bluuebunny/crossref_metadata_2025 huggingface dataset:
Ethanol injection therapy of an isolated bile duct associated with a biliary‐cutaneous fistula
Authors: MATSUMOTO TOSHIFUMI , IWAKI KENTARO , HAGINO YOSHIAKI , KAWANO KATSUNORI , KITANO SEIGO , TOMONARI KEN‐ICHIRO , MATSUMOTO SHUNRO , MORI HIROMIJ
Published: March 2003

Abstract
 Bile leakage after hepatic resection often results in the formation of a biliary‐cutaneous fistula. Such a fistula, when caused by an isolated bile duct in the remnant liver, can be intractable. We report a successful case of ethanol injection therapy of an isolated bile duct. A 73‐year‐old man underwent right hepatic resection for hepatocellular carcinoma. Bile leakage occurred after surgery, and the patient developed a biliary‐cutaneous fistula. Fistulography revealed an isolated bile duct in the remnant portion of the caudate lobe without communication to the main biliary system. As conservative management with simple drainage was ineffective, injection therapy with ethanol was performed with a balloon occlusion catheter. After 11 therapy sessions, the bile duct was eradicated, and the biliary‐ cutaneous fistula was completely healed. The post‐treatment course was uneventful. Ethanol injection therapy can be a choice for management of patients with a biliary fistula caused by an isolated bile duct.

© 2002 Blackwell Publishing Asia Pty Ltd
Polymorphism in alcohol‐metabolizing enzymes, glutathione S‐transferases and apolipoprotein E and susceptibility to alcohol‐induced cirrhosis and chronic pancreatitis
Authors: FRENZER ANDREAS , BUTLER WENDY J , NORTON IAN D , WILSON JEREMY S , APTE MINOTI V , PIROLA ROMANO C , RYAN PHILIP , ROBERTS‐THOMSON IAN C
Published: March 2003

Background and Aim Susceptibility to organ damage induced by alcohol may be due to inherited variation (polymorphism) in ethanol‐metabolizing enzymes, or to polymorphisms affecting free radical or lipid metabolism mediated by enzymes such as glutathione S‐transferases and apolipoprotein E. The aim was to compare the genotype frequencies of alcohol dehydrogenase‐2 (ADH2), ADH3, aldehyde dehydrogenase‐2 (ALDH2), cytochrome P450‐2E1 (CYP2E1), glutathione S‐transferase‐M1 (GSTM1), GSTT1, and apolipoprotein E in patients with alcoholic cirrhosis and alcoholic chronic pancreatitis to those in control groups.

Patients and Methods The case–control study was restricted to Caucasian adults: 57 with alcoholic cirrhosis, 71 with alcoholic chronic pancreatitis, 57 alcoholics without apparent organ damage and 200 healthy blood donors. Genotypes were determined by restriction fragment length polymorphism after amplification of genomic DNA by polymerase chain reaction.

Results The genotype ADH3*2/*2 was more frequent in patients with cirrhosis (40%) than blood donors (12%; OR 4.92, 95% CI 2.36–10.31) and patients with chronic pancreatitis (8%; OR 7.33, 95% CI 2.54–23.78) but was not significantly different from alcoholic controls (23%; OR 2.27, 95% CI 0.95–5.66). Patients with cirrhosis also had a higher frequency (P < 0.05) of ADH2*1/*1 (100%) than blood donors (92%) and those with chronic pancreatitis (93%). The frequencies of genotypes of ALDH2, CYP2E1, GSTM1, GSTT1 and apolipoprotein E were similar in all groups.

Conclusion Alcoholic cirrhosis but not alcoholic chronic pancreatitis is associated with ADH3*2/*2 and perhaps with ADH2*1/*1. Both genes encode less active alcohol‐metabolizing enzymes that may be associated with cirrhosis because of delayed formation of acetaldehyde (with higher intakes of alcohol), or diversion of alcohol metabolism through pathways other than ADH.
Introduction of lamivudine for the treatment of chronic hepatitis B: Expected clinical and economic outcomes based on 4‐year clinical trial data
Authors: CROWLEY STEVEN , TOGNARINI DAVID , DESMOND PAUL , LEES MICHAEL , SAAL GAURI
Published: March 2003

Background Chronic hepatitis B (CHB) is associated with a significant burden of illness and treatment involves substantial health‐care costs. This study estimates clinical outcomes and cost‐effectiveness of lamivudine compared with other treatment scenarios for CHB, from an Australian health‐care provider perspective.

Methods A two‐step modeling approach depicted clinical progression of hepatitis B in hypothetical patient cohorts using three different treatment scenarios: scenario A, lamivudine and α‐interferon (IFN‐α) available; scenario B, IFN‐α available only; and scenario C, no treatment available. Assumptions were based on clinical trials, published studies, a hepatologist’s questionnaire and an expert panel follow up. One‐year clinical outcomes and costs were estimated using a decision tree, while lifetime costs and outcomes were estimated using available clinical trial data for lamivudine (up to 4 years therapy duration) and a Markov model.

