Effect of hepatobiliary disease, chronic hepatitis C and hepatitis B virus infections and interferon-alpha on porphyrin profiles in plasma, urine and faeces

BACKGROUND

Documentation of the profiles of porphyrins in hepatobiliary disease is limited. Strong associations of hepatitis B and C virus infections with porphyria cutanea tarda have suggested causal relationships. This study aimed to determine the nature of porphyrin abnormalities in hepatobiliary disease and the effect of interferon-alpha on porphyrin profiles.

METHODS

Total porphyrins were measured in the plasma, urine and faeces of 83 patients with hepatobiliary disease (37 hepatitis C, 20 hepatitis B, 26 other causes) and 12 clinical controls, and porphyrin profiles were determined by high-performance liquid chromatography.

RESULTS

Porphyrins were elevated in the plasma of 11 and urine of 23 patients with hepatobiliary disease, as a result of elevated coproporphyrin I. This was reflected in increased coproporphyrin I:III ratios. Abnormal total porphyrin levels had a significant negative correlation with plasma albumin, and a positive correlation with bilirubin and alkaline phosphatase, but not with aminotransferases. Total urinary porphyrins were elevated in three control patients, but coproporphyrin I:III ratios were normal. Although not seen in plasma or urine, porphyrins that are specific for porphyria cutanea tarda were found in the faeces of six patients, but this occurred with similar frequency in hepatitis B or C infection (four of 50) as in the clinical controls (two of 12). Interferon-alpha had no effect during or after therapy in six patients with hepatitis C.

CONCLUSIONS

Reduced biliary excretion of coproporphyrin I occurs in more severe cholestasis and/or hepatic dysfunction. A causal relationship between viral liver disease and porphyria cutanea tarda which is unlikely to be precipitated by interferon-alpha, is not supported.

Multiple recurrent gram-negative cerebrospinal fluid shunt infections associated with a patient with a retained ventricular foreign body

A 3-year-old boy experienced 10 recurrent gram-negative ventriculoperitoneal shunt (VPS) infections with identical strains over a 17-month period. Multiple cranial MRI and CT scans to identify a retained foreign body were negative. CT myelography and pressure infusion radionuclide cisternography were also unhelpful. Ventriculoscopy revealed a small retained foreign body which was successfully removed, and cultures subsequently yielded gram-negative organisms identical to the previously identified bacteria by pulsed field gel electrophoresis. No further infections were noted after removal of the retained fragment. Exploratory ventriculostomy should be considered in patients with recurrent VPS infections where other techniques fail to reveal a cause.

Genetic and environmental influences on forced expiratory volume in midlife: a cross-cultural replication

Previous research has shown that forced expiratory volume (FEV) is a useful predictor of remaining life in older adults. The present analyses are an attempt to replicate results from a study of Swedish twins which demonstrated substantial heritability of FEV with a sample of middle-aged Russian adult twins. Data were collected from 116 pairs of Russian twins (monozygote = 71, dizygotic = 45, mean age = 40.9 years). Phenotypic correlations between FEV, age, gender, height, and cigarette consumption (in pack years) were all significant, ranging from -.72 to .31. After the effects of age, gender, height, and smoking were partialled out of FEV, quantitative genetic analyses were conducted. Shared environmental effects were significant, accounting for 47% of the variance in FEV. Genetic effects, which accounted for about 28% of the variance, could be dropped from the model without a significant decrease in the fit. These results are discussed in relation to previous research conducted in other countries.

Heterogeneity of chemosensitivity of metastatic cutaneous melanoma

Advanced melanoma has a poor prognosis and chemotherapy provides little benefit for most patients. This may be related to heterogeneity of chemosensitivity as well as frequent constitutive resistance to individual cytotoxic drugs. We have therefore examined the heterogeneity of chemosensitivity in metastatic cutaneous melanoma specimens using an ex vivo ATP-based chemosensitivity assay (ATP-TCA). Melanoma deposits (n=55) in skin or lymph node were tested using the ATP-TCA, performed in three separate laboratories. Analysis of the data collected (based on an arbitrary sensitivity index < 300) shows considerable heterogeneity of chemosensitivity. The most active single cytotoxic agents in the assay were identified as cisplatin, treosulfan, paclitaxel, vinblastine, gemcitabine and mitoxantrone. There was also a limited direct inhibition of melanoma cell growth by interferon-alpha2b, although this agent is known to have a number of indirect biological antitumor effects. Exposure of tumor cells to combinations of drugs at the concentrations tested as single agents showed the most active combinations to be treosulfan+gemcitabine, cisplatin+paclitaxel and vinblastine+paclitaxel. There was considerable heterogeneity of chemosensitivity: some tumors responded well to one agent or combination, while others showed no response to this and instead responded to one of the alternatives tested. Occasional highly resistant tumors showed no response to any of the single agents or combinations tested. The degree of heterogeneity observed suggests that the ATP-TCA could be used to select patients who might benefit from specific chemotherapeutic agents alone or in combination. This provides the rationale for future randomized controlled trials of ATP-TCA-directed chemotherapy versus physician's choice to determine whether assay-directed chemotherapy can improve patient response and survival.

