Factors influencing the career choices of general practitioner trainees in North West Thames Regional Health Authority.

The aim of this study was to identify those factors influencing general practitioner trainees when choosing their future place of work, with particular reference to those issues that might be relevant to a choice of practice in inner London. A questionnaire was sent to the 90 trainees undertaking the final component of general practice training within North West Thames Regional Health Authority in May 1991. Seventy five doctors responded to the questionnaire, of whom 47 (63%) were women. Forty five per cent of women indicated that they wished to work part time, compared with 6% of the men. Only 21 trainees (28%) said that they would consider working in inner London, 36 (48%) stating that they would definitely not work in this location, with only nine (12%) indicating a willingness to work in a single handed practice and 21 (28%) in a two doctor practice. Specific factors identified as important when choosing a practice included a good working relationship with partners and staff, the presence of a practice nurse and practice manager, attached health authority staff, opportunities for postgraduate education, and good relationships with hospitals. Of the 800 practices in the north west Thames region, 62% are either one or two doctor practices, these being more prevalent in inner London areas where training practices are less common. Given the preferences expressed by trainees, future recruitment in inner London is likely to be more difficult than elsewhere.(ABSTRACT TRUNCATED AT 250 WORDS)     

Esophageal transit scintigraphy--a cautionary note

Esophageal transit scintigraphy and esophageal manometry were compared in forty-two patients with symptoms of esophageal disease. Fifteen healthy volunteers were studied as a control group for the scintigraphic investigation. Agreement between the tests was present in 79% of patients. In all the five patients in whom the esophageal manometry was abnormal and the esophageal transit study was normal, the manometric finding was "giant esophageal contractions." In four of the control group an abnormal transit pattern was observed on one of two esophageal studies. Esophageal transit scintigraphy has some limitations as a screening test for esophageal motor dysfunction.     

Comparative activity of 4,4'-diaminobiphenyl (benzidine) and its terphenyl analogue, 4,4'-diaminoterphenyl, in two in vitro assays for potential carcinogenicity

The carcinogen 4,4'-diaminobiphenyl (benzidine) has been compared in vitro with its terphenyl analogue 4,4'-diaminoterphenyl using the Salmonella reverse mutation assay and the BHK cell-transformation assay. The responses observed, taken together with a consideration of chemical structures, indicate that the terphenyl compound is a potential carcinogen. These findings may contribute to an understanding of the mechanism of action of benzidine as a carcinogen.     

Studies in vitro to discern the structural requirements for carcinogenicity in analogues of the carcinogen 4-dimethylaminoazobenzene (butter yellow)

4-Dimethylaminoazobenzene (butter yellow, DAB), is the parent member of a large family of 'azo-carcinogens'. Experiments have been conducted in vitro to determine the key structural requirements for carcinogenic activity in this chemical class, and it is suggested, based on the activity observed for 4-cyano-N,N-dimethylaniline, that the 4-phenylazo group of DAB is not an essential structural feature per se. The N-oxide derivative of DAB has been evaluated in vitro and the positive response observed related to its metabolic activation. It is concluded that cyclic amines, such as pyrrolidine, can replace the N-dimethyl group of DAB with a retention of biological activity. The confusion that exists in the literature concerning the chemical identity and carcinogenic status of 2-dimethylaminobenzo[c]cinnoline has been investigated, and it is concluded that it is a potential animal carcinogen. This observation also indicates that the phenylazo group of DAB can be incorporated within an aromatic ring system with a retention of biological activity. As observed earlier with a mixture of azobenzene and DAB, azobenzene also potentiates the cell transforming properties of the above cinnoline derivative in vitro. Two charts are presented. The first attempts to integrate DAB within a much larger family of carcinogens, and the second illustrates the usefulness of structure-activity studies in general.     

Entry: a new approach

Despite all of the protections promised through grandfathering and pathways to educational mobility, the entry movement tends to be perceived by many to be "demoting" the lives and livelihoods of hundreds of thousands of RNs who do not possess the education to meet the proposed standard. Here is a proposal for a way out of the quagmire.     

