Endoscopic classification of the papilla of Vater. Results of an inter- and intraobserver agreement study.

BACKGROUND: Many endoscopists acknowledge that the appearance of the papilla of Vater seems to affect biliary cannulation. To assess the association between the macroscopic appearance of the papilla and biliary cannulation and other related clinical issues, a system is needed to define the appearance of the papilla. OBJECTIVE: The purpose of this study was to validate an endoscopic classification of the papilla of Vater by assessing the interobserver and intraobserver agreements among endoscopist with varying experience. METHODS: An endoscopic classification, based on pictures captured from 140 different papillae, containing four types of papillae was proposed. The four types are (a) Type 1: regular papilla, no distinctive features, 'classic appearance'; (b) Type 2: small papilla, often flat, with a diameter ≤ 3 mm (approximately 9 Fr); (c) Type 3: protruding or pendulous papilla, a papilla that is standing out, protruding or bulging into the duodenal lumen or sometimes hanging down, pendulous with the orifice oriented caudally; and (d) Type 4: creased or ridged papilla, where the ductal mucosa seems to extend distally, rather out of the papillary orifice, either on a ridge or in a crease. To assess the level of interobserver agreement, a web-based survey was sent out to 18 endoscopists, containing 50 sets of still images of the papilla, distributed between the four different types. Three months later a follow-up survey, with images from the first survey was sent to the same endoscopists. RESULTS: Interobserver agreement was substantial (κ = 0.62, 95% confidence interval (CI) 0.58-0.65) and were similar for both experts and non-experts. The intraobserver agreement assessed with the second survey was also substantial (κ = 0.66, 95% CI 0.59-0.72). CONCLUSION: The proposed endoscopic classification of the papilla of Vater seems to be easy to use, irrespective of the level of experience of the endoscopist. It carries a substantial inter- and intraobserver agreement and now the clinical relevance of the four different papilla types awaits to be determined.

Growing seasons of Nordic mountain birch in northernmost Europe as indicated by long-term field studies and analyses of satellite images.

The phenophases first greening (bud burst) and yellowing of Nordic mountain birch (Betula pubescens ssp.tortuosa, also called B. p. ssp. czerepanovii) were observed at three sites on the Kola Peninsula in northernmost Europe during the period 1964-2003, and at two sites in the trans-boundary Pasvik-Enare region during 1994-2003. The field observations were compared with satellite images based on the GIMMS-NDVI dataset covering 1982-2002 at the start and end of the growing season. A trend for a delay of first greening was observed at only one of the sites (Kandalaksha) over the 40 year period. This fits well with the delayed onset of the growing season for that site based on satellite images. No significant changes in time of greening at the other sites were found with either field observations or satellite analyses throughout the study period. These results differ from the earlier spring generally observed in other parts of Europe in recent decades. In the coldest regions of Europe, e.g. in northern high mountains and the northernmost continental areas, increased precipitation associated with the generally positive North Atlantic Oscillation in the last few decades has often fallen as snow. Increased snow may delay the time of onset of the growing season, although increased temperature generally causes earlier spring phenophases. Autumn yellowing of birch leaves tends towards an earlier date at all sites. Due to both later birch greening and earlier yellowing at the Kandalaksha site, the growing season there has also become significantly shorter during the years observed. The sites showing the most advanced yellowing in the field throughout the study period fit well with areas showing an earlier end of the growing season from satellite images covering 1982-2002. The earlier yellowing is highly correlated with a trend at the sites in autumn for earlier decreasing air temperature over the study period, indicating that this environmental factor is important also for autumn phenophases.

Efficacy of distant healing--a proposal for a four-armed randomized study (EUHEALS).

BACKGROUND: Distant healing as a treatment modality is frequently used by patients and healers. Some preliminary evidence suggests possible effects. Since patients suffering from multiple chemical sensitivity and chronic fatigue syndrome have only few effective treatment options, distant healing will be offered as a treatment within a formal trial of distant healing. DESIGN AND METHOD: A four-armed randomized trial will include 400 patients with self-attributed, environmental problems who fulfil the diagnostic criteria of severe idiopathic chronic fatigue, chronic fatigue syndrome or multiple chemical sensitivity. Patients will be recruited by specialized general practitioners and environmental clinics. They will be treated by healers distributed all over Europe, coming from various healing traditions and nationalities. Each patient will be treated by 3 healers. Healers will have no contact with the patients and will only be provided with the patient's Christian name and a photograph. The patients will be randomized to one of 4 groups in a 2 x 2 factorial design. They will either receive (distant) healing or not, and either know or not know this decision. Thereby the effects of expectation and of time can be disentangled from the specific effects of healing. OUTCOME MEASURE: Primary outcome measure will be the mental health summary scale of the MOS SF-36. The measure will be taken at the beginning and at the end of a 6- month treating or waiting period, respectively. A variety of moderator variables will be considered to evaluate which of these may be predictive of outcome.

Personality and abilities of children claiming previous-life memories.

Young children who claim memories of a previous life can be found in many countries, particularly in Asia. The child frequently states where he/she lived previously, often claims violent death in the previous life and shows phobias/philias, and sometimes has birthmarks or deformities that he/she associates with the previous life. The Gudjonsson Suggestibility Scale, Raven Progressive Matrices, Peabody Picture Vocabulary Test, and the Child Behavior Checklist were administered to 23 children in Sri Lanka who, mostly at an earlier age, had consistently been claiming memories of a previous life. They had greater verbal skills and better memory than their peers, performed much better in school, and were more socially active, but were not more suggestible. As judged by their parents, they had a higher Child Behavior Checklist problem score than their peers, but not according to their teachers.

The cost of treatment of dermatological disorders in hospital versus health centre.

Well-run outpatient services and reasonable charges to patients for drugs have led to reduced hospitalisation of dermatological patients and hence a reduction in the total cost of nursing and treating such patients in comparison with previous years, when there was greater emphasis on hospital treatment. There is at present no waiting list for dermatological beds at the National Hospital.

Development and evaluation of teaching course in general practice.

The further development of a teaching course in general practice medicine for fifth year students at Glasgow University is described. Lessons learnt from a previous experimental course have been applied: eight afternoon sessions of a structured nature and related to prescribed objectives and a syllabus were given to small groups of students. Questionnaires showed that the in-depth study of selected patients in their own homes, with student involvement in the preparation of problem lists for group discussion were thought by the students to be valuable. An objective assessment of the course using the modified essay question technique showed an improvement in factual clinical knowledge (P less than 0.05) and more importantly in areas relating to the general practice content of the teaching (P less than 0.001).