Open access gastroscopy--3 year experience of a new service

We have audited the first 3 yr of a new open access gastroscopy service in the Royal Victoria Hospital, Belfast to assess service demands, patient demography and diagnostic trends. Over 3 yr there were 1872 referrals (800 from fundholding general practitioners), 8.8 per cent were non attenders and 5.4 per cent cancelled appointments. Endoscopic diagnostic categories showed no significant change over the 3 yr, 39 per cent non ulcer dyspepsia, 35 per cent gastro-oesophageal reflux disease (GORD), 17 per cent peptic ulcer disease (PUD), 6 per cent GORD and PUD, 1 per cent gastric erosions and 0.8 per cent carcinoma.

Detection of undiagnosed coeliac disease with atypical features using antireticulin and antigliadin antibodies

Eighteen patients with a variety of non-gastrointestinal symptoms were incidentally found to have circulating antireticulin antibody and on subsequent testing were also positive for antigliadin antibody. They prospectively underwent jejunal biopsy to determine whether or not they had coeliac disease. Their age range was 21-79 years (mean 42 years). Enteropathy was present in 13 (72 per cent) and was always associated with circulating IgA antigliadin antibody. Enteropathy was not present in the five cases who had only IgG antibody. Clinical improvement occurred in eight of 11 patients who complied with a gluten-free diet and was paralleled by an improvement in the mucosal histology in seven of eight who were re-biopsied. The most remarkable cases were two patients who presented with severe debility and no apparent haematological or biochemical abnormalities, and who subsequently made a dramatic recovery on a gluten-free diet. It is concluded that antireticulin antibody detected by routine autoantibody screening and confirmed to have IgA antigliadin antibody specificity is a useful indicator of an otherwise undiagnosed enteropathy. This serves to emphasize that the condition can sometimes be associated with atypical features and significant morbidity.

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.

Comparison of teleconsultations and face-to-face consultations:preliminary results of a United Kingdom multicentre teledermatology study

The objective of this multicentre study was to undertake a systematic comparison of face-to-face consultations and teleconsultations performed using low-cost videoconferencing equipment. One hundred and twenty-six patients were enrolled by their general practitioners across three sites. Each patient underwent a teleconsultation with a distant dermatologist followed by a traditional face-to-face consultation with a dermatologist. The main outcome measures were diagnostic concordance rates, management plans and patient and doctor satisfaction. One hundred and fifty-five diagnoses were identified by the face-to-face consultations from the sample of 126 patients. Identical diagnoses were recorded from both types of consultation in 59% of cases. Teledermatology consultations missed a secondary diagnosis in 6% of cases and were unable to make a useful diagnosis in 11% of cases. Wrong diagnoses were made by the teledermatologist in 4% of cases. Dermatologists were able to make a definitive diagnosis by face-to-face consultations in significantly more cases than by teleconsultations (P = 0.001). Where both types of consultation resulted in a single diagnosis there was a high level of agreement (kappa = 0.96, lower 95% confidence limit 0.91-1.00). Overall follow-up rates from both types of consultation were almost identical. Fifty per cent of patients seen could have been managed using a single videoconferenced teleconsultation without any requirement for further specialist intervention. Patients reported high levels of satisfaction with the teleconsultations. General practitioners reported that 75% of the teleconsultations were of educational benefit. This study illustrates the potential of telemedicine to diagnose and manage dermatology cases referred from primary care. Once the problem of image quality has been addressed, further studies will be required to investigate the cost-effectiveness of a teledermatology service and the potential consequences for the provision of dermatological services in the U.K.

Primary dermatological care in general practice

Out of 2,409 clinical cases analysed over an eight-week period, 199 (8.2 per cent) were of a dermatological nature. Atopic eczema, warts, seborrhoeic eczema and acne vulgaris were encountered most frequently. The reaction to a skin clinic in the general practice, with access to liquid nitrogen, electrocautery and histopathology is described. Treatment of patients is summarized. It is suggested that having a practice skin clinic reduces the rate of hospital referrals by two thirds.