Results The analysis considered only patients with pretreatment elevated alanine aminotransferase levels ≥ 2 × upper limit of normal. In the short term, the introduction of lamivudine is expected to result in almost 3.5 times more CHB patients receiving therapy (lamivudine or IFN‐α) compared to IFN‐α only (67% compared to 20%, respectively). Hence, scenario A subsequently doubled the seroconver‐sion rate. The incremental cost‐effectiveness ratio was $A3341 per additional seroconversion. Also, non‐seroconverted lamivudine patients are less likely to progress to cirrhosis than those receiving IFN‐α/no treatment. One‐year progression to cirrhosis was estimated at 5.1% with scenario A, compared to 12.2% and 12.7%, scenarios B and C, respectively. From the long‐term analysis, lamivudine is expected to increase life expectancy by years and reduce the lifetime risk of compensated cirrhosis, decompensated cirrhosis and hepatocellular carcinoma by 6%, 12% and 12%, respectively. Additionally, the introduction of lamivudine decreases lifetime costs by $548, thus making it a cost‐saving and life‐extending strategy. In both short‐ and long‐term models, worst case scenarios in sensitivity analyses still associate lamivudine with a favorable cost‐effectiveness ratio.

Conclusion Introduction of lamivudine is expected to improve health outcomes in CHB patients, resulting in overall savings in health‐care costs. In this model, compared with IFN‐α only and no treatment, lamivudine allowed more CHB patients to be treated, increased the seroconversion rate, delayed disease progression and prolonged life expectancy.
Extrahepatic manifestations of cholestasis
Authors: Glasova Helena , Beuers Ulrich
Published: March 2003

Abstract  Pruritus, fatigue and metabolic bone disease represent three major extrahepatic manifestations of chronic cholestatic liver disease that considerably affect the patient"s quality of life. The present article reviews pathogenetic aspects of and current therapeutic approaches to extrahepatic manifestations of cholestatic liver disease. Pathogenesis of pruritus of cholestasis remains poorly understood. The involvement of putative peripherally acting pruritogens, such as bile acids or endogenous opioids, is being discussed. More recently, central mechanisms, including an increased central opioidergic tone and pertubations in the serotonergic system have been proposed. Treatment of the underlying disease is beneficial also for the control of cholestasis‐associated pruritus. Current therapeutic recommendations include ursodeoxycholic acid, cholestyramine, rifampicin and opioid antagonists. Liver transplantation may be indicated when severe pruritus is refractory to medical treatment. Fatigue is being recognized as the most frequent and one of the most disabling complaints in chronic cholestasis. Fatigue is presumably of central origin and its association with other neuropsychiatric disorders (e.g. depression, obsessive –compulsive disorders) is consistent with defective central neurotransmission. No specific therapies are currently available and a healthy lifestyle, regular sleep and avoidance of unnecessary stress and other precipiting factors are recommended. Antidepressant therapy may be warranted in selected patients. Osteopenia and osteoporosis are common in chronic cholestatic liver disease, whereas osteomalacia is rare. The pathophysiology of cholestasis‐associated metabolic bone disease is regarded as multifactorial. Therapeutic recommendations include regular exercise, calcium and vitamin D supplementation in late stage disease, hormone replacement therapy in postmenopausal women and bisphosphonates.

© 2002 Blackwell Publishing Asia Pty Ltd
Gastric cancer: Laboratory bench to clinic
Authors: Houghton Jeanmarie , Fox James G , Wang Timothy C
Published: March 2003

Abstract 
Gastric cancer is the second most common cause of cancer‐related mortality worldwide and the 14th overall cause of death. Detection of disease usually occurs at an advanced stage and overall survival rates for gastric cancer are poor. Our current model for gastric cancer progression clearly maintains Helicobacter infection as the primary inducer of gastric metaplastic and neoplastic disease. Helicobacter pylori is a ubiquitous organism, infecting more than half the world’s population. It has been suggested that this infection directly contributes to the formation of gastric cancer in up to 80% of cases; however, gastric malignancy develops in only a subset (< 1%) of infected patients. Therefore, predisposition to Helicobacter‐associated gastric cancer is most likely multifactorial, including the interaction of bacterial, host and environmental components. Our understanding of how the organism interacts with the gastric mucosa and synergizes with dietary and other environmental factors to induce malignant mucosal changes is evolving. Indeed, H. pylori has direct effects on the gastric mucosa, but the major factor in disease progression appears to be a robust host Th1 immune response in the setting of a permissive environment. In combination, these factors predispose to the formation of atrophy, metaplasia and gastric cancer. Understanding the interaction of the bacterium with the host and the environment can potentially identify patients most at risk. Identifying potentially removable factors (in addition to H. pylori infection) in the acquisition and progression of neoplastic disease may provide targets for early intervention and prevention strategies.

© 2002 Blackwell Publishing Asia Pty Ltd
Randomized open trial for comparison of proton pump inhibitors in triple therapy for Helicobacter pylori infection in relation to CYP2C19 genotype
Authors: INABA TOMOKI , MIZUNO MOTOWO , KAWAI KOZOU , YOKOTA KENJI , OGUMA KEIJI , MIYOSHI MASATSUGU , TAKE SUSUMU , OKADA HIROYUKI , TSUJI TAKAO
Published: March 2003

Abstract
Background and aims
: Genetic polymorphism of cytochrome P450 (CYP) 2C19 influences the efficacy of Helicobacter pylori eradication therapy with a proton pump inhibitor (PPI) and amoxicillin. However, in triple therapy (PPI plus amoxicillin and clarithromycin), little is known about the impact of CYP2C19 polymorphism, or the use of rabeprazole, which is not well metabolized by CYP2C19. The efficacy of three PPI (omeprazole, lansoprazole, and rabeprazole) in a 1‐week triple regimen were compared in relation to CYP2C19 polymorphism.