Approaches to experiential learning, course delivery and validation in medicine. A background document

Educational models and approaches change over time in their dominance and use, offering a wide selection to educational planners and teachers. This paper discusses aspects of experiential learning, distance learning, learning contracts, portfolios, reflection, appraisal, assessment and validation of education. It offers triggers to further thought and enables the analysis of current educational practice.

Williams syndrome: use of chromosomal microdeletions as a tool to dissect cognitive and physical phenotypes

In Williams syndrome (WS), a deletion of approximately 1.5 Mb on one copy of chromosome 7 causes specific physical, cognitive, and behavioral abnormalities. Molecular dissection of the phenotype may be a route to identification of genes important in human cognition and behavior. Among the genes known to be deleted in WS are ELN (which encodes elastin), LIMK1 (which encodes a protein tyrosine kinase expressed in the developing brain), STX1A (which encodes a component of the synaptic apparatus), and FZD3. Study of patients with deletions or mutations confined to ELN showed that hemizygosity for elastin is responsible for the cardiological features of WS. LIMK1 and STX1A are good candidates for cognitive or behavioral aspects of WS. Here we describe genetic and psychometric testing of patients who have small deletions within the WS critical region. Our results suggest that neither LIMK1 hemizygosity (contrary to a previous report) nor STX1A hemizygosity is likely to contribute to any part of the WS phenotype, and they emphasize the importance of such patients for dissecting subtle but highly penetrant phenotypes.

Etretinate therapy for refractory sclerodermatous chronic graft-versus-host disease

Chronic graft-versus-host disease (GVHD) is the most common late complication of allogeneic bone marrow transplantation (BMT). The sclerodermatous form of the disease is often refractory to standard treatment modalities. Based on reports of response to etretinate, a synthetic retinoid, among patients with scleroderma, we have added etretinate to the treatment regimen of 32 patients with refractory sclerodermatous chronic GVHD. This case series is comprised mainly of patients who had chronic GVHD of long duration (median of 30 months before the initiation of etretinate). Most had failed to respond to three or more agents before etretinate treatment was started. Clinical response was assessed after 3 months of therapy. Five patients did not complete a 3-month trial. Among the 27 patients evaluable for response, 20 showed improvement including softening of the skin, flattening of cutaneous lesions, increased range of motion, and improved performance status. Four showed no response after 3 months of therapy and 3 had progression of their sclerosis. Overall, etretinate has been fairly well tolerated in our patients, with skin breakdown and/or ulceration leading to its discontinuation in 6 patients. We believe the results in our patients are encouraging and suggest that further evaluation of etretinate in the treatment of sclerodermatous chronic GVHD is warranted.

Effect of pravastatin on cardiovascular events in older patients with myocardial infarction and cholesterol levels in the average range. Results of the Cholesterol and Recurrent Events (CARE) trial

BACKGROUND

A majority of all myocardial infarctions occur in patients who are 65 years of age or older and have average cholesterol levels, but little information is available on whether cholesterol lowering in such patients reduces the rate of recurrent cardiovascular disease.

OBJECTIVE

To determine whether pravastatin reduces the rate of recurrent cardiovascular events in older patients.

DESIGN

Subset analysis of a randomized, controlled trial.

SETTING

80 hospitals and affiliates in the United States and Canada.

PATIENTS

1283 patients aged 65 to 75 years who had had myocardial infarction and had a plasma total cholesterol level less than 6.2 mmol/L (240 mg/dL) and a low-density lipoprotein cholesterol level of 3.0 to 4.5 mmol/L (115 to 174 mg/dL).

INTERVENTION

Pravastatin, 40 mg/d, or placebo.

MEASUREMENTS

Five-year event rates of major coronary events (coronary death, nonfatal myocardial infarction, angioplasty, or bypass surgery) and stroke.

