The value of screening for Down's syndrome in a socioeconomically deprived area with a high ethnic population

OBJECTIVE: To assess the utility of biochemical antenatal screening for Down's syndrome in a socioeconomically deprived area with a high proportion of Asian women from the Indian Subcontinent. DESIGN: Audit of Down's syndrome biochemical screening service over a four-year period. SETTING: Teaching hospital and community antenatal clinic in inner city Birmingham. POPULATION: Women booked between October 1992 and December 1996. METHODS: Blood for screening was collected between 14 and 21 weeks gestation, alpha-fetoprotein and intact human chorionic gonadotrophin were measured in serum and the risk of Down's syndrome was calculated. MAIN OUTCOME MEASURES: Uptakes of screening and amniocentesis, screen positive rate, odds of being affected given a positive result, miscarriages associated with amniocentesis offered following a high risk result, detection rate, number of Down's cases prevented and a cost analysis. Outcome measures were compared between Asians and Caucasians. RESULTS: Overall 11,974 women (71%) accepted serum screening. The screen positive rate was 8.3% in Asians and 5.0% in Caucasians. The uptake of amniocentesis in women following a high risk result was 54% overall (35% Asian, 67% Caucasian). Nineteen cases of Down's syndrome were identified, of which 13 occurred in women who opted for biochemical screening. The detection rate of the biochemical screening programme was 85% (11/13). Of these 11 cases, six (none of whom were Asian) elected to have an amniocentesis, of whom four thereafter had a termination. CONCLUSION: In this study the public health benefits of screening for Down's syndrome in a socioeconomically deprived area with a high Asian population, were small.     

Osteoid osteoma of the proximal humerus: two misleading cases

OBJECTIVES: To investigate how often the ED ordering of stat serum calcium (Ca+2), magnesium (Mg+2), and phosphorus (PO4(-3)) levels affected clinical treatment; to define the diagnoses of patients for whom Ca+2, Mg+2, and PO4(-3) measurements did affect clinical therapy; and to suggest guidelines for more appropriate ordering of these laboratory tests. METHODS: A retrospective chart review was performed in an academic teaching hospital. All adult ED patients who had Ca+2, Mg+2, or PO4(-3) laboratory testing during the 9-month study period were included and evaluated for potential clinical impact of an abnormal Ca+2, Mg+2, or PO4(-3) laboratory test. RESULTS: 1.477 patients had Ca+2, Mg+2, or PO4(-3) measured while in the ED during the study period. Of these, 260 patients (17.6%) had a total of 312 abnormal Ca+2, Mg+2, or PO4(-3) values as defined by results exceeding +/- 15% of normal reference values. Of these, only 5 patients (0.3%) received treatment for abnormal values in the ED, while 75 patients (5.1%) were treated once admitted to the hospital. In this study, the only diagnostic groups to whom significant treatment was administered were diabetic patients (Ca+2 and PO4(-3); alcoholic patients (Mg+2); and renal failure patients (Ca+2, Mg+2, and PO4(-3). CONCLUSION: These results suggest that stat Ca+2, Mg+2, and PO4(-3) levels seldom affect clinical treatment in the ED. The frequency of ordering these tests may be reduced by obtaining Ca+2, Mg+2, or PO4(-3) measurements only for patients known to be at risk for such abnormalities, based on their existing or suspected diagnoses. The authors suggest obtaining these tests, when indicated, on a "non-stat" basis, with the subsequent laboratory results becoming available in-hospital, where treatment is more likely to occur.     