Method
: One hundred and eighty‐three patients were randomized to receive one of the following regimens: amoxicillin 500 mg t.i.d., clarithromycin 200 mg t.i.d., and PPI (omeprazole 20 mg, lansoprazole 30 mg, or rabeprazole 10 mg) b.i.d. CYP2C19 polymorphism was analyzed by PCR restriction fragment length polymorphism.

Results
: Intention‐to‐treat‐based overall cure rates for omeprazole, lansoprazole or rabeprazole regimens were 83.1% (95% confidence interval (CI): 69–89%), 86.7% (CI: 75–93%), and 76.6% (CI: 64–85%), respectively, without significant difference. The cure rate of the rabeprazole regimen (but not the lansoprazole or omeprazole regimens) tended to be correlated with CYP2C19 genotypes (P = 0.076). In patients with a homozygous extensive metabolizer genotype, the per protocol‐based cure rate with rabeprazole (62.5%) was significantly lower than that with lansoprazole (90.0%; P = 0.038).

Conclusion
: The overall cure rate of 1‐week triple therapy for H. pylori eradication was not significantly different between regimens with omeprazole, lansoprazole or rabeprazole, but the impact of CYP2C19 genetic polymorphism on the cure rate appeared to differ between these PPI.

© 2002 Blackwell Publishing Asia Pty Ltd
Community acquired fulminant Pseudomonas infection of the gastrointestinal tract in previously healthy infants
Authors: YEUNG CK , LEE KH
Published: March 2003

Three previously healthy infants presented with diarrhoea and pyrexia and deteriorated rapidly. Two patients had necrotizing bowel disease requiring aggressive surgical intervention. All survived. P. aeruginosa gastrointestinal infection in previously healthy children is an extremely rare condition with a high mortality. Ecthyma gangrenosum was present in over 60% of reported cases although often not recognized initially. A high index of clinical suspicion, including prompt recognition of ecthyma gangrenosum, is mandatory for an early diagnosis of P. aeruginosa gastrointestinal infection. Early diagnosis and treatment may improve the prognosis.
Risk factors for recurrent urinary tract infection in preschool children
Authors: Panaretto KS , Craig JC , Knight JF , Howman‐Giles R , Sureshkumar P , Roy LP
Published: March 2003

Objective: Children with urinary tract infections (UTI) are at risk of renal scarring which may lead to impaired renal function and hypertension. This study examines the risk factors that predispose to recurrent UTI in children and the role of recurrent UTI in renal scarring.

Methodology: A group of 290 children under 5 years of age with a first symptomatic UTI were studied. Micturating cystourethrogram and dimercaptosuccinic acid (DMSA) renal scintigraphy were performed at entry, and DMSA was repeated 1 year later. Two hundred and sixty‐one children (90%) were followed up at 1 year.

Results: There were 46 confirmed recurrent infections in 34 children, a recurrence rate of 12%. Multiple recurrence occurred in 14/34 (34%) children. Age of less than 6 months on entry independently predicted for recurrent UTI (odds ratio (OR): 2.9)). Compliance with prophylactic antibiotics fell throughout the year of follow up. Vesicoureteric reflux (VUR) was present in 14/34 (34%) of the group with recurrent UTI, 69/256 (27%) without recurrence. Urinary tract infection was significantly associated with bilateral and intrarenal reflux; grade 3–5 reflux independently predicted for recurrent UTI (OR: 3.5). Recurrent UTI was significantly associated with high grade DMSA defects on entry, renal parenchymal defects at 1 year follow up, and new defects at 1 year.

Conclusions: The independent risk factors for recurrent UTI identified by this study were an age of less than 6 months at the index UTI and grade 3–5 VUR. These findings suggest more selective targeting may minimize problems associated with prophylaxis and improve outcomes for children with urine infection.
Parent reported allergy and anaphylaxis in 4173 South Australian children
Authors: Boros CA , Kay D , Gold MS
Published: March 2003

Objectives: To determine the prevalence of parent reported allergy and anaphylaxis in a sample of children and to investigate the first aid management of anaphylaxis in the schools and preschools that these children attend.

Methods: The study sample comprised 4173 South Australian children aged 3–17 years. Information was collected regarding parent‐reported allergy and anaphylaxis. All children with known anaphylaxis were contacted and an attempt was made to contact those with reports of allergy to ascertain if these children had anaphylaxis. A telephone questionnaire was used to verify reports of anaphylaxis and determine the cause, severity and school first aid management of anaphylaxis.

Results: The rate of parent reported allergy and anaphylaxis was 7.3 and 0.59 per 100 children, respectively. Two‐thirds of children with anaphylaxis did not have emergency medication available at school, an emergency action plan, or a teacher on site able to administer adrenaline for first aid use.