RESULTS

Major coronary events occurred in 28.1% of placebo recipients and 19.7% of pravastatin recipients (difference, 9.0 percentage points [95% CI, 4 to 13 percentage points]; relative risk reduction, 32%; P < 0.001). Coronary death occurred in 10.3% of the placebo group and in 5.8% of the pravastatin group (difference, 4.6 percentage points [CI, 1.9 to 6.5 percentage points]; relative risk reduction, 45%; P = 0.004). Stroke incidence was 7.3% in the placebo group and 4.5% in the pravastatin group (absolute reduction, 2.9 percentage points [CI, 0.3 to 4.5 percentage points]; relative reduction, 40%; P = 0.03). The numbers of older patients needed to treat for 5 years were 11 (CI, 8 to 24) to prevent a major coronary event and 22 (CI, 15 to 53) to prevent a coronary death. For every 1000 older patients treated, 225 cardiovascular hospitalizations would be prevented compared with 121 hospitalizations in 1000 younger patients.

CONCLUSIONS

In older patients with myocardial infarction and cholesterol levels in the average range, pravastatin is associated with a clinically important reduction in risk for major coronary events and stroke. Given the high cardiovascular event rate in older patients, the potential for absolute benefit in this age group is substantial.

The history of neurological surgery at Northwestern University

The residency program in neurological surgery at Northwestern University was founded in 1924 by Loyal Davis and was formally accredited by the American Board of Neurological Surgery in 1946. Allen Kanavel, mentor to Davis, was one of the original members of the Society of Neurological Surgeons. Five individuals have served as chief of neurosurgery at Northwestern: Davis, Paul Bucy, Anthony Raimondi, Albert Butler, and H. Hunt Batjer. Davis was the first surgeon west of the Appalachians to limit his work to neurosurgery. Between 1954 and 1963, there were two independent neurosurgery residency programs at Northwestern, one headed by Davis and the other by Bucy. A master surgeon and superb teacher, Bucy trained more than 65 residents and became one of the greatest authors and leaders in the field of neurosurgery. Neurosurgical training at Northwestern has traditionally emphasized excellence of patient care, strong resident and student teaching, and basic science research. Through the years, a major strength of the program has been its clinical volume and diversity. Four hospitals have played major roles in the program: Northwestern Memorial Hospital (created by the merger of Chicago Wesley Memorial Hospital and Passavant Memorial Hospital), Children's Memorial Hospital, Evanston Hospital, and the Veterans Administration Lakeside Hospital. This article traces the development of neurological surgery at Northwestern, with an emphasis on its historical background and the contributions of Kanavel, Davis, and Bucy. The present philosophy and structure of the training program and the program's future under the direction of Batier are also described.

Burns of children caused by electric stoves

During a 2-year period, eight patients sustained burns caused by the tipping over of electric stoves. In seven of these cases, children aged 2 to 4 years stood up on the open oven door of a stove. The stove then tipped forward, and a pot of boiling liquid on the stove spilled onto the child, who fell forward across the oven door. The general area of involvement was back and buttocks, with spattered areas elsewhere on the body. In one other case, an older child, aged 8, sat on the open oven door and was burned when a pot fell on him. The weight of the children ranged from 12.7 to 20 kilograms, with a mean of 15.2 kilograms. The 8-year old weighed 14.9 kilos. Burn size ranged from 3% to 30%, with a mean of 16.75%. All burns were second-degree and were treated by debridement and coverage with either porcine grafts or Biobrane (Dow Hickman Pharmaceuticals, Inc.). Healing was satisfactory in all cases. Hospital stay ranged from 2 to 20 days. The increase in the use of electric stove has led to a situation in which children, usually toddlers, can overbalance the stove and bring down the pots sitting on the heating elements. This represents another mechanism by which young children can be injured in the kitchen; the awareness of this should be disseminated.

Brain biochemistry in Williams syndrome: evidence for a role of the cerebellum in cognition?

OBJECTIVE

To determine what biochemical changes may occur in the brain in Williams syndrome (WS) and whether these changes may be related to the cognitive deficits.

BACKGROUND

WS is a rare, congenital disorder with a characteristic physical, linguistic, and behavioral phenotype with known cognitive deficits.

METHODS

We obtained 31P magnetic resonance spectra (MRS) from a region consisting of mostly frontal and parietal lobe of 14 patients with WS (age, 8 to 37 years) and 48 similarly-aged controls. 1H MRS (27 cm3) localized to the left cerebellum obtained from the WS cohort were compared with those from 16 chronological age- and sex-matched normal controls. A battery of cognitive tests were administered to all subjects undergoing 1H MRS.

