Diagnostic accuracy and clinical management by realtime teledermatology. Results from the Northern Ireland arms of the UK Multicentre Teledermatology Trial

Diagnostic accuracy and management recommendations of realtime teledermatology consultations using low-cost telemedicine equipment were evaluated. Patients were seen by a dermatologist over a video-link and a diagnosis and treatment plan were recorded. This was followed by a face-to-face consultation on the same day to confirm the earlier diagnosis and management plan. A total of 351 patients with 427 diagnoses participated. Sixty-seven per cent of the diagnoses made over the video-link agreed with the face-to-face diagnosis. Clinical management plans were recorded for 214 patients with 252 diagnoses. For this cohort, 44% of the patients were seen by the same dermatologist at both consultations, while 56% were seen by a different dermatologist. In 64% of cases the same management plan was recommended at both consultations; a sub-optimum treatment plan was recommended in 8% of cases; and in 9% of cases the video-link management plans were judged to be inappropriate. In 20% of cases the dermatologist was unable to recommend a suitable management plan by video-link. There were significant differences in the ability to recommend an optimum management plan by video-link when a different dermatologist made the reference management plan. The results indicate that a high proportion of dermatological conditions can be successfully managed by realtime teledermatology.

Trends in the epidemiology of Candida bloodstream infections in Northern Ireland between January 1984 and December 2000

Objective: To describe the epidemiology of Candida bloodstream infections (BSI) in Northern Ireland. Methods: Retrospective collation of data relating to all clinically significant BSI in a university teaching hospital, which had been recorded prospectively, between 1984 and 2000. Results: One hundred and forty five episodes of candidaemia occurred in 144 patients (of mean age 56.6 years). The contribution of Candida spp. towards all significant BSI increased from 2.00% to 2.5%. C. albicans was the most frequently isolated species, however, its incidence fell from 70% to 53% during the study period. The greatest increase in incidence was seen with C. glabrata which was the most common non-albicans species. Twenty-nine per cent of isolates occurred in patients from an intensive care unit and, surprisingly, a further 25.5% occurred in patients from a surgical service. Conclusion: There appears to be several subtle differences in the epidemiology of candidal BSI between Northern Ireland and other countries. © 2002 The British Infection Society.

Explaining Social Class Inequalities in Smoking: The Role of Education, Self-Efficacy, and Deprivation

Rates of smoking have decreased dramatically in most Northern European countries over the last 50 years or so, but manual working class groups are substantially more likely to smoke daily than are the professional and managerial classes. This article examines three hypotheses about the processes producing these inequalities. The first argues that social class inequalities reflect differences across education groups in knowledge of the risks of smoking. The second suggests that the living conditions of lower social class groups leads to the development of lower self-efficacy and a lower propensity to quit smoking. The third states that smoking has a functional use among poorer individuals. This article draws upon data from the Republic of Ireland to assess these hypotheses. Our analysis provides some support for the first hypothesis in that education independently reduces the odds of a manual class person smoking relative to a non-manual by 12 per cent. The second hypothesis is not supported by the data. The third hypothesis gains the most support: measures of disadvantage and deprivation account for almost one-third of the class differential in smoking. The results suggest that smoking cessation policy should reflect the importance of social and economic context in quitting behaviour.

Mass-loss rates for hot luminous stars:The influence of line branching

The effect of photon frequency redistribution by line branching on mass-loss rates for hot luminous stars is investigated. Monte Carlo simulations are carried out for a range of OB star models which show that previous mass-loss calculations which neglect non-resonance line scattering overestimate mass-loss rates for luminous O stars by ~20 per cent. For luminous B stars the effect is somewhat larger, typically ~50 per cent. A Wolf-Rayet star model is used to investigate line branching in the strong wind limit. In this case the effect of line branching is much greater, giving mass-loss rates that are smaller by a factor ~3 from computations which neglect branching.