Conclusions: Children attending preschool or school may have had a past history of anaphylaxis. Arrangements for first aid management of these children while in this environment are often inadequate.
Diverticular rectal duplication with heterotopic gastric mucosa in a child: A rare cause of rectal bleeding
Authors: Kumar R , Shun A , Arbuckle S , Gaskin K
Published: March 2003

Abstract: This report describes a rare case of rectal bleeding and proctalgia in a child due to diverticular duplication of rectum associated with heterotopic gastric mucosa.
Gastric aspiration and sleeping position in infancy and early childhood
Authors: Byard Rw , Beal Sm
Published: March 2003

Abstract: Concern has been expressed that the recommendation of supine sleeping position for infants would result in an increase in deaths due to gastric aspiration. A review of 196 cases of infant and early childhood death in children under 3 years of age, occurring over a 9‐year period (September 1989 to August 1998) was undertaken to ascertain how many cases of significant gastric aspiration had occurred. Extensive and widespread filling of the airways/alveoli with gastric contents was found in three infants/young children aged 5, 6 and 30 months, respectively. In each instance the body had been found lying face down (prone), with the face in a pool of vomitus in at least one case. No cases of significant gastric aspiration were found in infants who had been found lying on their sides or backs (supine). In addition, no significant increase in numbers of infant and early childhood deaths in South Australia due to gastic aspiration over this time could be demonstrated. Concerns that the supine rather than the prone position is more likely to result in significant gastric aspiration are not supported by this study.
Does maternal obesity adversely affect breastfeeding initiation and duration?
Authors: Donath Sm , Amir Lh
Published: March 2003

Objective: To examine the relationship between maternal obesity and the initiation and duration of breastfeeding.

Methods: Analysis was made of the 1995 National Health Survey, in which personal interviews were conducted on a multistage area sample of private dwellings and a list sample of non‐private dwellings in all states and territories of Australia. Mothers between the ages of 17 and 50 years (n = 1991) with children under the age of 4 years in 1995 participated in the study.

Results: Of the group of mothers with a body mass index (BMI) of 20–25, 89.2% (95% confidence interval (CI) 87.4–91.0) initiated breastfeeding, compared with 82.3% (95% CI 77.6–87.0) of mothers with a BMI of 30 or more. There was also a significant difference between the mean and median duration of breastfeeding of obese and non‐obese mothers (BMI 30 and over, < 25, respectively). These differences remained significant when maternal smoking, age and other sociodemographic factors were taken into consideration.

Conclusions: Health professionals should be aware that obese women may be at increased risk of not breastfeeding or stopping breastfeeding prematurely.
Outcome of primary vesicoureteric reflux detected following fetal renal pelvic dilatation
Authors: McIlroy P J , Abbott G D , Anderson N G , Turner J G , Mogridge N , Wells J E
Published: March 2003

Objective: Postnatal investigation of mild degrees of fetal hydronephrosis has allowed subsequent detection of infants with vesicoureteric reflux (VUR). This study was designed to provide short to medium term information on such infants who had primary VUR, the rates of renal damage and progression over time, the risk factors for such damage and to compare the characteristics of those who had mild dilatation of the fetal renal pelvis (4–9 mm) with those who had moderate–severe dilatation (≥ 10 mm).

Methodology: Since June 1989, infants whose antenatal sonography had identified a fetal renal pelvis with an anteroposterior diameter of ≥ 4 mm were investigated postnatally with renal ultrasonography and micturating cystourethrogram (MCU), and placed on antimicrobial prophylaxis. Those with VUR received 99mTc‐dimercaptosuccinic acid (DMSA) scintigraphy. Infants were followed until discharge based on resolution of VUR, surgery, or low grade VUR. A 5.5 year cohort between June 1989 and December 1994 formed the study population. A review of notes and clinical review (if still under follow up) was undertaken. Vesicoureteric reflux on MCU was regraded according to the International Classification, and reflux nephropathy on DMSA scans was regraded according to criteria proposed by Goldraich. Regression analysis was used to assess risk factors for renal damage.

Results: There were 69 infants (37 girls, 32 boys) who were identified with primary VUR, with 37/69 having bilateral reflux. Eight had a urinary tract infection during the follow‐up period. There was a broad distribution of grades of reflux detected (Grades I – 3, Grades II – 23, Grades III – 19, Grades IV – 17, Grades V – 7). 99mTc‐dimercaptosuccinic acid scans on 57/69 (83%) demonstrated renal damage in eight infants (14%). This was predominantly global contraction of function. No progression of renal damage was seen over 2–7 years. Regression analysis showed a strong association between Grades IV, V reflux and the presence of renal damage (P < 0.001). Review of the degrees of fetal renal pelvic dilatation showed that 60/69 infants were detected because of mild (4–9 mm) dilatation. The majority (43/60) had lower grades of reflux (Grades I, II, 3), but there was no obvious cut‐off between 4 and 9 mm that could predict high grade VUR (Grades IV, V).

Conclusions: The use of 4 mm to define an abnormal fetal renal pelvis allows a much larger group of infants with high grade primary VUR to be detected than if a higher cut‐off measurement is used. Although it also detects many more infants with low grade primary VUR, there is no obvious cut‐off point at which this effect predominates. Progressive renal damage was not seen in follow up of up to 7 years of age. Renal damage on DMSA scanning in this group is almost exclusively a pattern of global contraction of function. The presence of high‐grade VUR appears to be the only important factor in predicting the presence of renal damage.
Meningococcal vaccination for adolescents? An economic evaluation in Victoria
Authors: Skull SA , Butler JRG
Published: March 2003

Objective: To undertake an economic evaluation of the options for vaccination of adolescents using meningococcal polysaccharide vaccine based on Victorian data.

Methodology: Cost‐effectiveness and cost–benefit analyses of three options for vaccination were undertaken for hypothetical populations aged 15–19 years. Baseline analyses assumed a single year of programme implementation and vaccine protection of 5 years. Sensitivity analyses of key variables were performed. Outcomes included the number of people vaccinated, cases averted, life years saved and disability adjusted life years (DALY) averted. Lost earnings avoided were included as a measure of vaccination benefit in cost–benefit analyses.