RESULTS

WS brains exhibited significant biochemical abnormalities. All 31P MRS ratios containing the phosphomonoester (PME) peak were significantly altered in WS, suggesting that PME is significantly decreased. Ratios of choline-containing compounds and creatine-containing compounds to N-acetylaspartate (Cho/NA and Cre/NA) were significantly elevated in the cerebellum in WS cf. controls, whereas the ratio of Cho/Cre was not altered. This suggests a decrease in the neuronal marker N-acetylaspartate in the cerebellum. Significant correlations were found between the cerebellar ratios Cho/NA and Cre/NA and the ability of all subjects at various neuropsychological tests, including Verbal and Performance IQ, British Picture Vocabulary Scale, Ravens Progressive Matrices, and Inspection Time.

CONCLUSIONS

The correlations can be interpreted in two ways: 1) Our sampling of cerebellar biochemistry reflects a measure of "global" cerebral biochemistry and is unrelated to cerebellar function, or 2) The relations indicate that cerebellar neuronal integrity is a requirement (on a developmental time scale or in real-time) for ability on a variety of cognitive tests.

A demographic and health survey of Spanish female sex workers: HIV prevalence and associated risk factors

In order to examine the prevalence of HIV infection and associated risk factors amongst Spanish female prostitutes a multicentre (n = 22) cross-sectional study was conducted between November 1989 and January 1991. Data collected included socioeconomic characteristics, sexual behavior and health status together with blood samples. A total of 1633 prostitutes were recruited into the study. Of these, 1433 (87.8%) consented to blood samples being taken and 180 (12.6%) were HIV positive. HIV seroprevalence was 54.7% for intravenous drug users (IVDUs) versus 3.7% for non-IVDUs. Previous imprisonment, hepatitis B and a partner who was an IVDU were significant predictors of HIV infection according to multivariate logistic regression models.

Quantitative structure-activity relationship studies of a series of sulfa drugs as inhibitors of Pneumocystis carinii dihydropteroate synthetase

Sulfone and sulfanilamide sulfa drugs have been shown to inhibit dihydropteroate synthetase (DHPS) isolated from Pneumocystis carinii. In order to develop a pharmacophoric model for this inhibition, quantitative structure-activity relationships (QSAR) for sulfa drugs active against DHPS have been studied. Accurate 50% inhibitory concentrations were collected for 44 analogs, and other parameters, such as partition coefficients and molar refractivity, were calculated. Conventional multiple regression analysis of these data did not provide acceptable QSAR. However, three-dimensional QSAR provided by comparative molecular field analysis did give excellent results. Upon removal of poorly correlated analogs, a data set of 36 analogs, all having a common NHSO2 group, provided a cross-validated r2 value of 0.699 and conventional r2 value of 0.964. The resulting pharmacophore model should be useful for understanding and predicting the binding of DHPS by new sulfa drugs.

Tick bites and Lyme disease in an endemic setting: problematic use of serologic testing and prophylactic antibiotic therapy

CONTEXT

The use of serologic testing to diagnose Lyme disease (LD) is a source of controversy. Expert recommendations also discourage the routine use of antibiotic therapy for prophylaxis of LD following tick bites, but the extent to which physicians in endemic areas have adopted these recommendations is not known.

OBJECTIVE

To assess the pattern of use of serologic testing and antibiotic therapy for tick bites and LD and associated charges for management in an endemic area.

DESIGN

Active surveillance of patient-physician encounters for tick bites and LD.

SETTING

Primary care practices on the Eastern Shore of Maryland.

PATIENTS

Consecutive sample of 232 patients with tick bites, LD (defined by physician diagnosis in medical record), and suspected LD (physician notation of possible, but not definite LD) seen in 1995.

MAIN OUTCOME MEASURES

Serologic testing for LD, test results, antibiotic therapy, and direct costs of management.