Phospholipase A2 levels in acute chest syndrome of sickle cell disease

Acute chest syndrome (ACS) is associated with significant morbidity and is the leading cause of death in patients with sickle cell disease (SCD). Recent reports suggest that bone marrow fat embolism can be detected in many cases of severe ACS. Secretory phospholipase A2 (sPLA2) is an important inflammatory mediator and liberates free fatty acids, which are felt to be responsible for the acute lung injury of the fat embolism syndrome. We measured SPLA2 levels in 35 SCD patients during 20 admissions for ACS, 10 admissions for vaso-occlusive crisis, and during 12 clinic visits when patients were at the steady state. Eleven non-SCD patients with pneumonia were also evaluated. To determine if there was a relationship between sPLA2 and the severity of ACS we correlated SPLA2 levels with the clinical course of the patient. In comparison with normal controls (mean = 3.1 +/- 1.1 ng/mL), the non- SCD patients with pneumonia (mean = 68.6 +/- 82.9 ng/mL) and all three SCD patient groups had an elevation of SPLA2 (steady state mean = 10.0 +/- 8.4 ng/mL; vaso-occlusive crisis mean = 23.7 +/- 40.5 ng/mL; ACS mean = 336 +/- 209 ng/mL). In patients with ACS sPLA2 levels were 100- fold greater than normal control values, 35 times greater than values in SCD patients at baseline, and five times greater than non-SCD patients with pneumonia. The degree of SPLA2 elevation in ACS correlated with three different measures of clinical severity and, in patients followed sequentially, the rise in SPLA2 coincided with the onset of ACS. The dramatic elevation of SPLA2 in patients with ACS but not in patients with vaso-occlusive crisis or non-SCD patients with pneumonia and the correlation between levels of SPLA2 and clinical severity suggest a role for SPLA2 in the diagnosis and, perhaps, in the pathophysiology of patients with ACS.     

Refining the value of secretory phospholipase A2 as a predictor of acute chest syndrome in sickle cell disease: results of a feasibility study (PROACTIVE)

Acute chest syndrome (ACS) is defined as fever, respiratory symptoms and a new pulmonary infiltrate in an individual with sickle cell disease (SCD). Nearly half of ACS episodes occur in SCD patients already hospitalized, potentially permitting pre-emptive therapy in high-risk patients. Simple transfusion of red blood cells may abort ACS if given to patients hospitalized for pain who develop fever and elevated levels of secretory phospholipase A2 (sPLA2). In a feasibility study (PROACTIVE; ClinicalTrials.gov NCT00951808), patients hospitalized for pain who developed fever and elevated sPLA2 were eligible for randomization to transfusion or observation; all others were enrolled in an observational arm. Of 237 enrolled, only 10 were randomized; one of the four to receive transfusion had delayed treatment. Of 233 subjects receiving standard care, 22 developed ACS. A threshold level of sPLA2 ≥ 48 ng/ml gave optimal sensitivity (73%), specificity (71%) and accuracy (71%), but a positive predictive value of only 24%. The predictive value of sPLA2 was improved in adults and patients with chest or back pain, lower haemoglobin concentration and higher white blood cell counts, and in those receiving less than two-thirds maintenance fluids. The hurdles identified in PROACTIVE should facilitate design of a larger, definitive, phase 3 randomized controlled trial.     

Curing of a Killer Factor in Saccharomyces cerevisiae

Many standard laboratory stocks of yeast are able to kill other yeast strains. This property has not been generally recognized because killing is observed only at low pH and not at the pH of standard media. In all strains examined, the genetic determinant for the killer trait shows non-Mendelian inheritance. The segregation patterns of our killer strains indicate that this killer determinant may be different from the killer previously described. Treatment of a killer strain with cycloheximide, but not with ethidium bromide, converts it into a sensitive nonkiller.     

The development and testing of an algorithm for diagnosis of active labour in primiparous women

OBJECTIVES: to describe the development and testing of an algorithm for diagnosis of active labour in primiparous women. DESIGN: qualitative and quantitative methods were used. A literature review was first conducted to identify the key cues for inclusion in the algorithm. Focus groups of midwives were then conducted to assess content validity, finally a vignette study assessed the inter-rater reliability of the algorithm. SETTING: midwives from two study sites were invited to participate. Data were collected during 2002 and 2003. PARTICIPANTS: midwives from the first site took part in the focus groups (n=13), completed vignettes (n=19), or both. Midwives from the second site then completed vignettes (n=17). FINDINGS: an algorithm, developed from the key informational cues reported in the literature, was validated in relation to content validity by the findings from the focus groups. Inter-rater reliability was tested using vignettes of admission case histories and was found to be moderate in the first test (K=0.45). However, after modifying the algorithm the kappa score was 0.86, indicating a high level of agreement. KEY CONCLUSIONS: diagnosis of labour may be straightforward on paper but is frequently problematic in practice. This may be because the diagnosis of labour is made in a high pressured environment where conflicting pressures of workload, limited resources and emotional pressures add to the complexity of the judgement. IMPLICATIONS FOR PRACTICE: we offer a valid and reliable decision-support tool as an aid for diagnosis of labour. The evaluation of the implementation of this tool is under way and will determine whether it is effective in reducing unnecessary admissions and improving clinical outcomes for women.