Results: Vaccination of people in Years 10–12 (secondary school) and first year university within a defined population with a high rate of disease was the most cost‐effective option. Excluding direct cost savings and compared with no vaccination, this resulted in a discounted cost per DALY avoided of $17 646 and benefits exceeding costs in discounted terms. The ‘break‐even’ incidence rate for this option in the cost–benefit analysis was 11.9/100 000.

Conclusions: Economic evidence favours the use of vaccination within well‐defined populations with a high rate of disease.
Why paediatricians rural out going to the country but support opportunities for change
Authors: Gorton SM , Buettner PG
Published: March 2003

Objectives: To determine the knowledge of vacant country specialist positions, the main barriers to filling country specialist positions, the acceptance of hypothetical creative employment models and to gain understanding of what would it take for respondents to accept a country position.

Methodology: Mailed self‐report questionnaires to all 103 Queensland paediatricians and finishing paediatric trainees (response rate 93.1%) to explore reasons for the long‐term vacancy of the Staff Paediatrician position at the Mount Isa Base Hospital, North‐west Queensland, Australia.

Results: Of the respondents, 87.4% were aware of the vacant position. The lack of adequate locum cover for leave (97.8%), on‐call load (92.2%), professional isolation (91.4%), and family commitments (91.4%) were identified as the four most frequently recognized recruitment barriers. Of the respondents, 30.2% said they could be attracted to such a position if they were guaranteed the ability to return to their present post in 2 years, 30.7% said they could be attracted to a rural exchange, and 73.1% suggested the position would be more attractive to new Fellows if at the end of a 2‐year period they were guaranteed some Visiting Medical Officer sessions or a temporary Staff Paediatrician position at a tertiary centre. Significantly, fewer of the 30–39‐years age group said available job opportunities for their spouse made it impossible for them to consider the advertised position, compared to older age groups (P = 0.003). In response to the question ‘What would it take for you to consider such a position?’, 22.6% answered a change in employment package, 22.6% a change in family commitments, 16.6% too subspecialized, and 7.1% could possibly consider a locum or exchange in the future.

Conclusions: Specialist positions, such as the advertised position, are well known, but remain unfilled because they are considered unsustainable. However, the response to hypothetical creative employment models suggests this could be changed, provided specialist training (e.g. paediatric training) is kept general and the younger consultant is given consideration.
Effect of cisapride on gastric emptying in premature infants with feed intolerance
Authors: Barnett CP , Omari T , Davidson GP , Goodchild L , Lontis R , Dent J , Haslam RR
Published: March 2003

Objective: To assess the effect of cisapride on gastric emptying and gastro‐oesophageal reflux (GOR) symptoms in preterm infants with feed intolerance.

Methods: Sixteen preterm infants (gestational age 24–35 weeks) with feed intolerance were enrolled in the study. Infants were randomized to receive 7 days of cisapride 0.2 mg/kg four times a day, immediately followed by 7 days of placebo or vice versa. Gastric emptying was measured using the [13C]‐octanoic acid breath test prior to study entry and repeated on day 5, 6 or 7 after randomization and 5, 6 or 7 days after crossover. The symptoms of GOR were monitored during the study period using a standardized reflux chart. Weight was recorded daily.

Results: There was no change in gastric emptying in infants prescribed cisapride (gastric half‐emptying time (t1/2) 31.9 ± 4.7 vs 34.2 ± 3.9 min for placebo vs cisapride, respectively; P = 0.65). Infants on cisapride had slower growth and there was no change in reflux symptoms.

Conclusions: The use of cisapride in preterm infants with feed intolerance cannot be recommended.
Oral bleeding: Child abuse alert
Authors: Stricker T , Lips U , Sennhauser FH
Published: March 2003

Abstract:  Physicians must be aware of histories, behaviours and physical findings of maltreated children. We report two cases of physical child abuse in which the initial symptom was oral bleeding. In both cases, the diagnosis was delayed and was made only after severe injuries were inflicted. Injuries to the oral cavity and oral bleeding of uncertain origin in infants should be considered seriously and should be carefully assessed in relation to adequacy of history to explain the mechanism of injury. When an infant has been injured and no adequate explanation is available to account for the mechanism, inflicted injury must be suspected and evaluated, so that in cases of child maltreatment, diagnosis and protection of the child from further injury can take place as early as possible.
Improvement in resuscitation knowledge after a one‐day paediatric life‐support course
Authors: Durojaiye L , O’Meara M
Published: March 2003

Objective:  To assess the effect of a one‐day paediatric life‐support course on the knowledge of paediatric trainees.

Methods:  A telephone survey was performed prior to and at set intervals following the course. Responses to individual questions before and after the course were analysed and an overall test score was calculated. The acquisition and retention of knowledge was measured by comparing test scores for the same group of trainees at time intervals after the course.

Results:  All candidates were surveyed. The median duration of paediatric training prior to the course was 3 years. Eighteen candidates (78%) had previously intubated a child and 13 (57%) had previously used an intraosseous needle. Prior to the course, few of the 23 candidates had adequate knowledge of either the management of the cervical spine in the seriously injured child (17%), fluid resuscitation in meningococcal septicemia (52%), shock dose in ventricular fibrillation (61%), or the management of anaphylactic shock (35%). There was a significant improvement in the knowledge of the group after the course, with median test scores increasing from 19 to a maximum of 22 (P < 0.001). This knowledge was retained at 4 months after the course.