RESULTS

Surveillance identified 142 patients (61.2%) with diagnoses of tick bites, 40 patients (17.2%) with LD, and 50 patients (21.6%) with suspected LD. Of the 142 patients seen for tick bites, 95 (67%) underwent serologic testing for LD. Of these, 93 patients had initial negative or equivocal results; 24 (26%) of the 93 had convalescent testing, with 1 seroconversion. Seventy-eight patients (55%) with a diagnosis of tick bite received antibiotic therapy. No patients with tick bite developed clinical LD. Serologic testing for LD was performed for 36 patients (90%) with a diagnosis of LD and 46 patients (92%) with suspected LD. In most cases, antibiotics were prescribed before serologic test results became available. Convalescent testing was not performed for 37 (86%) of the 43 patients with suspected LD who had initial negative or equivocal results. Of these 37 patients, 25 (68%) did not receive antibiotic therapy. Direct charges for treatment of these 232 patients totaled $47 595, one third of which was attributable to serologic testing. A total of 32% of direct charges were for patients with tick bites, 48% were for patients with LD, and 20% were for patients with suspected LD.

CONCLUSIONS

In this setting, most patients consulting physicians for tick bites received prophylactic antibiotic therapy of unproven efficacy and underwent unnecessary, costly serologic testing. Despite almost universal use in this study, serologic testing for LD did not appear to influence treatment of patients diagnosed as having LD.

The prevalence of serological markers for syphilis amongst a sample of Spanish prostitutes

The results of a multicentre study of 1668 Spanish prostitutes are described with regard to syphilis infection. For those women who permitted serological tests (n = 1095), 30.59% (confidence interval (CI): 30.55%-30.63%) were positive for markers indicating current or prior infection. After adjustment was made for other variables, a significant association with syphilis infection was observed for periods of exposure (i.e. age and years working as a prostitute). No significant associations were detected for either intravenous drug use, or educational attainment. The results of this study are similar to those of some other investigations into the prevalence of syphilis amongst prostitutes.

Do individuals with Williams syndrome have bizarre semantics? Evidence for lexical organization using an on-line task

Williams syndrome, a neurodevelopmental disorder, has attracted a great deal of debate concerning the purported intactness of language in the face of other serious cognitive deficits. As more in-depth studies of specific aspects of WS language have emerged, the notion of a preserved language module has been seriously challenged. Although WS vocabulary scores are often impressive, several investigators have claimed the WS semantics are aberrant. All studies hitherto have been based on off-line experiments which necessarily involve metalinguistic processes. This clearly affects the performance of individuals with cognitive deficits. We report here an on-line study probing the semantic structure of the WS lexicon, using a task-semantic priming-which minimises metalinguistic demands. We show that WS subjects display the same taxonomic/category and thematic/functional priming effects as normal controls. The results are discussed in terms of the differences between receptive and expressive language, as well as the fact that although semantic memory and the automatic access to semantic information for individual words is normal in WS, the integration of semantic information into sentence comprehension may be abnormal. The importance of online tasks to highlight such differences is stressed.

Community hospitals and general practice: extended attachments for medical students

The first year experience of an innovative experiment in undergraduate medical education is described. The study investigated the educational effectiveness of prolonged clinical attachments for medical undergraduates in community hospital-based general practice. It has also assessed the ability of students to take some responsibility for their own learning in a clinically challenging environment. A retrospective evaluation of the experience obtained during the 3 month attachments for a self-selected group of fourth year Dundee medical school undergraduates was made. These undergraduates were placed in 10 mainly rural Scottish general practices with attached community hospitals providing a wide spectrum of inpatient and outpatient medical and surgical care. Students were assessed on the satisfactory completion of a portfolio of learning experiences and a practical clinical skills list. They were also required to submit a clinical project based on some aspect of their work during the attachment. The initial results showed a high degree of student and tutor satisfaction with the attachments. The assessment of all 10 of the students' educational achievements in their attachment were regarded as satisfactory and two were assessed as outstanding. Tutor assessment confirmed the validity of the initiative. Prolonged attachments in community hospital-based general practice for medical undergraduates have proved educationally valid and popular with both students and tutors. The development and dissemination of this model on a wider scale has resource issues which require to be addressed.

Language and Williams syndrome: how intact is "intact"?

It has been claimed that Williams syndrome (WS), a rare neurodevelopmental disorder, is characterized by serious cognitive deficits alongside intact language. The syndrome is often used as a prime example of the modularity of an innate faculty for morphosyntactic rules. We challenge this claim and hypothesize that morphosyntax, although surprisingly good given WS level of mental retardation, is by no means intact. We make an initial test of this hypothesis through an analysis of the receptive language of a group of English-speaking WS individuals on a standardized morphosyntactic test. We then present an experimental study of expressive language that examines grammatical gender assignment in French-speaking WS patients. Despite a Verbal Mental Age selected to be higher than the chronological age of the young control group, these people with WS continue even in adulthood to show clear-cut deficits in their production of an aspect of morphosyntax that normal children acquire effortlessly very early. The results of the 2 studies, one focusing on receptive language and the other on expressive language, challenge the notion that comprehension and use of morphosyntactic rules in WS individuals are intact. The Within-domain dissociations regarding the use of grammatical gender assignment across several sentence clements and their difficulties in understanding embedded sentences-two quintessentially linguistic skills-suggest that we must rethink the notion of spared, modular, language capacities in Williams syndrome. We conclude that WS language follows a different path to normal acquisition and may turn out to be more like second language learning.

