Agreement between histological diagnosis of skin lesions by histopathologists and a dermato‐histopathologist

Background Skin cancer is an increasing problem in fair‐skinned populations worldwide. It is important that doctors are able to diagnose skin lesions accurately, and this is supported by accurate histological diagnosis. Objective To compare agreement for histological diagnosis between local histopathologists with a dermato‐histopathologist from a stratified random sample of excised skin lesions derived from a set of epidemiological data. Methods All excised and histologically confirmed skin cancers in Townsville/Thuringowa, Australia from December 1996 to October 1999 were recorded. A stratified sample of 407 of 8694 skin excisions slides was analyzed. Results Positive predictive values (PPVs) for the primary histological diagnosis were above 90% for basal cell carcinoma, cutaneous melanoma, and common naevus. For squamous cell carcinoma (SCC), the PPV was 72.6% [95% CI = (65.5, 79.0)]. Discussion Lack of agreement between histopathologists regarding the diagnosis of SCC and actinic keratosis has been previously recognized in the literature and this is again reflected in our study. The result also illustrates the difficulty involved for doctors in accurately clinically diagnosing lesions for which a consensus is hard to reach histologically.     

When doctors disagree: a qualitative study of doctors' and parents' views on the risks of childhood food allergy

Objective  To examine the views of doctors which underpin clinical practice variation concerning an uncertain health risk, and the views of parents who had sought advice from these doctors, using the example of childhood food allergy.
Study design  Qualitative study involving in-depth interviews and participant observation over 16 months. Focus groups and consultation audio-recordings provided corroborative data.
Setting  Three specialist allergy clinics located in one metropolitan area.
Participants  Eighteen medical specialists and trainees in allergy, and 85 parents (from 69 families) with food allergic children.
Results  Doctors expressed a spectrum of views. The most divergent views were characterized by: scientific scepticism rather than precaution in response to uncertainty; emphasis on quantifiable physical evidence rather than parental histories; professional roles as providers of physical diagnosis and treatment rather than of information and advocacy; libertarian rather than communitarian perspectives on responsibility for risk; and values about allergy as a disease and normal childhood. Parents held a similar, but less divergent range of views. The majority of parents preferred more moderate doctors' views, with 43% (30 of 69) of families expressing their dissatisfaction by seeking another specialist opinion. Many were confused by variation in doctors' opinions, preferring relationships with doctors that recognized their concerns, addressed their information needs, and confirmed that they were managing their child's allergy appropriately.
Conclusions  In uncertain clinical situations, parents do not expect absolute certainty from doctors; inflexible certainty may not allow parental preferences to be acknowledged or accommodated, and is associated with the seeking of second opinions.     

Revitalizing primary health care and family medicine/primary care in India – disruptive innovation?

Context India has rudimentary and fragmented primary health care (PHC) and family medicine systems, yet it also has the policy expectation that PHC should meet the needs of extremely large populations with slums and difficult to reach groups, rapid social and epidemiological transition from developing to developed nation profiles. Historically, the system has lacked impetus to achieve PHC. Objective To provide an overview of PHC approaches and the current state of PHC and family medicine in India in order to assess the opportunities for their revitalization. Methods A narrative review of the published and grey literature on PHC, family medicine, Web2.0 and health informatics key papers and policy documents, pertinent to India. Outcomes A conceptual framework and recommendations for policy makers and practitioner audiences. Findings PHC is constructed through systems of local providers who address individual, family and local community basic health needs with strong community participation. Successful PHC is a pre‐eminent strategy for India to address the determinants of health and the almost chaotic of massive social transition in its institutions and health care sector. There is a lack of an articulated comprehensive framework for the publicly stated goals of improving health and implementing PHC. Also, there exists a very limited education and organization of a medical and PHC workforce who are trained and resourced to address individual, family and local community health and who have become increasingly specialized. However, emerging technology, Health2.0 and user generated health care informatics, which are largely conducted through mobile phones, are co‐evolving patient‐driven health systems, and potentially enhance PHC and family medicine workforce development. Conclusions In order to improve health outcomes in an equitable manner in India, there is a pressing need for a framework for implementing PHC. The co‐emergence of information technologies accessible to the mass population and user‐driven health care provide a potential catalyst or innovation for this transition.     

Pre-operative Predictors of Weight Loss at 1-Year after Lap-Band® Surgery

Background: The authors studied a range of preoperative factors for their predictive value of effectivenes of Lap-Band? placement, using the percentage of excess weight loss at 1-year as the outcome measure (%EWL1). Methods: All factors were measured and recorded prior to surgery. Factors included: patient demographics, family, medical and weight history. Laboratory measures and the responses to the SF36 Health Survey were also assessed. Factors were assessed for correlation with %EWL1. Results: The group (N=440, F:M 383:57) had mean age 40.0 ± 9.5 years, weight of 126 ± 25 kg, and BMI 45.6 ± 7.5 kg/m2 pre-operatively. At 1-year follow-up, the group had mean weight 97.6 ± 20 kg, BMI 35.6 ± 6.3 kg/m2, and %EWL1 45.8 ± 17%. Increasing age (R=-0.13, p<0.01) and preoperative BMI (R=-0.22, p<0.001) were significantly associated with less %EWL1 and all other factors were controlled for these before assessing significance. Important factors associated with a lower %EWL1 included: hyperinsulinemia (R=-0.36, p<0.001), insulin resistance (R=-0.33, p<0.001) and disease associated with insulin resistance, poor physical ability, pain, and poor general health responses to the SF-36 Health Survey. Patients who consumed alcohol regularly had a better rate of weight loss (R= 0.23, p<0.005). Factors that had no influence included gender, a history of mental illness and measures of mental health, previous bariatric surgery, and a history of many medical conditions associated with obesity. Conclusion: Important physical factors have been found to influence the rate of weight loss.Those with increased age, pain, physical disability and insulin resistance have a great deal to gain from weight loss. Although this study has identified factors that are associated with less weight loss, we have not found any factor that predicts an unacceptably low weight loss and thus provides a contraindication to Lap-Band? placement. The findings of this study allow us to set more realistic goals for the rate of weight loss in specified sub-groups of our patients.     

An Aeardiac Twin

EDITORIAL COMMENT: : We accepted this case for publication because it nicely reviews the rare problem of an aeardiac twin which can be a cause of nonimmune hydrops in the 'normal' twin - apparently the normal twin develops cardiac failure because of the extra circulatory burden. Such cases when diagnosed antenatally present the problem of timing of delivery, especially if the parasitic twin 'dies' (cessation of blood flow as assessed by Doppler study). In addition to serial ultrasonography to detect the onset of hydrops in the normal twin, regular cardiotocography is indicated since twin to twin transfusion may result in signs of severe fetal distress (type 2 decelerations, loss of beat to beat variation or sinusoidal pattern typical of fetal anaemia/ warranting prompt delivery.