Quality, efficiency, and cost of a physician-assistant-protocol system for managment of diabetes and hypertension.

Briefly trained physicians assistants using protocols (clinical algorithms) for diabetes, hypertension, and related chronic arteriosclerotic and hypertensive heart disease abstrated information from the medical record and obtained history and physical examination data on every patient-visit to a city hospital chronic disease clinic over a 18-month period. The care rendered by the protocol system was compared with care rendered by a "traditional" system in the same clinic in which physicians delegated few clinical tasks. Increased thoroughness in collecting clinical data in the protocol system led to an increase in the recognition of new pathology. Outcome criteria reflected equivalent quality of care in both groups. Efficiency time-motion studies demonstrated a 20 per cent saving in physician time with the protocol system. Coct estimates, based on the time spent with patients by various providers and on the laboratory-test-ordering patterns, demonstrated equivalent costs of the two systems, given optimal staffing patterns. Laboratory tests were a major element of the cost of patient care,and the clinical yield per unit cost of different tests varied widely.     

Bipartite parietal bone: A rare cause of plagiocephaly

A case of an infant with an asymmetrical head is presented. On clinical assessment the patient displayed features of deformational plagiocephaly. With the aid of three‐dimensional CT imaging of the skull, a bipartite parietal bone was diagnosed. The prevalence and possible aetiology of a bipartite parietal bone is discussed as well as a brief overview of the common causes of plagiocephaly.     

Involvement of deprivation and environmental lead in neural tube defects: a matched case-control study

OBJECTIVE: To analyse the prevalence of neural tube defects in small geographical areas and seek to explain any spatial variations with reference to environmental lead and deprivation. SETTING: The Fylde of Lancashire in the north west of England. DESIGN: Cases were ascertained as part of a prospective survey of major congenital malformations in babies born in the Fylde to residents there between 1957 and 1981. A matched case-control analysis used infants with cardiovascular system, alimentary tract, and urinary system malformations as controls. Conditional logistic regression was used to assess the effects of more than 10 micrograms/l lead in drinking water and the Townsend deprivation score. RESULTS: The prevalence of neural tube defects in 1957-73 was higher in Blackpool, Fleetwood, and North Fylde, whereas the three control groups showed no significant spatial variation. In 1957-81 mothers living in electoral wards with either a higher proportion of houses with more than 10 micrograms/l lead in the water or a higher deprivation score had a greater risk of having a baby with a neural tube defect. For spina bifida and cranium bifidum alone, this was also true. For anencephaly, deprivation was less important although the effect of lead was still seen. In some neural tube defects, lead may act independently of other possible factors associated with deprivation. It seemed unlikely that lead levels changed significantly during the survey. The percentage of houses with 10 micrograms/l or more of lead in the water in 1984-5 was similar to that found in Great Britain 10 years previously. CONCLUSION: There is evidence to suggest that lead is one cause of neural tube defects, especially anencephaly. This could link the known preventive actions of hard water and folic acid. Calcium is a toxicological antagonist of lead. One cause of a deficiency of folic acid is impaired absorption secondary to zinc deficiency, which may be produced or exacerbated by lead.     

Tuberous sclerosis complex and Wolff-Parkinson-White syndrome

This report highlights the association between tuberous sclerosis and Wolff-Parkinson-White syndrome. Ten patients with concurrent diagnoses of Wolff-Parkinson-White syndrome and tuberous sclerosis were identified. Wolff-Parkinson-White syndrome presented early in life, nine cases being diagnosed in the first year. Eight of the 10 cases were male. In eight cases, the syndrome was associated with supraventricular tachycardias, and in nine with cardiac rhabdomyomata. One child died from cardiac failure secondary to obstruction of the left ventricular outflow tract by a rhabdomyoma. Five of nine survivors showed resolution of Wolff-Parkinson-White syndrome on follow up. The accessory pathway was localised in nine patients from surface electrocardiograms: six children had left sided pathways and three had right sided pathways.     

Blood-brain barrier and blood volume imaging of cerebral glioma using functional CT: A pictorial review

Five cases of cerebral glioma are presented here that illustrate the benefit of functional CT imaging of blood-brain barrier permeability and cerebral blood volume. Functional CT uses Patlak analysis of a single location dynamic sequence to extract physiological information that is useful clinically in the assessment of cerebral gliomas. Functional CT offers distinct advantages over other functional modalities including clearer delineation of tumour, tumour grading, measurement of tumour activity and monitoring response to therapy.     

Sirenomelia with an angiomatous lumbosacral myelocystocele in a full-term infant.

Sirenomelia, also known as the mermaid syndrome, is a rare congenital malformation of uncertain etiology. It is characterized by fusion of the lower limbs and commonly associated with severe urogenital and gastrointestinal malformations. In this report, we describe the first case of an infant with sirenomelia and a massive angiomatous lumbosacral myelocystocele.     

A systematic review on the effectiveness of sex offender risk assessment tools in predicting sexual recidivism of adult male sex offenders

PurposeThis study aimed to systematically review the effectiveness of risk assessment tools in predicting sexual recidivism of adult male offenders.BackgroundSex offender risk assessment aids risk management within the criminal justice system. Some tools follow an actuarial approach and some adopt structured professional judgement. There has not been a systematic review evaluating and comparing the effectiveness of those tools and appraising the overall quality of the primary research.MethodsSix electronic databases and reference lists of relevant meta-analyses were searched. Three experts were contacted to obtain relevant studies. Inclusion criteria were applied to the identified references and the included studies were quality assessed, using pre-defined criteria, prior to data extraction and synthesis.ResultsElectronic search yielded 4949 hits. Of these, 1419 duplicates, 1 meta-analysis and 3382 irrelevant hits were excluded. 14 publications identified from previous meta-analyses were included. 2 non-English language duplications of publications were excluded. 89 publications that did not meet inclusion criteria and 15 inaccessible publications were excluded. 11 studies that did not meet minimum threshold criteria and 1 study that re-analysed an already included sample were then excluded, leaving 43 publications containing 43 studies.ConclusionsAll included tools demonstrated at least moderate predictive accuracy, with two reporting a large effect size (VRS-SO and SRA), although these two came under much less empirical scrutiny than the others and may have been the subject of developer bias in the research that is available. The VRS-SO was found to have the highest mean quality score, this again being limited by the number of studies and developer bias. The quality of the primary research is variable. More independent high quality research is needed, particularly on structured professional judgement incorporating dynamic risk factors.     

Confidence of pediatric trainees in dermatologic conditions,preferred learning styles,and suggested improvements to training

Dermatological conditions in children often present initially to general pediatricians. Senior pediatric trainees in the UK were surveyed regarding their experience and confidence in diagnosis and management with skin conditions, and their satisfaction with postgraduate training. Confidence was reasonable in common conditions but lower for emergencies, reflecting a lack of exposure, and satisfaction with training was low. On the job learning and clinic attendance were felt to be most beneficial, alongside learning from specialist review, however dermatologists were not found to be accessible. Informal learning methods are key within postgraduate education and educators must maximise learning opportunities. Dermatologists can play a vital role by encouraging trainees to learn from feedback following specialist review.