Association of use of a log book and experience as a preregistration house officer: interview survey

OBJECTIVE

To determine whether use of a log book improved the experiences of preregistration house officers.

DESIGN

Confidential questionnaire and interview survey of preregistration house officers carried out as part of University of London inspection process.

MEASURES

Preregistration house officers were asked to rate educational and pastoral elements of their posts and about the use made of previously distributed log books.

SUBJECTS AND SETTING

Preregistration house officers in North Thames.

RESULTS

The incumbents of 535 of 560 (95%) preregistration house officer posts in the region were surveyed between June 1994 and July 1995, 490 by questionnaire and interview, 45 by questionnaire alone. House officers who had discussed the log book with their consultant expressed more satisfaction with their induction, consultant supervision and feedback, and formal and informal education and were more likely to recommend their job to a friend.

CONCLUSION

Preregistration house officers who had discussed the log book with their consultant expressed more satisfaction with the educational elements of their jobs. The structured discussion with their consultant about the job and their performance seemed to make the difference.

Management of acute myocardial infarction in Auckland

AIM

To analyse the utilisation of therapies in coronary care units for patients with acute myocardial infarction.

METHODS

An evaluation form was completed prospectively by a designated nurse in each coronary care unit of the four Auckland hospitals in 1993.

RESULTS

One thousand and eighty one patients who were admitted with definite or probable acute myocardial infarction had a coronary care unit stay of 63.4 (SD 49.3) hours, and hospital stay of 7.3 (5.1) days. The mortality for definite myocardial infarction was 13.7% (< 70 years 7.1%). Coronary angiography was performed on 10% of patients during their hospital admission, and 4.9% underwent revascularisation. Thrombolytic therapy was administered to 52% (495/948) of patients with definite infarction and 4% had contraindications. Patients aged > or = 70 years (47% vs 55% p = 0.02) or diabetics (46% vs 56%, p = 0.04) were less likely to receive thrombolysis. The utilisation of aspirin and oral beta-blockers was 86% and 40%, respectively, in patients with definite infarction and both were used less frequently in patients > or = 70 years. Intravenous beta-blockers were administered to < 1% of patients. Angiotensin converting enzyme (ACE) inhibitors were prescribed in 21%, intravenous or long acting nitrates in 41% and calcium antagonists in 14%; the latter two therapies were used more frequently in patients > or = 70 years. There was no evidence of gender or ethnic bias for either investigation or treatment.

CONCLUSION

On the basis of results of recent clinical trials, there may be under utilisation of some treatments for acute myocardial infarction including aspirin, thrombolytic therapy, beta-blockers and ACE inhibitors, while calcium antagonists may be over used.

Content of a trainer's report for summative assessment in general practice: views of trainers

BACKGROUND

Summative assessment of doctors completing general practice vocational training will become compulsory for those completing training after 1 September 1996. One component of the assessment will be a trainer's report.

AIM

A study set out to consider the content of the trainer's report. It aimed to determine which elements of general practice general practitioner trainers believe are the most important for independent general practice; to seek the views of trainers as to the most appropriate methods for assessing these elements in summative assessment of general practitioner registrars; and to determine how frequently trainers have been sufficiently concerned about the performance of registrars to consider not signing the form denoting satisfactory completion of the training year.

METHOD

A questionnaire was sent to 1296 general practitioner trainers in the United Kingdom. The main outcome measures used were: the percentage of respondents indicating that an element was very important/crucial for independent general practice; the percentage of respondents indicating a favoured method of assessment that did not include a trainer's report at all; and the proportion of trainers who had ever considered not signing the form denoting satisfactory completion of the training year.

RESULTS

The response rate was 78%. Of 75 elements examined, 31 were considered important for independent general practice by 70% or more of respondents. For 29 of these 31 elements, fewer than 30% of respondents would choose a method of assessment that did not include a trainer's report at all. Twenty-six per cent of respondents had considered not signing the form denoting satisfactory completion of the training year, which represents a trainer considering not signing this form once every 29 years.