Conclusion:  Despite a high level of experience and previous training in paediatric resuscitation, many candidates lacked the basic knowledge necessary for the resuscitation of seriously ill or injured children. There was a significant improvement in this knowledge after the course, and this was maintained for 4 months. The paediatric life‐support course is an important means of resuscitation training for junior doctors.
Comparison of health‐risk behaviours among students in alternative high schools from New Zealand and the USA
Authors: Denny SJ , Clark TC , Watson PD
Published: March 2003

Objectives:  To describe the prevalence of health‐risk behaviours of New Zealand alternative education students, and to compare these behaviours to similar students in the USA.

Methods:  Thirty‐six alternative education schools in the northern region of New Zealand were surveyed. A total of 269 students completed a youth health questionnaire using laptop computers. These data were compared to data from an equivalent population of alternative education students in the USA.

Results:  Alternative education students from New Zealand and the USA engage in similar high levels of health‐risk behaviours. Female students in New Zealand are at particularly high risk of poor health and social outcomes due to high levels of alcohol and marijuana use, driving under the influence of alcohol and high prevalence of risky sexual behaviours. Such health‐risk behaviours place alternative education students at greater risk of some of the leading causes of morbidity and mortality in both youth and adult populations.

Conclusions:  Findings from the present study support the need for specific health policies and programmes for alternative high school students. Providers of New Zealand alternative education should be aware that female students are at particularly high risk of many health‐risk behaviours.
Death due to electrocution in childhood and early adolescence
Authors: Byard RW , Hanson KA , Gilbert JD , James RA , Nadeau J , Blackbourne B , Krous HF
Published: March 2003

Objectives:  To delineate the clinicopathological features of fatal childhood electrocutions and to identify specific risk factors.

Methods:  Coronial files in Adelaide (Australia) were searched from 1967 to 2001 and Medical Examiners’ files in San Diego (USA) were searched from 1988 to 2001, for cases of deaths of children and adolescents younger than 16 years attributed to electrocution.

Results:  Sixteen cases were identified aged between 10 months and 15 years (mean 8.0 years) with a male : female ratio of 5 : 3. Deaths were due to accidents occurring while playing with or near faulty electrical equipment at home or at school (n = 8), electrical equipment while in the bath (n = 2), damaged outdoor electrical equipment (n = 1), overhead wires (n = 1), and a high voltage electricity substation (n = 1). In addition, one death was due to suicide involving an electrical appliance placed in a bath, and two other deaths occurred in older children who were moving equipment under overhead wires. No homicides were identified.

Conclusions:  Childhood deaths due to electrocution are rare and are more likely to occur when children are playing around electrical wires or equipment, and often result from either faulty apparatus, or a lack of understanding of the potential dangers involved. The majority of deaths (11/16; 69%) occur in the home environment. In contrast to adult electrical deaths, high‐voltage electrocutions, suicides and workplace deaths are uncommon. Strategies for eliminating childhood electrocution should concentrate on ensuring safe domestic environments with properly maintained electrical devices.
Sticky issue of adherence
Authors: Sawyer SM , Aroni RA
Published: March 2003

The phenomenon of adherence, also known as compliance, is the vital link that allows effective medications to have the desired clinical effect when self‐administered. It is often assumed that the population is generally adherent, but more than 50% of people with chronic illness do not take their medication as prescribed. We highlight how the terminology and language of non‐adherence act to conceptualize adherence as a patient problem in a manner that is inadvertently judgmental, narrowly focused and clinically unhelpful. In contrast, knowledge of the dynamic nature of adherence promotes the conceptualization of adherence as the common problem that it is, where the responsibility for improving it lies primarily with the health professional. The example of asthma is used to highlight how individually focused clinical strategies can fit within a population perspective that, in its entirety, can be conceptualized as a framework of adherence‐promoting strategies.
Scurvy: Forgotten but not gone
Authors: Akikusa JD , Garrick D , Nash MC
Published: March 2003

Scurvy is still seen sporadically in the developed world. At a time when subclinical vitamin C deficiency in the general population is being recognized increasingly, the need for clinicians to be aware of this disease remains. We present the case of a 9‐year‐old boy admitted to hospital with musculoskeletal pain, weakness and changes in the skin and gums. After extensive investigation, he was found to have vitamin C deficiency resulting from a restricted eating pattern. Musculoskeletal complaints are a common mode of presentation of scurvy in children. Failure to appreciate this fact and the risk factors for poor vitamin C intake in the paediatric age group can result in unnecessary and invasive investigations for apparent ‘multisystem’ disease.
Frequency, consequences and prevention of adverse drug events
Authors: Bates DW
Published: March 2003

Abstract Iatrogenic injuries are important because they are frequent and many may be preventable; those caused by therapeutic drugs are among the most frequent. While medication errors are common, most have little potential for harm. However, some errors, such as giving a patient a drug to which they have a known allergy, are more likely to cause injury. Error theory provides insights into the changes required to reduce medication error injury rates. Data from the Adverse Drug Event (ADE) Prevention study suggest that most serious errors occur at the ordering and dispensing stages, while another, smaller, proportion occur at the administration stage. These data suggest that physician computer‐order entry, where physicians write orders on‐line with decision support, including patient‐specific information and alerts about potential problems, has the potential to significantly reduce the number of serious medication errors.
An analysis of Australian adverse drug events
Authors: Malpass A , Helps SC , Runciman WB
Published: March 2003

