings to exposure to natural pollution is unclear. This study was performed to determine whether air pollution at typical levels found in the UK has demonstrable effects on respiratory function and symptoms in subjects with airways disease.

METHODS

Seventy five adult patients with diagnoses of asthma or chronic obstructive pulmonary disease (COPD) were studied for a period of four weeks during which they kept records of their peak expiratory flow (PEF) rates, symptoms (wheeze, dyspnoea, cough, throat and eye irritation), and bronchodilator use. Thirty six patients in whom the provocative dose of methacholine causing a 20% fall in FEV1 was below 12.25 mumol were classified as reactors. Ambient air pollution was measured with absorption spectroscopy.

RESULTS

There were modest but significant increases in PEF variability, bronchodilator use, and wheeze with increasing sulphur dioxide levels; bronchodilator use, dyspnoea, eye irritation, and minimum PEF readings were related to ozone levels. In the subgroup of reactors falls in mean and minimum peak flow and increases in wheeze, dyspnoea, and bronchodilator use were associated with increases in levels of both sulphur dioxide and ozone. Some associations were seen with pollution levels on the same day, but for others the pollution effects appeared to be delayed by 24 or 48 hours. Pollution levels did not breach the WHO guide levels during the course of the study.

CONCLUSIONS

Increases in environmental levels of ozone and sulphur dioxide are associated with adverse changes in peak flow measurements and both ocular and respiratory symptoms in subjects with obstructive airways disease. Although the peak flow and symptom changes were modest, they occurred at pollution levels below current WHO guide levels.

A comparison of 25 G and 27 G Whitacre needles for caesarean section

Spinal needles with a pencil-point tip and those of a finer gauge are known to be associated with a lower incidence of postdural puncture headache. This study set out to determine if fine pencil-point needles were acceptably easy to use in routine clinical practice. Two hundred and twelve women undergoing elective Caesarean section were randomly allocated to receive a subarachnoid block using either a 25 G or 27 G Whitacre needle. Factors determining ease of needle use, adequacy of block, incidence of postdural puncture headache, backache and neurological sequelae were assessed. Successful intrathecal injection was achieved in all patients in the 25 G group. Using the 27 G needle, the anaesthetist failed to reach the subarachnoid space in eight patients of which seven subsequently had a successful intrathecal injection with a larger needle. These failures were attributed to excessive needle flexibility which was the only significant difference in ease of use between the 25 G and 27 G needles. In the 25 G group, there was one severe postdural puncture headache which required an epidural blood patch and three mild headaches which resolved spontaneously. There were no postdural puncture headaches in the 27 G group. We conclude that the final choice of needle is a compromise between the ease of use and lower failure rate of the 25 G needle and the, as yet unproven, possibility of a lower incidence of postdural puncture headache with the 27 G needle.

CDC WONDER: a cooperative processing architecture for public health

CDC WONDER is an information management architecture designed for public health. It provides access to information and communications without the user's needing to know the location of data or communication pathways and mechanisms. CDC WONDER users have access to extractions from some 40 databases; electronic mail (e-mail); and surveillance data processing. System components include the Remote Client, the Communications Server, the Queue Managers, and Data Servers and Process Servers. The Remote Client software resides in the user's machine; other components are at the Centers for Disease Control and Prevention (CDC). The Remote Client, the Communications Server, and the Applications Server provide access to the information and functions in the Data Servers and Process Servers. The system architecture is based on cooperative processing, and components are coupled via pure message passing, using several protocols. This architecture allows flexibility in the choice of hardware and software. One system limitation is that final results from some subsystems are obtained slowly. Although designed for public health, CDC WONDER could be useful for other disciplines that need flexible, integrated information exchange.

CDC WONDER: a comprehensive on-line public health information system of the Centers for Disease Control and Prevention

OBJECTIVES

CDC WONDER, a comprehensive on-line public health information system of the Centers for Disease Control and Prevention (CDC), was developed to place timely, action-oriented information in the hands of public health professionals.

METHODS

A unified system was developed de novo to be used for and to evolve along with public health. All data are stored and updated on the CDC mainframe.

RESULTS

CDC WONDER provides menu-driven access to 24 databases with information on mortality, hospital discharges, cancer incidence, notifiable diseases, acquired immunodeficiency syndrome, the Morbidity and Mortality Weekly Report, etc.; each database has on-line documentation. Results can be tabulated and graphed, and there is full-text searching of textual databases. Non-CDC staff have access via telephone connection. From August 1991 through June 1992, system databases were accessed 10,698 times, and there were 842 users (mean of 97 new users per month).

CONCLUSIONS

CDC WONDER has shown that it is possible to build a large, on-line database of scientific data for public health professionals. CDC WONDER provides a common foundation from which to build information-based public health plans and policy and could help strengthen the public health system.