CONCLUSION

These results provide a basis for the content of a structured trainer's report for summative assessment in general practice; such a report is likely to contain about 30 items. Data from the Joint Committee on Postgraduate Training for General Practice and the present study suggest that, for every form not signed, trainers considered not signing the forms of another 13 general practitioner registrars. This highlights the need for a report that will help trainers to make the difficult decision as to whether or not a registrar is ready for independent practice.

Consensus minimum standards for use in a trainer's report for summative assessment in general practice

BACKGROUND

Summative assessment of general practitioner registrars is to be introduced in September 1996, one component of which will be a report by the trainer. Standards must be set and guidance provided as to the most appropriate ways of obtaining evidence for the trainer's assessment.

AIM

The first aim of this study was to set consensus minimum standards for 30 items that are likely to form the content of a trainer's report; the second aim was to provide a consensus view on the most appropriate methods of assessment to be used by trainers.

METHOD

A consensus conference was held in March 1995 during which the 30 items were discussed by a group of 30 general practitioners, of whom 27 were experienced trainers. This resulted in a draft document that was circulated to the conference attenders and other experts for consultation.

RESULTS

Draft minimum standards were produced for all 30 items after the consensus conference with a mean of 2.5 standards for each item. Of those involved in the consultation exercise, 82% replied. Most of the revisions suggested at this stage were of a minor nature; the only major revision was to divide one item into two, resulting in a final total of 31 items. All but one of the 80 standards could be assessed by direct observation; 41 (51%) could be assessed by tutorial-based discussion and 61 (76%) by methods specific to that standard. Trainers or their practice partners were viewed as acceptable sources of evidence for all items and hospital consultants and primary health care team members were viewed as acceptable for just over half of the items.

CONCLUSION

Standards for use by trainers when providing a general practitioner report for the summative assessment of registrars have been developed by consensus conference and have been subjected to review by consultation. Acceptable methods by which registrars could be assessed against these standards, and suitable personnel who could provide evidence, have also been suggested.

Rethinking metalinguistic awareness: representing and accessing knowledge about what counts as a word

Developmentalists have argued that young children have a confused notion of the metalinguistic concept word and that they cannot focus on single word boundaries when words occur in normal syntactic/semantic frames. We challenge these assumptions and present a new technique which engages normal syntactic-semantic processing but which, once it is interrupted on-line, introduces a metalinguistic component. In three experiments, children listened to a story in which the narrator paused on open or closed class words and then asked children to repeat "the last word" or "the last thing" that she had said each time she stopped. The results show that children as young as 4 1/2-5 years treat both open and closed categories as words and clearly differentiate word and thing. We conclude by suggesting that the new technique may be useful for enhancing early reading readiness and for reassessing the relationship between literacy and metalinguistic awareness.

Freeman-Sheldon syndrome (whistling face syndrome) and cranio-vertebral junction malformation producing dysphagia and weight loss

The whistling face syndrome has been reported, with complications of the respiratory system and feeding problems due to microstomia, since 1938. Dysphagia, however, has not previously been reported as a complication of whistling face syndrome. We report a 13-year-old with the whistling face syndrome and dysphagia of late onset who has the typical whistling face, scoliosis and multiple joint contractures. Dysphagia occurred as a result of compression at the cervicomedullary junction by a cranio-vertebral junction malformation and impingement by the tip of the odontoid process. This child had undergone multiple surgical procedures for cleft palate, clubfeet, contractures of the hip and knee and scoliosis. Halo traction and posterior occipital-cervical decompression and fusion successfully treated the dysphagia.

Dizocilpine-like discriminative stimulus effects of low-affinity uncompetitive NMDA antagonists

