Observer variability among colposcopists from the West Midlands region

OBJECTIVE: To assess variation in diagnoses and management decisions among colposcopists when presented with cervical images; to see the impact of the referral cytology report on diagnostic accuracy. DESIGN: A two-part video questionnaire study. PARTICIPANTS: Colposcopists from West Midlands Region. METHODS: Twenty cervical images displaying a range of transformation zones from normal through varying abnormalities up to cervical intraepithelial neoplasia (CIN) grade 3 were shown on video tape together with basic patient information. Two sets of videos were made, the second being identical to the first other than including the referral cytology. Participants recorded their diagnoses and management decisions on prepared questionnaires. The two sets of videos were viewed several weeks apart. RESULTS: Completed questionnaires to both videos were received from 30 colposcopists. Diagnostic accuracy improved with knowledge of the cervical cytology result in cases of CIN 2/3 (chi 2 = 19.45, P < 0.0001) but not where the histology was CIN 1 or less (chi 2 = 2.64, P = 0.10). Overall interobserver agreement improved slightly from kappa = 0.169 to kappa = 0.212 when the cytology was revealed. While only 2.6% of cases of CIN 2/3 would have been under-managed after the second questionnaire, 37.5% cases where the abnormality did not amount to CIN would have been overtreated. CONCLUSION: There is considerable inter-observer variability and variation in diagnostic accuracy in scoring cervical images particularly at the lower end of the spectrum of abnormality which has the potential to lead to over-treatment. We rely considerably on the cervical cytology result in forming a diagnosis. We recommend that a see-and-treat approach be abandoned when the referral smear shows minor abnormalities. The study has implications for both training and audit in colposcopy.     

An epidemiological study of acute carbon monoxide poisoning in the West Midlands

OBJECTIVES: To describe the epidemiology of carbon monoxide (CO) poisoning in a defined population, identifying those at greatest risk from acute poisoning resulting in admission to hospital or death. METHODS: A retrospective study with routinely collected information, set in the former West Midlands Regional Health Authority; population of 5.2 million. The data comprised 939 deaths and 701 hospital admissions due to CO poisoning between January 1988 to December 1994. The main outcome measures were age and sex standardised incidence rates (SIRs) for non-intentional, suicidal, and undetermined poisonings for health authorities and the linear relation with socioeconomic deprivation. RESULTS: Overall rate of non-intentional poisonings over the 7 year period was 7.6/100,000, an annual rate of 1.1/100,000. The 7 year rates were highest in people > or = 85; men 24.0/100,000 and women 19.7/100,000. For suicides the 7 year rate was 19.6/100,000, an annual rate of 2.8/100,000. The 7 year rates were highest for men of 35-39, 64.1/100,000, and for women aged 45-49, 15.3/100,000. None of the causes of poisoning were related to deprivation. Non-intentional poisonings showed a strong seasonal variation with the highest rates being recorded in the months October to March. Increased rates of poisoning were found in the rural districts of the West Midlands. There seems to have been a decline in suicides coinciding with the introduction of three way catalytic converters on cars. CONCLUSIONS: Elderly people and the very young are at the greatest risk from non-intentional CO poisoning and rates are highest in the winter months. Although deaths from non-intentional CO poisoning are declining nationally, in the West Midlands they have remained stable and hospital admissions are increasing. It is not solely an urban phenomenon with rates for non-intentional CO poisoning and suicides higher in the rural districts. Health authorities need to consider all populations in any prevention programme. Further work is needed to establish the extent of the burden of chronic CO poisoning and the impact of catalytic converters on suicides.     

A survey of respiratory and dermatological disease in the chrome plating industry in the West Midlands, UK

OBJECTIVE: To determine whether the clinical use of 5-fluorouracil (5-FU) may have any toxic effects on trabecular meshwork cells. METHODS: Bovine trabecular meshwork (BTM) cells were cultured in vitro. The effects of 5-FU on BTM cells concerning cellular morphology, ultrastructure, vitality and phagocytosis were observed. RESULT: The safe dosage of 5-FU on BTM cell was 1 x 10-6g.ml-1. CONCLUSION: Based on the pharmacokinetic data in the rabbit anterior chamber, it is suggested that the 5-FU dosage of conventional use cause no injury to human trabecular meshwork cells.     

