A randomized controlled trial assessing the health economics of realtime teledermatology compared with conventional care: an urban versus rural perspective

A randomized controlled trial was carried out to measure the cost-effectiveness of realtime teledermatology compared with conventional outpatient dermatology care for patients from urban and rural areas. One urban and one rural health centre were linked to a regional hospital in Northern Ireland by ISDN at 128 kbit/s. Over two years, 274 patients required a hospital outpatient dermatology referral -126 patients (46%) were randomized to a telemedicine consultation and 148 (54%) to a conventional hospital outpatient consultation. Of those seen by telemedicine, 61% were registered with an urban practice, compared with 71% of those seen conventionally. The clinical outcomes of the two types of consultation were similar - almost half the patients were managed after a single consultation with the dermatologist. The observed marginal cost per patient of the initial realtime teledermatology consultation was f52.85 for those in urban areas and f59.93 per patient for those from rural areas. The observed marginal cost of the initial conventional consultation was f47.13 for urban patients and f48.77 for rural patients. The total observed costs of teledermatology were higher than the costs of conventional care in both urban and rural areas, mainly because of the fixed equipment costs. Sensitivity analysis using a real-world scenario showed that in urban areas the average costs of the telemedicine and conventional consultations were about equal, while in rural areas the average cost of the telemedicine consultation was less than that of the conventional consultation.

Body size and latitudinal gradients in regional diversity of New World birds

Axe latitudinal gradients in regional diversity random or biased with respect to body size? Using data for the New World avifauna, I show that the slope of the increase in regional species richness from the Arctic to the equator is not independent of body size. The increase is steepest among small and medium-sized species, and shallowest among the largest species. This is reflected in latitudinal variation in the shape of frequency distributions of body sizes in regional subsets of the New World avifauna. Because species are added disproportionately in small and medium size classes towards low latitudes, distributions become less widely spread along the body size axis than expected from the number of species. These patterns suggest an interaction between the effects of latitude and body size on species richness, implying that mechanisms which vary with both latitude and body size may be important determinants of high tropical diversity in New World birds.

Patterns and levels of endemism in the Australian Wet Tropics rainforest: evidence from flightless insects

This study examines the level and pattern of endemism among 274 flightless rainforest insects found in the Wet Tropics region of Australia. Endemism is measured at two nested scales: (1) those confined to the Wet Tropics, termed 'regional endemics'; and (2) the subset of those species confined to a single subregion of the Wet Tropics, termed 'subregional endemics'. Fifty per cent of the regional endemic flightless insects are also subregional endemics compared with 15% of the known regional endemic vertebrates. The four subregions with the most endemic flightless insect species are the uplands of Mt Finnigan, Carbine, Bellenden-Ker/Bartle Frere and Atherton. Multiple regression suggests that the combination of rainforest area and shape explain the most variance (R-2 = 0.603) in the numbers of species of regional endemic insects. However, subregional endemism is not closely correlated with the size or shape of the subregions in which they occur, or a combination of these factors. Candidate refugial and recolonised subregions are identified, and are consistent with data from palaeoclimatic models and refugia identified using other taxa. We group upland subregions into larger areas of endemism using parsimony analysis of endemism. These groupings are consistent with our understanding of the history of the Wet Tropics rainforests.

Mapping intertidal habitats and an evaluation of their conservation status in Queensland, Australia

The goal of biodiversity conservation has been described as the conservation of diversity at three levels: ecosystem, species and genetic diversity. Developing a representative system of marine protected areas (MPAs) is considered an effective way to achieve this goal in the marine environment. In the absence of detailed information relating to biological distributions there has been increasing use of biodiversity surrogates to determine MPA priorities at regional levels. The development of biodiversity surrogates at fine scales (i.e. habitats) will have an increasingly important role in the identification of sites that will contribute to a representative system of MPAs. This is because it will increase the likelihood that the system will adequately achieve biodiversity objectives by ensuring protection of a greater range of habitats and species. This article provides an explanation of an intertidal shoreline habitat surrogate used to describe 24,216km of Queensland's coastline. The protective status of intertidal habitats was evaluated to assist with designing a representative system of intertidal MPAs. (C) 2002 Elsevier Science Ltd. All rights reserved.