Review of patients with infective endocarditis of native valves over a five-year period

The clinical characteristics, echocardiographic features, bacteriologic data, morbidity and mortality of patients who were admitted to our hospital with infective endocarditis of their native valves over a five-year period were reviewed. There were 32 patients with a mean age of 38.2 +/- 16.2 years (range: 17 to 71 years) in our study population; 24 patients had underlying valvular abnormalities, six patients had congenital heart disease and two patients had no structural cardiac abnormality. Echocardiography was performed for all patients. Vegetations were absent in three (9.4%) patients, single in 19 (59.4%) patients and multiple in ten (31.3%) patients. Of the 24 (75%) patients who had left-sided endocarditis, mitral valve disease was the commonest valvular abnormality (16 patients). Ventricular septal defect was the commonest underlying abnormality in patients with right-sided endocarditis. Blood cultures were positive in 26 (81.3%) patients; the commonest organism was streptococcal (16 or 50% patients). Complications were present in 13 (40.6%) patients, of which eight patients had evidence of embolism, four patients had cardiac failure and one patient had a paravalvular abscess. Four (12.5%) patients died, two as a result of refractory heart failure and two as a consequence of septic embolism. Advances in medicine have resulted in a better outcome for patients with infective endocarditis, however, it remains an important disease with significant morbidity and mortality.     

Coping with serum screening for Down syndrome when the results is given as a numeric value

Forty-six pregnant women undergoing second-trimester biochemical screening for Down syndrome were asked to fill in the State-Trait Anxiety Inventory (STAI) questionnaire to assess their anxiety level at two different moments: when recruited to the study (at 11-13 weeks' gestation), and after the test result was communicated. The test result was given as a numeric value of risk (1/x), rather than as positive/negative. There were 10 women in whom the risk after biochemical screening increased (median delta risk = +1/535, range = 1/69 to 1/1083), whereas in the remainder the risk decreased (median delta risk = -1/1576; range = -1/142 to -1/4947) compared with the baseline value calculated on maternal age alone. Although only in a minority of women the STAI score after biochemical screening exceeded the reference range, the change in the STAI score was significantly higher when the risk increased, and the change in the risk estimate correlated significantly with the change in this index of anxiety. Three out of seven women with a 'negative' test, but increased risk estimate and increased anxiety after biochemical screening chose to undergo amniocentesis. A policy of providing the result of biochemical screening for Down syndrome as a numeric value, even for 'negative' tests, may cause some women to experience anxiety and request amniocentesis.     

Transrectal ultrasound in male urethritis

OBJECTIVE: To assess the prevalence of prostatic abnormalities in men with gonococcal and non-gonococcal urethritis using trans-rectal ultrasonic markers. DESIGN: A case control study of patients attending a department of genitourinary medicine with symptoms of urethritis. SETTING: Department of Genitourinary Medicine and Department of Radiology in Manchester Royal Infirmary. RESULTS: A total of 42 patients were recruited to the study: 26 with urethritis and 16 controls. Of the 26 study patients, six were gonococcal, four chlamydial, two mixed gonococcal and chlamydia and nine non specific (no organisms detected). Of the 26 study patients, 16 had abnormal scans (61.5%), eight from the chlamydia group and eight from the non specific group. No abnormalities were found in the gonococcal and mixed group. Of the 16 control patients, five had abnormal scans (31.25%), three of these have had a past history of chlamydial urethritis. CONCLUSION: The prevalence of prostatic abnormalities in patients with non-gonococcal urethritis was significantly higher when compared with controls. The cause of these abnormalities is unclear, but is compatible with inflammatory changes within the gland.     

Emergency medical care

A survey carried out over five periods between 1973 and 1975 to study the mode of referral of emergency medical patients to a district general hospital showed that, out of a total of 2511 patients, 51% referred themselves, 40-8% were referred by general practitioners, and only 4-7% by doctors employed by the emergency treatment service. Of the 1720 patients admitted to the medical wards, 50-9% were referred by general practitioners and 37-3% were self-referred while the corresponding figures for the 791 not admitted were 19% and 80-7% respectively. Two-thirds of the self-referred patients came from their own homes, usually by ambulance ordered by a "999" emergency call. The figures were similar in each of the five periods.     