West Midlands regional training scheme for orthodontics in dental practice

The need for continuing education in orthodontics is recognised by many practitioners and the demand for post-graduate courses is high. The limitations of such courses, particularly the short technique type, are recognised and within the West Midlands the value of a longer term clinical attachment has been emphasised. The West Midlands has a well established orthodontic consultant service with fifteen NHS and one honorary consultant; the specialist practitioner service is small by national standards. All of the orthodontic consultants have long supported the clinical assistant post as a valuable vehicle for practitioners' continuing education. Building on the example given by the consultants in the four Thames Regions, a structured, centralised academic programme has been developed to enhance the clinical training given during these two year posts.     

A large outbreak of Q fever in the West Midlands: windborne spread into a metropolitan area?

OBJECTIVE: To compare the effect of a gonadotropin releasing hormone (GnRH) analog plus 'add-back' oral contraceptive (OC) therapy with OC therapy alone on the clinical and hormonal parameters that are characteristic of polycystic ovary syndrome (PCOS). DESIGN: Prospective, randomized study. SUBJECTS: Thirty PCOS patients were randomly assigned to treatment with leuprolide acetate for depot suspension plus a combined monophasic OC (Group I) or to OC alone (Group II). METHODS: Hormonal (luteinizing hormone (LH), follicle stimulating hormone (FSH), LH : FSH concentration ratio, estradiol, androstenedione, testosterone), clinical (Ferriman-Gallwey score), ultrasonographic (ovarian volume, number of subcapsular follicles, stromal score) and Doppler (uterine artery and ovarian intraparenchymal vessels' pulsatility index, ovarian stromal vascularization) parameters were evaluated during 6 months' therapy and 6 months' follow-up. RESULTS: Significant changes in all the parameters analyzed occurred as a result of therapy and the changes were more marked in the group undergoing treatment with GnRH analog plus OC. CONCLUSIONS: GnRH analog plus OC use has a more rapid and marked effect on the hormonal milieu as well as the ovarian architecture and vascularization in patients with PCOS than OC used alone. The former treatment may be a more efficient therapy for PCOS.     

Cancer and congenital abnormalities in Asian children: a population-based study from the West Midlands

Cancer and associated congenital abnormalities were investigated in Muslim and non-Muslim Asian children from the West Midlands. Cancer incidence rates were calculated for Indian (non-Muslim), Pakistani/Bangladeshi (Muslim) and white children diagnosed from 1978 to 1992. Incidence was significantly higher in the Pakistanis, with an age-standardised rate (ASR) of 163 cases per million per year, compared with 115 for Indian and 125 for white children. Among Asian cancer patients, congenital malformations were significantly more common in Muslim (21%) compared with non-Muslim (7%). In Muslims the malformation excess was caused by autosomal recessive and dominant disorders (in 8% and 5% of cases respectively). Cancer malformation/predisposition syndromes were found in 10% of Muslims, compared with 2% of non-Muslims. In 33% of the Muslims with malformations, childhood cancer and a malformation were also present in a close relative. None of the non-Muslims with malformations had a relative with childhood cancer. The cancer excess in Muslims may be partly related to inherited genes causing both malformations and cancer. The prevalence of autosomal recessive disorders may be related to consanguinity, which is common in the Pakistani Muslim population. The high incidence of autosomal dominant disorders may be related to older paternal age at conception, giving rise to spontaneous mutations.     

Temporal distribution of rotavirus G-serotypes in the West Midlands region of the United Kingdom, 1983-1994

In memoriam Professor Hugo Adrian, born 1926, deceased 1994, in Santiago, Chile. After completion of his studies in veterinary medicine, he followed a successful career in neurophysiological research. He was Research Associate (1961-1962) and Visiting Professor (1973-1976) at the Neurophysiology Department University of Wisconsin, USA. He was the first Director (1958-1960) of the Institute of Physiology at the Austral University, Valdivia, and was Professor (1963-1973; 1977-1994) and Chairman of the Department of Physiology and Biophysics, University of Chile, Santiago, Chile, where he led a group of researchers in auditory physiology, introduced the use of computer techniques to physiological studies, and developed several projects of applied neurophysiology.     

Audit of HIV RNA quantitation measurements in the West Midlands: a preliminary report. Collaborating HIV Physicians

Many deaths and disabling sequelae in children following poisoning could be prevented if more attention were given to implementing preventive measures at home. Medications and chemicals should always be safely packed and stored. Education on which products are highly dangerous and the giving of precautionary advice to parents would also help to reduce the incidence of childhood poisoning. In Hong Kong, imported vegetables (contaminated by methamidophos) and coral reef fish (containing ciguatoxins) cause poisoning in both children and adults. Advice on preventive measures should be given to the public.     