Medical audit of community screening for undescended testes in Halton District

OBJECTIVES

To evaluate the quality of screening in the community for undescended testis and to determine the percentage of boys referred for surgery before their second birthday.

DESIGN

Population-based retrospective study of hospital and community clinic records of boys resident in Halton Health District who underwent surgery for undescended testicle during 1987-89.

SETTING

Community Child Health Clinics. Medical Records Department of referral hospitals surrounding Halton district.

RESULTS

During 1987-89, 76 boys from Halton district underwent surgery for undescended testis in the neighbouring hospitals: 64 (84%) of these boys had attended at least one screening examination in the community clinics; 12 (16%) did not attend any. Among the 64 who attended 18 (28%) were not considered to have undescended testis. Of the 30 boys diagnosed to have undescended testis after school entry, six were diagnosed incidentally in hospital and 24 were detected by general practitioners and School Medical Service. The age range for surgical referral varied from six months to 12.5 years. The percentage of boys referred for surgery before their second birthday was only 13%.

CONCLUSION

Many cryptorchid boys were not picked up in community screening and many of these did not receive early surgery. This audit report suggested the following recommendations: (a) increased awareness of the condition amongst doctors and health visitors performing screening examination; (b) early surgical referral. These recommendations have been implemented in the district. Our further plan is to repeat the audit in three years to assess changes.

Radiation exposures around a panoramic dental x-ray unit

To evaluate the radiation hazard in the vicinity of a panoramic x-ray unit, Ektaspeed periapical films were placed in an array behind and to the side of the unit. They were left in place for 7 months, during which 1414 examinations were carried out. The maximum exposure at 80 cm from the patient was determined to be about 1 mGy in 7 months with a heavy workload. This shows clearly that no special environmental shielding barriers are necessary around this unit.

Weyers' ulnar ray/oligodactyly syndrome and the association of midline malformations with ulnar ray defects

We describe a two generation family with variable ulnar and radial ray reduction and midline craniofacial abnormalities. The features suggest a diagnosis of Weyers' ulnar ray/oligodactyly syndrome originally described in two isolated cases. Syndromes of ulnar ray reduction are briefly reviewed and the relationship between limb bud and midline development discussed.

Effect of adrenaline on extradural anaesthesia, plasma lignocaine concentrations and the feto-placental unit during elective caesarean section

Extradural anaesthesia was induced with either 2% lignocaine or 2% lignocaine with adrenaline 1:200,000 in 20 patients undergoing elective Caesarean section. With the adrenaline-containing solution, a smaller dose of lignocaine was required to produce an adequate block and the lignocaine concentrations in both mother and neonate were significantly smaller compared with the plain solution. Arterial pressures were less in the adrenaline group, but there was no difference in umbilical flow velocity waveform, fetal heart rate or fetal outcome. Neither feto-placental circulation nor fetal outcome were affected adversely by episodes of hypotension or the ephedrine used for treatment.

Single-dose trospectomycin for chlamydial urethritis in men

Trospectomycin is an aminocyclitol analog of spectinomycin with significant in vitro activity against Chlamydia trachomatis. A single 1-g intramuscular dose was administered to 10 men with symptomatic, culture-positive chlamydial urethritis. Trospectomycin was well tolerated but failed to eradicate chlamydial infection, as determined by cultures obtained approximately 1 week after treatment.

Development and testing of artificial low-frequency speech codes

In a new approach to the frequency-lowering of speech, artificial codes were developed for 24 consonants (C) and 15 vowels (V) for two values of lowpass cutoff frequency F (300 and 500 Hz). Each individual phoneme was coded by a unique, nonvarying acoustic signal confined to frequencies less than or equal to F. Stimuli were created through variations in spectral content, amplitude, and duration of tonal complexes or bandpass noise. For example, plosive and fricative sounds were constructed by specifying the duration and relative amplitude of bandpass noise with various center frequencies and bandwidths, while vowels were generated through variations in the spectral shape and duration of a ten-tone harmonic complex. The ability of normal-hearing listeners to identify coded Cs and Vs in fixed-context syllables was compared to their performance on single-token sets of natural speech utterances lowpass filtered to equivalent values of F. For a set of 24 consonants in C-/a/ context, asymptotic performance on coded sounds averaged 90 percent correct for F = 500 Hz and 65 percent for F = 300 Hz, compared to 75 percent and 40 percent for lowpass filtered speech. For a set of 15 vowels in /b/-V-/t/ context, asymptotic performance on coded sounds averaged 85 percent correct for F = 500 Hz and 65 percent for F = 300 Hz, compared to 85 percent and 50 percent for lowpass filtered speech. Identification of coded signals for F = 500 Hz was also examined in CV syllables where C was selected at random from the set of 24 Cs and V was selected at random from the set of 15 Vs. Asymptotic performance of roughly 67 percent correct and 71 percent correct was obtained for C and V identification, respectively. These scores are somewhat lower than those obtained in the fixed-context experiments. Finally, results were obtained concerning the effect of token variability on the identification of lowpass filtered speech. These results indicate a systematic decrease in percent-correct score as the number of tokens representing each phoneme in the identification tests increased from one to nine.