Abstract Previous research has shown that there is a high error rate associated with medication use, resulting in significant patient morbidity and mortality, as well as increasing health care costs. Analysis of available Australian data on adverse drug events shows that incident monitoring and retrospective medical record review provide different, but complementary ‘windows’ into the errors that occur. While retrospective medical record review provides information on the frequency of specific adverse drug events, incident monitoring gives an insight into the contributing factors. From this information, priorities can be set and preventative strategies can be developed.
Care co‐ordination improves quality‐of‐care at South Auckland Health
Authors: Gow P , Berg S , Smith D , Ross D
Published: March 2003

Abstract Inpatient discharge surveys at Middlemore hospital, a 600 bed hospital in South Auckland, New Zealand, consistently rate communication and co‐ordination of care as parameters in need of improvement. A case management model of care was suggested as a means of achieving this. The objective of this study was to determine the effectiveness of care co‐ordination in an acute general medical setting in a pilot study over a 4 week period. A care co‐ordinator identified 18 patients with complex problems among 48 patients admitted to a single medical ward under the care of a single multidisciplinary team, with their care being co‐ordinated over the entire episode of illness. A control group of 59 similarly complex patients admitted to other wards and teams without care co‐ordination over the same period was also studied and the outcomes compared. Communication and co‐ordination, discharge information, involvement in discharge planning and information on post‐discharge services were rated by the study patients as good or very good by 77, 85, 69 and 77%, respectively, compared with 62, 30, 41 and 45% in the control group. The same parameters were rated as poor or very poor by 13, 30, 36 and 15% of the control patients, compared with 0% in all these measures in the study group. Twenty‐one clinical staff involved in the study agreed that there was an improvement in care co‐ordination with respect to efficiency, reduction of workload and better communication, with approval ratings being 71, 76 and 76%, respectively. There was no difference in Average Length of Stay between the control and study groups, but three of the patients in the control group may have had their preventable readmissions within 10 days avoided if their care had been co‐ordinated during their initial admission.
Optimising care of acute myocardial infarction: Results of a regional quality improvement project
Authors: Scott Ian A , Eyeson‐Annan Margo L , Huxley Sue L , West Malcolm J
Published: March 2003

Abstract The effects of a quality improvement intervention were evaluated in a before–after time‐series study of 649 consecutive patients suffering acute myocardial infarction (AMI) in the West Moreton Health District over 2.5 years from March 1996 through to August 1998. After a 6‐month baseline period, clinical practice guidelines were issued followed by sequential feedback to providers of clinical indicator data over a 1‐year period. Resultant changes in practice were then evaluated during a 12‐month post‐intervention period. The proportion of eligible patients receiving early thrombolysis, lipid‐lowering drugs and cardiac rehabilitation increased, respectively, from 30.8 to 70.0% (P = 0.001), from 23.4 to 56.4% (P = 0.003), and from 23.6 to 54.3% (P = 0.003). The in‐hospital death rate, incidence of postinfarct angina and mean length of stay decreased, respectively, from 15.8 to 8.6% (P = 0.02), from 30.1 to 14.3% (P < 0.001), and from 7.4 to 6.3 days (P = 0.001). Despite the absence of control groups, the present study suggested that clinical guidelines combined with feedback of clinical indicators were useful in improving quality of care.
A comparative study of the nutrient status of two reservoirs in southeast Ghana
Authors: Ansa‐Asare O. D. , Asante Kwadwo Ansong
Published: March 2003

The nutrient status of Weija and Kpong reservoirs, southeast Ghana, was assessed by determining seasonal indices and interannual changes. The nutrient levels were found to be higher in Weija Reservoir. However, ammonia did not follow that pattern. Seasonal distribution of nutrients also showed higher levels in Weija than in Kpong. Seasonal variation showed higher levels of nitrates in the rainy season at Weija than at Kpong; however, data from Kpong Reservoir involved considerable experimental error. The monthly trend of nitrates showed a unique pattern in the months of March and May, the main ploughing periods for farming in the Weija catchment area when most fertilizer is applied. In general, over a 5‐year period, there were no trends in nutrient levels. However, for sulfates there was a gradual decrease in spatial distribution from 1993 to 1997. The seasonal distribution for sulfate increased slightly. Seasonal trends as well as a seasonal index were determined and in all cases Weija showed higher levels than Kpong derived from land‐based fertilizers on the reservoir. On average, there was a higher seasonal index in the rainy season than in the dry season. However, the phosphate index in January at both Weija and Kpong was high. The seasonal index for both Weija and Kpong was high in the rainy season and low in the dry season. However, the phosphate index in January at both Weija and Kpong was high. The high nitrate index in March was due to rain in the latter part of that month. Ammonia–nitrogen in November also showed high levels; November was just after the rainy season so some influence from rain persisted.
Watershed management in the Lake Ohrid region of Albania and Macedonia
Authors: Spirkovski Zoran , Avramovski Oliver , Kodzoman Anita
Published: March 2003