City profile - Colombo

Rooted in a history that dates back 1500 years, the concentration of economic activity and infrastructure in Colombo represents an extreme case of urban primacy within the national context of Sri Lanka. Located on the West Coast of the country, the Colombo metropolitan area accommodates a quarter of the country's 18.6 million population, and is the economic and political core of the country. However, Colombo is a city of extremes. Its modem and well-serviced core stands in stark contrast to the circumstances of more than half of its population, who live in poorly serviced shack and shanty settlements. The proportion of the population living in these areas continues to expand, notwithstanding a history of innovative and participatory approaches to development planning and management. Complicating these development challenges, the potential of the city is undermined by a civil war that has been under way since the early 1980s, taking an immense toll in loss of life, political polarization, and economic opportunity costs. This paper traces Colombo's historical development, provides a description of contemporary characteristics and challenges faced by the city, and examines the evolution of plans and programmes designed to improve the conditions of low-income settlements in the city. (C) 2002 Elsevier Science Ltd. All rights reserved.

Determinants of tissue Doppler measures of regional diastolic function during dobutamine stress echocardiography

Background Diastolic dysfunction induced by ischemia may alter transmitral blood flow, but this reflects global ventricular function, and pseudonormalization may occur with increased preload. Tissue Doppler may assess regional diastolic function and is relatively load-independent, but limited data exist regarding its application to stress testing. We sought to examine the stress response of regional diastolic parameters to dobutomine echocardiography (DbE). Methods Sixty-three patients underwent study with DbE: 20 with low probability of coronary artery disease (CAD) and 43 with CAD who underwent angiography. A standard DbE protocol was used, and segments were categorized as ischemic, scar, or normal. Color tissue Doppler was acquired at baseline and peak stress, and waveforms in the basal and mid segments were used to measure early filling (Em), late filling (Am), and E deceleration time. Significant CAD was defined by stenoses >50% vessel diameter. Results Diastolic parameters had limited feasibility because of merging of Em and Am waves at high heart rates and limited reproducibility. Nonetheless, compared with normal segments, segments subtended with significant stenoses showed a lower Em velocity at rest (6.2 +/- 2.6 cm/s vs 4.8 +/- 2.2 cm/s, P < .0001) and peak (7.5 +/- 4.2 cm/s vs 5.1 +/- 3.6 cm/s, P < .0001), Abnormal segments also showed a shorter E deceleration time (51 +/- 27 ms vs 41 +/- 27 ms, P = .0001) at base and peak. No changes were documented in Am. The same pattern was seen with segments identified as ischemic with wall motion score. However, in the absence of ischemia, segments of patients with left ventricular hypertrophy showed a lower Em velocity, with blunted Em responses to stress. Conclusion Regional diastolic function is sensitive to ischemia. However, a number of practical limitations limit the applicability of diastolic parameters for the quantification of stress echocardiography.

Automated regional myocardial displacement for facilitating the interpretation of dobutamine echocardiography