Leucocyte elastase as a marker in the diagnosis of acute appendicitis

OBJECTIVE: To investigate the value of measuring the activity of the leucocyte elastase complex in plasma in the diagnosis of acute appendicitis, either as a single or four-hourly test. DESIGN: Open study. SETTING: Teaching hospital, Sweden. SUBJECTS: 165 consecutive patients admitted with suspected acute appendicitis. MAIN OUTCOME MEASURES: Correlation of concentrations of leucocyte elastase complex (elastase) and total white blood cell count (WBC) with C-reactive protein concentration and histological appearance of the appendix. RESULTS: Of 165 patients, 101 patients had their appendixes removed, and of these 86 had histologically confirmed appendicitis. An elastase value of less than 54 micrograms/l was considered to be the reference range. Elastase activity measured on admission gave a sensitivity of 61% and a specificity of 43% for acute appendicitis compared with the WBC which had a sensitivity of 81% and a specificity of 36%. The above blood tests were taken on two or more occasions four hourly after admission in 29 patients. Appendicitis was found in 25 of the 29 cases (87%), in which repeated tests showed a significant reduction in WBC together with a definite but not significant reduction in the elastase activity during the preoperative period. Repeated tests were of no value. CONCLUSIONS: Measurement of the leucocyte elastase complex in plasma does not increase the accuracy of the diagnosis of acute appendicitis. There was no significant correlation between the leucocyte elastase activity and the total white cell count.     

Significance of lymphadenectomy in renal cancer]

BACKGROUND: This study was done to determine the prevalence of folate deficiency and macrocytosis in patients admitted to the hospital medicine service with alcohol and nonalcohol-related illnesses. METHODS: Two groups of patients, with and without alcohol-related illnesses, were included. Patients were excluded if they received folate therapy, medications known to alter folate concentrations, or if they had an uncertain diagnosis. Complete blood count and erythrocyte folate concentrations were determined from each patient. A Fisher's Exact Test and odds ratio were used to determine the prevalence of macrocytosis and correlation between folate deficiency and macrocytosis in the alcoholic group, respectively. RESULTS: Of the 36 alcoholic patients, 11.1% were folate deficient, and 33.3% had macrocytosis. Only 2 of 12 patients with macrocytosis were folate deficient. No control patient had macrocytosis or folate deficiency. CONCLUSION: The prevalence of folate deficiency among patients with alcohol-related illness is low. There is no correlation detected between macrocytosis and folate deficiency. Our findings suggest that it may be inappropriate to routinely supplement all alcoholics with folic acid, but certainly a small minority may benefit from it.     

A clinical trial of a financial incentive to go to the tuberculosis clinic for isoniazid after release from jail

PURPOSE: To assess the effect of insurance status on the probability of admission and subsequent health status of patients presenting to emergency departments. SUBJECTS AND METHODS: We performed a prospective cohort study of patients with common medical problems at five urban, academic hospital emergency departments in Boston and Cambridge, Massachusetts. The outcome measure for the study was admission to the hospital from the emergency department and functional health status at baseline and follow-up. RESULTS: During a 1-month period, 2,562 patients younger than 65 years of age presented with either abdominal pain (52%), chest pain (19%) or shortness of breath (29%). Of the 1,368 patients eligible for questionnaire, 1,162 (85%) completed baseline questionnaires, and of these, 964 (83%) completed telephone follow-up interviews 10 days later. Fifteen percent of patients were uninsured and 34% were admitted to the hospital from the emergency department. Uninsured patients were significantly less likely than insured patients to be admitted, both when adjusting for urgency, chief complaint, age, gender and hospital (odds ratio = 0.5, 95% confidence interval 0.3 to 0.7), and when additionally adjusting for comorbid conditions, lack of a regular physician, income, employment status, education and race (odds ratio = 0.4, 95% confidence interval 0.2 to 0.8). However, there were no differences in adjusted functional health status between admitted and nonadmitted patients by insurance status, either at baseline or at 10-day follow-up. CONCLUSIONS: Uninsured patients with one of three common chief complaints appear to be less frequently admitted to the hospital than are insured patients, although health status does not appear to be affected. Whether these results reflect underutilization among uninsured patients or overutilization among insured patients remains to be determined.     