Evidence for relativistic features in the X-ray spectrum of Mrk 335

We present an analysis of hard X-ray features in the spectrum of the bright Sy 1 galaxy Mrk 335 observed by the XMM-Newton satellite. Our analysis confirms the presence of a broad, ionized Fe Ka emission line in the spectrum, first found by Gondoin et al. The broad line can be modelled successfully by relativistic accretion disc reflection models. This interpretation is unusually robust in the case of Mrk 335 because of the lack of any ionized ('warm') absorber and the absence a clear narrow core to the line. Partial covering by neutral gas cannot, however, be ruled out statistically as the origin of the broad residuals. Regardless of the underlying continuum we report, for the first time in this source, the detection of a narrow absorption feature at the rest frame energy of ~5.9 keV. If the feature is identified with a resonance absorption line of iron in a highly ionized medium, the redshift of the line corresponds to an inflow velocity of ~0.11-0.15c. We present a simple model for the inflow, accounting approximately for relativistic and radiation pressure effects, and use Monte Carlo methods to compute synthetic spectra for qualitative comparison with the data. This modelling shows that the absorption feature can plausibly be reproduced by infalling gas providing that the feature is identified with Fe xxvi. We require the inflowing gas to extend over a limited range of radii at a few tens of r to match the observed feature. The mass accretion rate in the flow corresponds to 60 per cent of the Eddington limit, in remarkable agreement with the observed rate. The narrowness of the absorption line tends to argue against a purely gravitational origin for the redshift of the line, but given the current data quality we stress that such an interpretation cannot be ruled out. © 2006 The Authors.

On the brightness distribution of type ia supernovae from violent white dwarf mergers

We investigate the brightness distribution expected for thermonuclear explosions that might result from the ignition of a detonation during the violent merger of white dwarf (WD) binaries. Violent WD mergers are a subclass of the canonical double degenerate scenario where two carbon-oxygen (CO) WDs merge when the larger WD fills its Roche lobe. Determining their brightness distribution is critical for evaluating whether such an explosion model could be responsible for a significant fraction of the observed population of Type Ia supernovae (SNe Ia). We argue that the brightness of an explosion realized via the violent merger model is mainly determined by the mass of Ni produced in the detonation of the primary COWD. To quantify this link, we use a set of sub-Chandrasekhar mass WD detonation models to derive a relationship between primary WD mass (m) and expected peak bolometric brightness (M). We use this m-M relationship to convert the masses of merging primary WDs from binary population models to a predicted distribution of explosion brightness. We also investigate the sensitivity of our results to assumptions about the conditions required to realize a detonation during violent mergers ofWDs. We find a striking similarity between the shape of our theoretical peak-magnitude distribution and that observed for SNe Ia: our model produces a M distribution that roughly covers the range and matches the shape of the one observed for SNe Ia. However, this agreement hinges on a particular phase of mass accretion during binary evolution: the primary WD gains ~0.15-0.35M? from a slightly evolved helium star companion. In our standard binary evolution model, such an accretion phase is predicted to occur for about 43 per cent of all binary systems that ultimately give rise to binary CO WD mergers. We also find that with high probability, violent WD mergers involving the most massive primaries (?1.3M?, which should produce bright SNe) have delay times ?500 Myr. © 2012 The Authors. Published by Oxford University Press on behalf of the Royal Astronomical Society.

Attitudes of consultant ophthalmologists in the UK to initial management of glaucoma patients presenting with severe visual field loss: a national survey

BACKGROUND: Recent National Institute of Clinical Excellence guidance suggests primary surgery should be offered to patients presenting with glaucoma with severe visual field loss. We undertook a survey of UK consultant ophthalmologists to determine if this represents current practice and explore attitudes towards managing patients with advanced glaucoma at presentation.

DESIGN: Questionnaire evaluation study.

PARTICIPANTS: All consultant ophthalmologists currently practicing in the UK.

METHODS: A single-page questionnaire was posted to all consultants (n = 910) currently practicing in the UK along with a pre-paid return envelope. A second questionnaire was sent to non-responders (n = 459).

MAIN OUTCOME MEASURES: Questionnaire responses.

RESULTS: 626 responses were received representing 68.8% of the population surveyed. 152 (24%) volunteered a specialist interest in glaucoma. Consensus opinion for both glaucoma specialists (64.9%) and non-glaucoma specialists (62.4%) was to start with primary medical therapy, most commonly citing surgical risk as the primary reason (23% and 22%, respectively) for this approach. Most felt the highest intraocular pressure measurement during follow up (measured in clinic) was the most important variable for prevention of further visual loss (60% of glaucoma specialists and 55% of non-glaucoma specialists). Eighty-three per cent of all responders suggested they would change their practice if evidence supporting primary surgery as a safe and more effective approach existed.