7-Oxabicyclo[2.2.1]heptyl carboxylic acids as thromboxane A2 antagonists: aza omega-chain analogues

A novel bicyclic prostaglandin analogue, [1S-[1 alpha, 2 alpha (Z), 3 alpha, 4 alpha]]-7-[3-[[[[(1- Oxoheptyl)amino]acetyl]amino]-methyl]-7-oxabicyclo[2.2.1]hept-2- yl]-5-heptenoic acid [-)-7) was found to be a potent and selective thromboxane A2 (TxA2) receptor antagonist. Unlike the related series of omega-chain allylic alcohols, amide 7 and its congeners were uniformly free of direct contractile activity in vitro (bovine coronary) and in vivo (anesthetized guinea pig). Amide 7 was effective in the inhibition of (a) arachidonic acid induced platelet aggregation of human platelet-rich plasma (I50 = 0.18 +/- 0.006 microM), (b) 11,9-epoxymethano-PGH2 induced platelet aggregation of human platelet-rich plasma (I50 = 0.24 microM), (c) 11,9-epoxymethano-PGH2 induced contraction of guinea pig trachea (Kb = 3.0 +/- 0.3 nM) or rat aorta (Kb = 8.8 +/- 1.1 nM), and (d) arachidonic acid induced bronchoconstriction in the anesthetized guinea pig (0.1-1.0 mg/kg iv). Amide 7 inhibited the binding of [5,6-3H2]-[1S- (1 alpha, 2 alpha (Z), 3 alpha, 4 alpha)]-7-[3-[[2-[(Phenyl- amino)carbonyl]hydrazino]methyl]-7-oxabicyclo[2.2.1]hept-2-yl]-5- heptenoic acid to human platelet membranes in a specific and saturable manner with a Kd = 49.6 +/- 1.4 nM.

Infection of staff during an outbreak of viral gastroenteritis in an elderly persons' home

An outbreak of viral gastroenteritis in an elderly persons' residence is reported. Seventeen of 37 (47%) residents and 22 of 50 (44%) staff developed illness. Adenovirus was seen by direct electron microscopy in two vomitus and two faeces specimens. It is suggested that the most likely mode of transmission was environmental contamination by vomitus.

9,11-epoxy-9-homoprosta-5-enoic acid analogues as thromboxane A2 receptor antagonists

A novel bicyclic prostaglandin analogue, (1S)-[1 alpha, 2 alpha(Z),3 alpha(1E,3S*,4R*),4 alpha]-7-[3-(3-hydroxy-4-phenyl-1-pentenyl)-7- oxabicyclo[2.2.1]hept-2-yl]-5-heptenoic acid (4), was found to be a potent and selective thromboxane A2 (TxA2) receptor antagonist. Alcohol 4 was the only member in a series of allylic alcohols which did not display direct contractile activity in the rat stomach strip model. Alcohol 4 was effective in the inhibition of (a) arachidonic acid induced platelet aggregation of human platelet-rich plasma (I50 = 0.65 +/- 0.1 microM); (b) 11,9-epoxymethano-PGH2 induced contraction of guinea pig trachea (pA2 = 8.0 +/- 0.2) or rat aorta (pA2 = 8.1 +/- 0.2); and (c) arachidonic acid induced bronchoconstriction in the anesthetized guinea pig (1 mg/kg iv). A radioiodinated analogue of 4 bound in a specific and saturable manner to human platelet membranes with a Kd = 2.3 +/- 0.9 nM. Modification of the alpha-chain, in an attempt to minimize in vivo metabolism, resulted in TxA2 receptor antagonists of reduced in vitro potency.

Vaccination viewpoints

Liverpool is an area of lower than average immunisation uptake. A survey of health visitors, school nurses and clinical medical officers suggests that professional disagreements and lack of belief are contributory factors.

The unerupted or impacted third molar--a critical appraisal of its pathologic potential

The prophylactic removal of asymptomatic unerupted or impacted third molars constitutes a major proportion of all oral surgical procedures. Patients are advised to have this preventive surgery on the basis that such teeth, if retained, are likely to cause certain pathologic lesions. The evidence in the scientific literature on the prevalence of dentigerous cysts, mural ameloblastoma, epidermoid carcinoma and root resorption indicates that this concern is exaggerated. The retrospective data on the reasons for extractions of third molars confirm this conclusion. Until there are prospective studies which demonstrate a significant patient benefit from surgery exceeding the risks of retention, the practice should be discontinued. Third molars should be removed only where there is a defined pathologic indication.