Genetic variation in the east Midlands

According to history, the population of the British Isles derives its genepool from a succession of invaders and immigrants. The settlement pattern of these invaders gave rise to a patchwork of genepools, shown in previous genetic surveys. Specimens from 1117 blood donors of regionally subdivided East Midlands (Derbyshire, Nottinghamshire and Leicestershire) were analysed for 18 conventional genetic systems (blood groups, serum proteins and red cell enzymes), according to place of residence. Significant differences exist among the five geographically defined sub-populations, and it is argued that these are derived from the historical settlement of continental European populations in the region, especially the Danes and the Vikings.     

Married women doctors'' training and re-employment schemes in the West Midlands Region, with particular reference to psychiatry

A 39-year-old woman with right ovarian vein syndrome accompanied by contralateral ovarian cyst is reported. Removal of the left ovarian cyst with right ureterolysis for removal of the mechanical obstruction gave a good result. It is concluded that the etiology in this case was compression of the ureter by the enlarged ovarian vein, which had an increased blood flow from contralateral venous anastomose.     

A comparison of pulmonary function in male smokers and nonsmokers

Results of certain tests of pulmonary function, including a questionnaire, single-breath N2 test of closing capacity, forced expiration, and diffusing capacity were significantly different in groups of male smokers and nonsmokers. The influence of age on these smoking-related changes of pulmonary function was evaluated. The analyses indicated that (1) some tests including number of symptoms; closing capacity, i.e., closing volume plus residual volume as a percentage of total lung capacity; residual volume as a percentage of total lung capacity; Phase III of the single-breath N2 test, and steady-state diffusing capacity (ml of CO/mm Hg - min) revealed significant differences between adjusted mean smoker and nonsmoker values but did not reveal differences associated with age. (2) Tests of forced expiration (1-sec forced expiratory volume/vital capapity, reciprocal of the maximal mid-expiratory flow, maximal flow at 50 per cent of vital capacity; and moments) however, revealed differences between smoker and nonsmoker means )adjusted and unadjusted), as well as increasing smoker-nonsmoker differences with increasing age. It is suggested that the first group of tests probably measured an all-or-none response that occurred with the onset of smoking and was not affected by duration of smoking. The second group of tests probably measured the effects of continued smoking and indicated increasing abnormality associated with longer exposure (years of smoking). Test showing age-related differences between smokers and nonsmokers may reflect cummulative, irreversible changes in pulmonary function to a greater extent than test that do not.     

A longitudinal study of pulmonary function in Danish patients with systemic sclerosis

Allergen-specific lymphocyte proliferation was measured by flow cytometry in 16 children with atopic dermatitis (AD). 26 with bronchial asthma (BA) and 13 non-atopic controls. Although the level of mite-S.I.F. (stimulation index measured by flow cytometry) in the younger AD children (2-7 y) was significantly higher than that in the non-atopic subjects (189.6 +/- 70.7 vs 113.9 +/- 11.0, p < 0.02), there was no elevation in the younger BA children (122.6 +/- 23.4). It is therefore likely that the elevated mite-S.I.F. level is related to the development of the allergic cellular inflammation representing the pathology of AD, rather than the IgE-mediated allergic reaction as a mechanism of childhood BA. Because the level of mite-specific IgE antibody in the younger BA children is elevated (93.6 +/- 41.2 PRU/ml), the result also indicates that mite-specific peripheral T lymphocytes do not play a critical role in stimulating the mite-specific IgE synthesis. On the contrary, the older BA children (8-15 y) showed an elevated mite-S.I.F. level (176.0 +/- 54.6) significantly higher than that in the non-atopic subjects (114.6 +/- 13.9, p < 0.05) as well as that in the younger BA children (p < 0.05). Because other investigators have reported that the level of mite-specific lymphocyte proliferation is increased in the adult BA patients, the transition from childhood BA to adult-type BA may start at the age of about 8 y.     

Marked pulmonary function abnormalities in a case of HIV-associated pulmonary hypertension

Recent reports have suggested an association between primary pulmonary hypertension and human immunodeficiency virus (HIV) infection. This appears to be an accelerated syndrome, associated with a relatively brief duration of symptoms, yet prominent right ventricular failure and severe pulmonary hypertension on presentation. We present a case of a primary pulmonary hypertension in a 35-year-old HIV-seropositive hemophiliac. His accelerated clinical course is consistent with previously reported cases of HIV-related pulmonary hypertension. However, this patient's pulmonary function tests revealed marked hyperinflation, a decreased diffusing capacity, and no airflow obstruction. To our knowledge, this very usual constellation of pulmonary function changes has not been described previously in this syndrome.     