Lake Ohrid is the oldest lake in Europe and one of the oldest lakes in the world, formed 4–10 million years ago. Lake Ohrid serves as a refuge for numerous freshwater organisms from the tertiary period, whose close relatives can be found only as fossils. A breeding programme that artificially hatches the native and endemic trout supports the natural recruitment of lake Ohrid trout and since 1935 the lake has been stocked with more than 600 million young trout. The critical transboundary issue for Lake Ohrid water quality is phosphorus pollution. The current phosphorus load of the lake is estimated at 150 ton per year and needs to be reduced to 50 ton per year to keep the mean concentration of phosphorus below 7 mg m–3 in the lake water. In 1996, a Memorandum of Understanding between the Macedonian and Albanian governments was signed and a binational Lake Ohrid Management Board was established, with substantial funding by the Global Environmental Facility. Both governments agreed to undertake appropriate legal, institutional, investment and technical measures to protect Lake Ohrid. The Lake Ohrid Conservation Project has four main goals: (i) to develop the institutional legal and regulatory framework for environmental management in the Lake Ohrid watershed; (ii) to establish a comprehensive binational monitoring programme, (iii) to mobilize and secure commitments from all the stakeholders in the watershed who will need to take measures to prevent degradation of the lake; and (iv) to increase public awareness and participation. Harmonizing Albanian and Macedonian laws and regulations may be the Lake Ohrid Conservation Project’s greatest challenge, particularly on fisheries and wastewater treatment issues.
Dementia of the frontal lobe type with clinicopathological features of corticobasal degeneration except for lack of glial cytoskeletal abnormalities
Authors: Yamaguchi Shin‐ichi , Kojima Hideaki , Ohtake Toshiyuki , Oda Masaya
Published: March 2003

A 60‐year‐old left‐handed lawyer presented with a pro‐gressive dementing, aphasic, and akinetic–rigid syndrome. He later developed stimulus‐sensitive myoclonus, supranuclear gaze palsy, postural finger tremor, and finally, an akinetic‐mute state with contracture of the limbs. Left predominance was evident in the neurological signs and symptoms throughout the course. Corticobasal degenera‐tion (CBD) was clinically suspected. He died of respiratory failure due to repeated aspiration pneumonias 12 years and 7 months after the onset of the disease. The neuro‐pathological examination revealed a right‐dominant hem‐ispheric atrophy, pronounced in the frontal lobes, with numerous ballooned neurons and degeneration in the substantia nigra, corpus striatum, globus pallidus, thal‐amus, inferior olivary nucleus, cerebellum, frontopontine tract and corticospinal tract. While neurofibrillary tangles were sparsely detected in the brain stem, neither Gallyas‐Braak nor tau stainings showed any cytoskeletal abnormalities of glia cells. Our case and previously re‐ported similar cases could belong to a certain category of dementia of the frontal lobe type, such as Pick's disease without Pick's bodies, mimicking CBD both clinically and pathologically. These cases provide essential insight into the concept of CBD and allied disorders.
Cerebral amyloid angiopathy: An overview
Authors: Yamada Masahito
Published: March 2003

Cerebral amyloid angiopathy (CAA) is characterized by amyloid deposition in cortical and leptomeningeal vessels. Several cerebrovascular amyloid proteins (amyloid β‐protein (Aβ), cystatin C (ACys), prion protein (AScr), transthyretin (ATTR), gelsolin (AGel), and ABri (or A‐WD)) have been identified, leading to the classification of several types of CAA. Sporadic CAA of Aβ type is commonly found in elderly individuals and patients with Alzheimer’s disease. Cerebral amyloid angiopathy is an important cause of cerebrovascular disorders including lobar cerebral hemorrhage, leukoencephalopathy, and small cortical hemorrhage and infarction. We review the clinicopathological and molecular aspects of CAA and discuss the pathogenesis of CAA with future perspectives.
Subacute myelo‐optico‐neuropathy: Clioquinol intoxication in humans and animals
Authors: Tateishi Jun
Published: March 2003

It remains a tragic event that some 10 000 individuals in Japan developed a unique neurologic disease, subacute myelo‐optico‐neuropathy (SMON). Many of the affected patients still suffer serious sequelae, such as dysesthesia and muscle weakness in the lower extremities, and loss or deficits in visual acuity. Neuropathologic studies on SMON patients and experimental reproduction of the disease in animals which had been administered clioquinol helped resolve the etiology of this disease. Common pathologic features seen in SMON patients and in dogs and cats chronically intoxicated with clioquinol were distal dominant axonopathy, mainly in the spinal long tracts and optic tracts. Particular abdominal symptoms present in patients after clioquinol ingestion could also be reproduced experimentally in dogs. SMON research in Japan may be worth reviewing for determining the etiology and preventing similar neurotoxic diseases in the future.
Juvenile muscular atrophy of distal upper extremity (Hirayama disease): Focal cervical ischemic poliomyelopathy
Authors: Hirayama Keizo
Published: March 2003

Hirayama disease is characterized by an initially progressive muscular weakness and atrophy of the distal upper limb(s) in adolescence, occurring predominantly in males, followed by spontaneous arrest within several years. Although the disease could be separated from motor neuron disease, some authors considered the illness to be a variant of degenerative motor neuron disease until the first autopsy case was reported which showed focal ischemic changes in the anterior horn of the lower cervical cord. Since then, many in Japan have recognized the disease as cervical ischemic poliomyelopathy; however, several authors in foreign countries did not or do not appreciate the pathologic findings of the disease, and still consider the illness a degenerative motor neuron disease. The pathology of the disease prompted neuroradiologic investigations, which have revealed dynamic changes of the cervical dural sac and spinal cord induced by neck flexion. The cause of these dynamic changes is unknown. However, as the number of patients is exceedingly large in Japan, there may be an ethnic factor.