Child Welfare as Child Protection Then and Now: What Social Workers Did and Continue to Do

The research reported here builds on the work of one of the authors who, some thirteen years ago, in a similar study, examined the potential for social workers to shift from a child protection to a child welfare practice orientation. As with the original research study, this present project seeks to examine the everyday practices of social workers with children and families as revealed by file analysis, vignette questionnaires (reported here) and interviews with families and social workers (to be reported). A twenty-item vignette questionnaire was completed by fifty-five social workers (65.5 per cent response rate). It was found that there was little agreement on coding decisions with regard to which cases should be designated child protection or child welfare. Further analysis revealed that, regardless of such coding decisions, families tended to receive similar responses by social workers. The results demonstrate that, whilst there has been a reduction in the headline numbers of child protection investigations undertaken across Health and Social Care Trusts in Northern Ireland, the everyday patterns of practice with families and children where parenting concerns remain evident reflect child protection risk management priorities and practices. 

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.

Zoonotic helminth infections with particular emphasis on fasciolosis and other trematodiases

Zoonotic infections are among the most common on earth and are responsible for >60 per cent of all human infectious diseases. Some of the most important and well-known human zoonoses are caused by worm or helminth parasites, including species of nematodes (trichinellosis), cestodes (cysticercosis, echinococcosis) and trematodes (schistosomiasis). However, along with social, epidemiological and environmental changes, together with improvements in our ability to diagnose helminth infections, several neglected parasite species are now fast-becoming recognized as important zoonotic diseases of humans, e.g. anasakiasis, several fish-borne trematodiasis and fasciolosis. In the present review, we discuss the current disease status of these primary helminth zoonotic infections with particular emphasis on their diagnosis and control. Advances in molecular biology, proteomics and the release of helminth genome-sequencing project data are revolutionizing parasitology research. The use of these powerful experimental approaches, and their potential benefits to helminth biology are also discussed in relation to the future control of helminth infections of animals and humans.

Low Pay, In-Work Poverty and Economic Vulnerability: A Comparative Aanalysis Using EU-SILC

We explore the potential of data from EU-SILC (Statistics on Income and Living Conditions) for the enlarged European Union for the study of low pay and its relationship to household poverty and vulnerability. Limitations of the earnings data currently available mean the analysis covers only 14 of these countries. For employees who are not low paid, income poverty is seen to be rare. The low paid face a much higher risk of being in a household below relative income poverty thresholds, ranging from 7 per cent in Belgium and the Netherlands up to 1718 per cent in Austria, Estonia and Lithuania. The likelihood of their being in a poor household is clearly linked to gender, age and social class. In most of the countries only a minority of low-paid individuals are in vulnerable households.

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.

Nurse practitioner and physician collaboration in long-term care homes:Survey results

This survey assessed the extent of and satisfaction with collaboration between physicians and nurse practitioners (NPs) working in Ontario long-term care homes. Questionnaires, which included the Measure of Current Collaboration and Provider Satisfaction with Current Collaboration instruments, were mailed to NPs and physicians with whom the NP most frequently worked. The 14 matched-pairs of NPs and physicians reported similar levels of collaboration; however, physicians were significantly more satisfied with collaboration than were NPs (z = -2.67, p = 0.008). The majority of physicians (85%) and NPs (86%) indicated that collaboration was occurring, and 96 per cent of physicians and 79 per cent of NPs were satisfied with their collaboration. About one third of physicians reported that the NP had a negative effect on their income, but their satisfaction with collaboration did not differ from those who reported a positive effect. Overall, these physicians and NPs collaborate in delivering care and are satisfied with their collaboration. © 2009 Canadian Association on Gerontology.

Older adults awareness of community health and support services for dementia care

The article examines where older adults seek help in caring for a parent with dementia and the factors associated with their identification of community health and support services as sources of assistance. The authors conducted telephone interviews, using random digit dialing, of 1,152 adults aged 50 and over in the city of Hamilton. Respondents received a vignette that raised issues related to parental dementia. In identifying support sources, over 37 per cent of respondents identified their physician, 33 per cent identified informal support such as family and neighbors, and 31 per cent identified home health services. Only 18 per cent identified community support services. Female participants having higher levels of education were more likely to identify their physician as a source of support. Knowing where to find information about community support services was associated with an increased likelihood of mentioning physicians and home health services as sources of assistance. © 2009 Copyright Canadian Association on Gerontology.