The dizocilpine-like discriminative stimulus effects of a variety of channel blocking (uncompetitive) N-methyl-D-aspartate (NMDA) receptor antagonists were examined in rats trained to discriminate dizocilpine (0.17 mg/kg, i.p) from saline in a two-lever operant procedure. The dissociative anesthetic-type NMDA antagonists dizocilpine (ED50 0.05 mg/kg), phencyclidine (ED50 3.4 mg/kg) and ketamine (ED50 14 mg/kg) showed complete substitution without producing significant decreases in response rates, whereas dexoxadrol (ED50 4.3 mg/kg) also produced complete substitution with a concomitant decrease (35%) in response rate. Similarly, the low-affinity antagonist memantine resulted in complete substitution (ED50 9.7 mg/kg) at doses that significantly reduced (68%) the response rate. All other low-affinity antagonists resulted in either partial or no substitution for the discriminative stimulus effects of dizocilpine at doses that significantly decreased average response rates. These include (ED50 values in parentheses) remacemide (29 mg/kg), the remacemide metabolite 1,2-diphenyl-2-propylamine (ARL 12495) (14 mg/kg), phencylcyclopentylamine (25 mg/kg), dextromethorphan (46 mg/kg), (+/-)-5-aminocarbonyl-10,11-dihydro -5H-dibenzo-[a,d]cyclohepten-5,10-imine (ADCI; no substitution) and levoxadrol (no substitution). We conclude that low-affinity uncompetitive NMDA antagonists have discriminative stimulus properties distinct from dissociative anesthetic-type uncompetitive NMDA antagonists. The lowest-affinity antagonists show virtually no substitution for dizocilpine, whereas the relatively more potent low-affinity antagonists (such as memantine) exhibit greater substitution, but complete substitution is obtained only at rate-reducing doses.

The use of ultrasound-guided cutting-needle biopsy in the neck

Histological analysis of an abnormal neck mass has traditionally required an excision biopsy under general anaesthetic. We evaluated the safety and accuracy of a new spring loaded cutting-needle for obtaining tissues cores of neck masses under ultrasound (US) guidance. Sixty biopsies were performed on an outpatient basis under local anaesthesia in 52 patients referred with a neck mass. Patients ranged in age from 10 months to 89 years and masses varied in size from 5 mm to 5 cm. Fifty-eight of the 60 biopsies provided a diagnostic histological specimen. Of the remaining two patients, one required open biopsy and the other returned for a second needle biopsy. All five cases of lymphoma were correctly diagnosed on needle biopsy; in three cases full tumour sub-classification was possible but in two patients an open biopsy was subsequently required. In 49 patients the needle biopsy obviated the need for a surgical biopsy for diagnostic purposes, although in 12 cases a therapeutic excision biopsy was performed. Apart from one subclinical haematoma, visualized on US, there were no immediate or delayed complications. In all patients, the histological diagnosis was compatible with subsequent clinical, radiological, surgical or autopsy findings. Cutting-needle biopsy of neck masses under US guidance is an effective and safe procedure which should be considered before resorting to routine surgery.

The impact of knowledge of human immunodeficiency virus serostatus on contraceptive choice and repeat pregnancy

OBJECTIVE

To examine relationships among human immunodeficiency virus (HIV) serostatus, postpartum contraceptive choice, and the rate of repeat pregnancy within a short interval.

METHODS

This retrospective cohort study was performed in 83 seropositive and 218 seronegative women identified from an inner-city prenatal population undergoing routine voluntary HIV antibody screening from July 1987 through June 1989. Postpartum contraceptive choices and rate of repeat pregnancies were compared based on HIV serostatus.

RESULTS

Seropositive women were significantly more likely than seronegative women to undergo tubal sterilization (27 versus 15%; odds ratio [OR] 2.9, 95% confidence interval [CI] 1.5-5.9). This relationship persisted after controlling for age, race, marital status, and parity by logistic regression modeling (adjusted OR 2.9, 95% CI 1.4-5.9). Seropositive women were significantly less likely than seronegative women to select oral contraceptives (34 versus 68%; OR 0.2, 95% CI 0.1-0.4), a relationship that persisted after controlling for age, race, marital status, parity, and foam and condom use (adjusted OR 0.2, 95% CI 0.1-0.5). Seropositive women were significantly more likely than seronegative women to select foam and condoms as their primary method of contraception (30 versus 15%; OR 2.4, 95% CI 1.2-4.5), a relationship that did not persist after controlling for age, race, marital status, and parity (adjusted OR 0.7, 95% CI 0.4-1.3). The risk of repeat pregnancy was slightly lower in seropositive versus seronegative women (34 versus 44%; OR 0.7, 95% CI 0.4-1.3). Most repeat pregnancies among seropositive and seronegative women were unplanned (90 and 82%, respectively).

CONCLUSION

There was a relationship between the method of postpartum contraception and HIV serostatus, but no significant difference in repeat pregnancy rates associated with choice of method.

Comparability of English and Welsh doctor of medicine degrees

A comparison of the regulations required for the degree of Doctor of Medicine revealed wide variations between different universities, e.g. candidates may not receive much supervision or structured teaching. Universal reform is needed to bring this degree in line with the degree of Doctor of Philosophy.