CONCLUSIONS: Recent National Institute of Clinical Excellence guidance does not reflect the current management approach of UK ophthalmologists. The primary concern was related to potential complications of surgery although most practitioners would be willing to change their practice if evidence existed supporting primary surgery in patients presenting with advanced glaucoma.

Surgical checklist for cataract surgery:progress with the initiative by the Royal College of Ophthalmologists to improve patient safety

PurposeThe World Health Organisation (WHO) identified patient safety in surgery as an important public health matter and advised the adoption of a universal peri-operative surgical checklist. An adapted version of the WHO checklist has been mandatory in the National Health Service since 2010. Wrong intraocular lens (IOL) implantation is a particular safety concern in ophthalmology. The Royal College of Ophthalmologists launched a bespoke checklist for cataract surgery in 2010 to reduce the likelihood of preventable errors. We sought to ascertain the use of checklists in cataract surgery in 2012.Patients and methodsA survey of members of the Royal College of Ophthalmologists seeking views on the use of checklists in cataract surgery. Four hundred and sixty-nine completed responses were received (18% response rate).ResultsRespondents worked in England (75%), Scotland (11%), Wales (5%), Northern Ireland (2%), the Republic of Ireland (1%), and overseas (6%). Ninety-four per cent of respondents support the use of a checklist for cataract surgery and 85% say that they always use a checklist before cataract surgery. Sixty-seven per cent of cataract surgeons stated they undertake a pre-operative team brief. Thirty-six per cent use a cataract surgery checklist developed locally, 18% use the college's bespoke cataract surgery checklist, 39% use a generic surgical checklist, and 4% reported that they do not use a checklist.ConclusionNinety-three per cent of cataract surgeons responding to the questionnaire report using a surgical checklist and 67% use a team brief. However, only 54% use a checklist, which addresses the selection of the correct intraocular implant. We recommend wider adoption of checklists, which address risks relevant to cataract surgery, in particular the possibility of selection of an incorrect IOL.Eye advance online publication, 24 May 2013; doi:10.1038/eye.2013.101.

Familial hypocalciuric hypercalcaemia as a differential diagnosis of hyperparathyroidism:studies in a large kindred and a review of surgical experience in the condition

We have studied 46 members of a large kindred with familial hypocalciuric hypercalcaemia (FHH) after a neck exploration failed to cure hypercalcaemia in an asymptomatic patient. Serum calcium, serum phosphate, plasma parathormone and vitamin D metabolites do not distinguish affected members from patients with hyperparathyroidism. Because of the continuing debate as to whether or not FHH is a variant of, or distinct from, hyperparathyroidism, we have carried out a review of surgical experience with subtotal parathyroidectomy in hyperparathyroidism secondary to parathyroid hyperplasia and in FHH. Whereas the procedure is successful in 90 per cent of the former cases only one case of FHH has been cured by it. This provides evidence for the two conditions being aetiologically distinct. Before patients with asymptomatic hypercalcaemia are referred for parathyroid surgery the calcium:creatinine clearance ratio should be measured using a 2 h urine sample collected after an overnight fast and a fasting blood sample. If this ratio is less than 0.01 then screening of first degree relations should be undertaken before any parathyroid surgery is performed. Unnecessary surgery can therefore be avoided.

A J-band detection of the sub-stellar mass donor in SDSS J1433+1011

We present time-resolved J-band spectroscopy of the short-period cataclysmic variable SDSS J143317.78+101123.3. We detect absorption lines from the sub-stellar donor star in this system, which contributes 38 +/- 5 per cent to the J-band light. From the relative strengths of the absorption lines in the J band, we estimate the spectral type of the donor star to be L2 +/- 1. These data are the first spectroscopic detection of a donor with a confirmed sub-stellar mass in a cataclysmic variable, and the spectral type is consistent with that expected from semi-empirical evolutionary models.

Using skew mapping, we have been able to derive an estimate for the radial velocity of the donor of K-d = 520 +/- 60 km/s. This value is consistent with, though much less precise than, predictions from mass determinations found via photometric fitting of the eclipse light curves.