Extraorganic vascular system of adrenal glands in human fetuses

PURPOSE: To identify ancillary tests for which there are criteria defining the earliest interval at which a repeat test might be indicated, to determine how often each test is repeated earlier than these intervals and, if repeated, provides useful information. SUBJECTS AND METHODS: We performed a retrospective cohort study of 6,007 adults discharged from a large teaching hospital during a 3-month period in 1991. We measured the proportion of commonly performed diagnostic tests that were redundant, and their associated charges. RESULTS: Of the 6,007 patients discharged, 5,289 (88%) had at least one of 12 target tests performed. Overall, 78,798 of the target tests were performed during the study period, of which 22,237 (28%) were repeated earlier than test-specific predefined intervals. This percentage varied substantially by test (range, 2% to 62%). To assess how many early repeats were justified, we performed chart reviews in a random sample stratified by test. For two tests, nearly all the initial results in the sample were abnormal, and all repeats were considered justified. Of early repeats following a normal initial result for the remaining 10 tests, chart review found no clinical indication for 92%, and a weighted mean of 40% appeared redundant. Overall, 8.6% of these 10 tests appeared redundant; if these were not performed, the annual charge reductions would be $930,000 at our hospital, although the impact on costs would be much smaller. CONCLUSIONS: For some tests, an important proportion are repeated too early to provide useful clinical information. Most such tests might be eliminated using computerized reminder systems.     

Economic effects of community versus hospital-based faculty pneumonia care

To compare the length of stay and charges for patients with pneumonia admitted in 1995 to the teaching and nonteaching services of a Northeastern teaching hospital, we reviewed the charts of 237 patients. Patients cared for by hospital-based generalists working with housestaff (teaching service) were discharged more quickly and with lower or equivalent charges than patients cared for by community-based attending physicians working either with housestaff (private teaching service) or alone (nonteaching service). Academic teaching services staffed by general medicine faculty may provide efficient inpatient pneumonia care.     

Hypothyroidism and hyperthyroidism in major depression revisited

BACKGROUND: The aim of our study was to evaluate the prevalence of thyroid abnormalities among depressed outpatients and to examine the response to treatment of those subjects with relatively low or high thyroid hormone levels. METHOD: Outpatients (N = 200) 18 to 65 years of age who met DSM-III-R criteria for major depression were screened for the presence of thyroid abnormalities using a number of thyroid indices. Of these patients, 166 were then treated openly with the antidepressant fluoxetine for 12 weeks. We assessed whether patients with relatively low or high thyroid hormone levels had a different response to treatment compared with other patients. The 17-item Hamilton Rating Scale for Depression (HAM-D-17) was administered during the study to assess changes in depressive symptoms. Thyroid function was assessed by measuring T3, T4, free T4 index (FT4I), T3 uptake (T3U), and serum thyroid-stimulating hormone (TSH) levels. RESULTS: No clinical cases of hyperthyroidism or hypothyroidism were detected. Of the patients examined, 5 (2.6%) had slightly elevated TSH levels (range, 4.7-8.2); none of these had T4 or FT4I levels below the normal range. Subnormal levels of T4 or FT4I were found in 1 subject (0.5%). T3 and T3U levels were below the normal range in a larger number of patients (7.6% and 15.0% respectively), but only 1 of these patients had elevated TSH levels. None of the patients had levels of TSH below the normal range, and only 3 subjects (1.5%) had T4 levels above the normal range. No relationship was found between response rate (assessed as either change in HAM-D-17 score or as remission of depressive symptoms with a HAM-D-17 score < or = 7 for 3 consecutive weeks) and each of the thyroid tests, even after adjusting for baseline severity of depression. CONCLUSION: In depressed outpatients, it appears that hypothyroidism and hyperthyroidism are extremely uncommon and that the presence of subtle thyroid function abnormalities does not have an impact on treatment outcome.     