Quantification of stress echocardiography may overcome the training requirements and subjective nature of visual wall motion score (WMS) assessment, but quantitative approaches may be difficult to apply and require significant time for image processing. The integral of long-axis myocardial velocity is displacement, which may be represented as a color map over the left ventricular myocardium. This study was designed to explore the feasibility and accuracy of measuring long-axis myocardial displacement, derived from tissue Doppler, for the detection of coronary artery disease (CAD) during dobutamine stress echocardiography (DBE). One hundred thirty patients underwent standard DBE, including 30 patients at low risk of CAD, 30 patients with normal coronary angiography (both groups studied to define normal ranges of displacement), and 70 patients who underwent coronary angiography in whom the accuracy of normal ranges was tested. Regional myocardial displacement was obtained by analysis of color tissue Doppler apical images acquired at peak stress. Displacement was compared with WMS, and with the presence of CAD by angiography. The analysis time was 3.2 +/- 1.5 minutes per patient. Segmental displacement was correlated with wall motion (normal 7.4 +/- 3.2 mm, ischemia 5.8 +/- 4.2 mm, viability 4.6 +/- 3.0 mm, scar 4.5 +/- 3.5 mm, p <0.001). Reversal of normal base-apex displacement was an insensitive (19%) but specific (90%) marker of CAD. The sum of displacements within each vascular territory had a sensitivity and specificity of 89% and 79%, respectively, for prediction of significant CAD, compared with 86% and 78%, respectively, for WMS (p = NS). The displacements in the basal segments had a sensitivity and specificity of 83% and 78%, respectively (p = NS). Regional myocardial displacement during DBE is feasible and offers a fast and accurate method for the diagnosis of CAD. (C),2002 by Excerpta Medica, Inc.

Resources for security and stability? The politics of regional cooperation on the Mekong, 1957-2001

This article tells about the relationship between resource politics and security in international relations. Using the Mekong River Basin as its case study, the article examines the place of resource and development issues in attempts to develop regional institutions. The question of whether a resource development regime with apparently low productivity in terms of technical output, but high levels of resilience and longevity, should be considered a failure or not, is considered. This question is examined within the broader context of Southeast Asian politics during the First, Second, and Third Indochina conflicts as well as the post-cold war era. The article argues that survival and a capacity to change to meet the challenges of extreme broader events are clear evidence of regime success. From this standpoint, the article explores ways in which the Mekong resource regime is linked to more general concerns for political security and stability and may in fact reflect political concerns for subregional neighborhood maintenance.

Intrinsic regional differences in androgen receptors and dihydrotestosterone metabolism in human preadipocytes

Androgens play an important role in regulating the central obesity that is a strong risk factor for cardiovascular disease and insulin resistance. This study confirms that androgen receptors are present in subcultured human preadipocytes, with androgen receptor gene expression and saturable specific dihydrotestosterone binding, dissociation constant 1.02 - 2.56 nM and maximal binding capacity 30.8 - 55.7 fmol/mg protein. There was an intrinsic regional difference in androgen receptor complement, with more androgen receptors in visceral than in subcutaneous preadipocytes. Dihydrotestosterone was metabolised by human preadipocytes, with more androstanediol produced by subcutaneous than visceral preadipocytes. While dihydrotestosterone metabolism was insufficient to explain the regional variation in androgen binding, both of these differences would reduce the androgen responsiveness of the subcutaneous preadipocytes compared with visceral preadipocytes. There were no gender differences in androgen binding or metabolism. While the direct effects of androgens on human PAS remain uncertain, these regional differences suggest that AR-mediated regulation of certain PA functions influences adipose tissue distribution.

Differences in physical activity between black and white girls living in rural and urban areas

This study examined the relationship of race and rural/urban setting to physical, behavioral, psychosocial, and environmental factors associated with physical activity. Subjects included 1,668 eighth-grade girls from 31 middle schools: 933 from urban settings, and 735 from rural settings. Forty-six percent of urban girls and 59% of rural girls were Black. One-way and two-way ANOVAs with school as a covariate were used to analyze the data. Results indicated that most differences were associated with race rather than setting. Black girls were less active than White girls, reporting significantly fewer 30-minute blocks of both vigorous and moderate-to-vigorous physical activity. Black girls also spent more time watching television, and had higher BMIs and greater prevalence of overweight than White girls. However, enjoyment of physical education and family involvement in physical activity were greater among Black girls titan White girls. Rural White girls and urban Black girls had more favorable attitudes toward physical activity. Access to sports equipment, perceived safety of neighborhood, and physical activity self-efficacy were higher in White girls than Black girls.