A survey of nucleic acid services in core laboratories

Core facility services related to DNA synthesis and sequencing were surveyed by the Association of Biomolecular Resource Facilities. Responses from 85 facilities offering DNA synthesis and 37 facilities offering DNA sequencing were obtained. Data on instrumentation, volume, number of users, cost, methodology and a number of other criteria were obtained. The volume of work performed by these centralized core facilities was quite substantial (combined synthesis output of 4 million bases per year and a combined sequencing output of 35 million bases per year). The large number of users supported by these facilities and the high sample throughput make these core resource facilities good indicators of technological trends.     

Regional pulmonary function in scimitar syndrome

Analysis of regional pulmonary function distribution using radioactive 133xenon gas and eight scintillation detectors was performed in a patient with scimitar syndrome. Zonal ventilation per unit of lung volume within the slightly hypoplastic right lung was normal. The pulmonary blood flow to the lower right zone was significantly reduced due to aberrant systemic arterial supply to the right lower lobe. The 133xenon technique provides a simple nontraumatic method of evaluating the functional integrity of the right lung in this cardiopulmonary syndrome.     

Home monitoring of pulmonary function

The use of healthcare technology in homes is increasing. This article details an electronic home spirometry unit used by lung transplant patients. The unit can also be used with other populations including persons with asthma or cystic fibrosis, or persons awaiting transplants. Home health nurses are in a prime position to assist patients in using technology that provides direction for the treatment regimen.     

Milrinone improves pulmonary hemodynamics and right ventricular function in chronic pulmonary hypertension

BACKGROUND: Right ventricular failure after cardiac transplantation is commonly related to preexisting recipient pulmonary hypertension. This study was designed to investigate the effects of intravenous milrinone on pulmonary hemodynamic indices and right ventricular function in a canine model of monocrotaline pyrrole-induced chronic pulmonary hypertension. METHODS: Eight mongrel dogs underwent pulmonary artery catheterization to measure right-sided hemodynamic indices before and 6 weeks after a right atrial injection of monocrotaline pyrrole. Six weeks after injection, all hearts were instrumented with a pulmonary artery flow probe, ultrasonic dimension transducers, and micromanometers. Data were collected at baseline and after milrinone infusion. RESULTS: Six weeks after monocrotaline pyrrole injection, significant increases in the pulmonary artery pressure and pulmonary vascular resistance were observed. Milrinone led to significant increases in right ventricular function as well as significant improvements in pulmonary vascular resistance, pulmonary blood flow, and left ventricular filling. CONCLUSIONS: This investigation demonstrates the well-known hemodynamic and inotropic effects of milrinone which, in the setting of monocrotaline pyrrole-induced pulmonary hypertension, were also associated with significant increases in pulmonary blood flow and left ventricular filling.     

Organization of laboratories in the German Democratic Republic

The effectivity of the clinical medicine becomes increasingly dependent on the efficiency of medico-experimental subjects, to which belong pathological chemistry and clinical biochemistry as well as haematology. The scientifically proved increasing demands made on the laboratories concern the quality of the results of investigations, constantly increasing numbers of investigations as well as a considerable enlargement of the investigation programmes. Adequate developments of workman are not to be expected. The requirements are to be met by the increase of the working productivity, for which a good organisation of work the use of mechanisation and automatisation means for the elaboration of large series of investigations are the prerequisite. A high degree of centralisation ascertains the effectivity of the adequate investments. Exceeding the ascertained foundations for a project of organisation of the laboratory work in the GDR in the next time still various problems must be solved which especially influence the organisation. Among others they concern the necessary investigation programme for the general practitioner in an out-patient practice, moreover the establishment of investigation programmes for several levels of care, the necessary quality (precision and exactness) of the results of investigations, the suitableness of stripe tests and the influence of preanalytic factors and especially of the biorhythmics on the findings of investigations. The tendencies described are accompanied by the danger that the reciprocities between clinic and laboratory becoming increasingly more necessary for the interpretation and classification of laboratory findings into the symptom complex become rather loose. Therefore, it will be one of the most important tasks of future to develop together reorganisation and collaboration.