Long-term sequelae of pneumococcal meningitis in children

The purpose of this study was to assess the long-term effects of pneumococcal meningitis in children. From 1967 to 1988, a total of 90 children were admitted to the Hospital for Infectious Diseases, Thessaloniki, Greece, with the diagnosis of pneumococcal meningitis. Sixteen patients died in the hospital as a direct result of meningitis. Eleven others were excluded from the study (neurologic deficits prior to onset of meningitis, two; death subsequent to hospitalization, two; recurrent meningitis, seven). Of the remaining 63 survivors, we were able to evaluate 47 patients (75%). Evaluation was performed 4 to 23 years (mean 12.3 +/- 5.8 years) after discharge. Forty patients returned to hospital for evaluation, and seven were evaluated by their primary physicians, who sent information by a standardized questionnaire. The following examinations were carried out: history, physical and neurologic examination, ophthalmologic and hearing evaluation, and psychometric testing. Fourteen patients (30%) had at least one neurologic handicap; nine (19%) had mental retardation, eight (17%) hearing loss, seven (15%) seizure disorder, five (11%) motor defects, and one each (2%) behavioral problems and visual impairment. The presence of coma was the strongest predictor of increased morbidity. The high frequency of long-term sequelae observed in our study supports the need of an effective vaccine.     

Electrical injury and the frequency of cardiac complications

A retrospective review of the patients with electrical injuries admitted over a 5-year period was performed to establish the frequency of cardiac complications. There were 145 admissions during this time. A total of 128 (88 per cent) were low voltage injuries and 17 (12 per cent) were high voltage (> 1000 V) injuries. Of the 145 admissions, 104 (72 per cent) had a 12-lead electrocardiogram (ECG) recorded within 24 h of their injury. Of these patients, 73 (75 per cent) were then observed on a cardiac monitor for at least 24 h post-injury. Cardiac abnormalities were noted in four patients (3 per cent) during this period. Three patients had occasional ectopic beats which settled spontaneously over a 24 h period post-injury. The fourth patient developed atrial fibrillation (AF) after a high voltage injury which resolved following intravenous digoxin. Cardiac complications were more frequent in those who had experienced a loss of consciousness at the time of injury and in those who suffered a high voltage electrical injury. All of the patients with cardiac complications had these at the time of admission to hospital. This suggests that if there is no history of a loss of consciousness and the 12-lead ECG recorded on attendance at the hospital is normal, it is unlikely that the patient will go on to develop cardiac problems.     

Weighing the risks and benefits of an oral cancer screening

The study into the causes underlying nonspecific lymphadenitis (NSL) and adenophlegmons of the maxillofacial region and the neck (AF) revealed a great variety of etiological factors and primary infectious foci in these diseases. Of 204 children admitted to hospital of the city of Derbent, odontogenic genesis of the disease was determined in 27.45% of cases; dermatogenic, stomatogenic in 23.04 and 12.74% of cases, respectively. ENT and systemic diseases were responsible for NSL and AF in 13.23 and 3.43% of cases. The cause remained unclear in 20.09% of patients. NSL and AF occurred most frequently in the coldest (January, February) and the hottest (July, August) months of the year.     

Clonidine and vasomotion physiology

BACKGROUND: Serological rapid whole-blood tests for the detection of H. pylori are presently being promoted for use in primary care. We conducted a multi-center study to investigate the diagnostic accuracy of the Boehringer Mannheim Helicobacter pylori test (BM test), which is identical with the Cortecs Helisal test. PATIENTS AND METHODS: A previous diagnosis of H. pylori, a history of peptic ulcer diseases, or proton-pump inhibitor, bismuth or antibiotic use during the preceding month were exclusion criteria. The BM test was performed prior to endoscopy by 7 primary care physicians, 5 practicing gastroenterologists, or a single physician in the university hospital outpatient service. During endoscopy, antral and corpus biopsies were obtained for histology and rapid urease testing (RUT). H. pylori positivity was defined by histology and/or RUT as reference methods. H. pylori IgG-ELISA was performed additionally. RESULTS: Of the 203 patients included, 151 were H. pylori-positive by reference methods (74.4%). The overall accuracy of the BM test was 77.3%. Eight BM tests were indeterminate, and in the other 195 patients the test performed as follows: sensitivity 80.3%, specificity 81.3%, positive predictive value 92.9%, negative predictive value 57.4%. Using IgG-ELISA as reference, the BM test performance was similar. It also did not differ substantially among the three groups of physicians involved. CONCLUSIONS: We found the performance of the BM test to be insufficiently accurate, as both over- and underdiagnosis of H. pylori infection were not infrequent. This test needs to be improved before its use in primary care can be recommended.     

Fatality outside hospital from acute coronary events in three British health districts, 1994-5. United Kingdom Heart Attack Study Collaborative Group

OBJECTIVES: To provide a contemporary account of the treatment and outcomes of acute coronary attacks in England and Wales and to identify strategies that might improve the outcome. DESIGN: Two year community and hospital based study in three British health districts. SETTING: Health districts of Brighton (population 282,000), South Glamorgan (408,000), and York (264,000). SUBJECTS: 3523 men and women under 75 years of age who died outside hospital from acute coronary causes, who were admitted to hospital with acute myocardial infarction, or who developed acute infarction or died unexpectedly from acute coronary causes while they were already in hospital. INTERVENTIONS: Attempted resuscitation in people having a cardiac arrest outside hospital. MAIN OUTCOME MEASURES: Total case fatality, case fatality outside and inside hospital, and the effect of resuscitation on case fatality outside hospital. RESULTS: 1589 patients died within 30 days of the acute event. Case fatality was 45% (95% confidence interval 43% to 47%), rising from 27% (160/595) (23% to 31%) at age < 55 years to 53% (1019/1916) (51% to 55%) at 65-74 years. Overall, 74% (1172/1589) (72% to 76%) of fatal events happened outside hospital, and there was a negative age gradient (P < 0.001) such that 91% (145/160) (87% to 95%) of fatalities occurred outside hospital at age < 55 compared with 70% (710/1019) (67% to 73%) at 65-74 years. Without successful resuscitation of 55 patients outside hospital, total case fatality at 30 days would have risen from 45% to 46.7%. CONCLUSION: Opportunities for reducing fatality from acute coronary attacks lie mainly outside hospital. These results and others imply that survival from cardiac arrest outside hospital might be trebled by improved ambulance and patient response. Proper application of secondary preventive measures for patients with coronary disease could have an even larger impact.     

Radiographic patterns and associations of osteoarthritis of the knee in patients referred to hospital

OBJECTIVES: To investigate differing patterns and associations of osteoarthritis of the knee in patients referred to hospital. METHODS: Two hundred and fifty two consecutive patients (161 women, 91 men; mean age 70 years, range 34-91 years) referred to hospital with osteoarthritis of the knee underwent clinical, radiographic, and synovial fluid screening. RESULTS: Radiographic changes of osteoarthritis of the knee (definite narrowing with or without osteoarthritic features) were bilateral in 85% of patients. Of 470 knees affected, 277 (59%) were affected in two compartments and 28 (6%) in three compartments. Unilateral and isolated medial tibiofemoral osteoarthritis were more common in men. Calcium pyrophosphate crystal deposition was common (synovial fluid identification in 132 (28%) knees; knee chondrocalcinosis in 76 (30%) patients) and associated with disability, bilateral, multicompartmental and severe radiographic osteoarthritis, marked osteophytosis, attrition, and cysts. Multiple clinical nodes (58 (23%) patients) and radiographic polyarticular interphalangeal osteoarthritis (66 (26%) patients) were associated with a higher frequency of inactivity pain, disability, multicompartmental and severe radiographic change. Forestier's disease predominated in men but showed no other associations. CONCLUSIONS: In a group of patients referred to hospital osteoarthritis of the knee is usually bilateral and affects more than one compartment. Severe and multicompartmental radiographic changes are associated with calcium pyrophosphate crystal deposition, nodal change, and polyarticular interphalangeal osteoarthritis.