DVT presentations to an Emergency Department: A study of guideline based care and decision making.

Pre-test probability scoring and blood tests for deep venous thrombosis (DVT) assessment are sensitive but not specific leading to increased demands on radiology services. 385 patients presenting to an Emergency Department with suspected DVT were studied to explore our actual work up of patients with possible DVT relating to risk stratification, further investigation and follow up. Of the 205 patients with an initially negative scan, 36 (17.6%) were brought for review to the Emergency Department Consultant clinic. 34 (16.6%) patients underwent repeat compression ultrasound with 5 (2.4%) demonstrating a DVT on the second scan. Repeat compression ultrasound scans were performed on 34 (16.6%) of patients with an initially negative scan with essentially the same diagnostic yield as other larger studies where 100% of such patients had repeat scanning. Where there is ongoing concern, repeat above knee compression ultrasound within one week will pick up a small number of deep venous thromboses.

Factors that influence the patient uptake of diabetic retinopathy screening.

AIM: To assess whether patients were receiving regular diabetic retinopathy screening and to examine factors influencing screening uptake. METHODS: A questionnaire covering demographics, diabetic medical history and the knowledge of and attitudes to diabetic retinopathy was administered to all adults who were due to attend diabetes clinics in two centres in Dublin, Ireland over two months in 2001/2002. RESULTS: Of the 209 people who completed the questionaire, 169 (81%) had a dilated fundal examination within the last year. The most significant predictor for receiving screening was a previous physician recommendation about the necessity of a regular eye examination. The main barriers to receiving adequate screening were lack of knowledge regarding the need for ocular examination and the effect of mydriasis in prohibiting driving. CONCLUSIONS: It is essential that patients are fully aware of the need for a regular eye examination. Once a physician recommends this the screening rate improves.

Trends and geographic inequalities in the prevalence of Down syndrome in Europe, 1980-1999.

BACKGROUND: EUROCAT is a network of population-based registries for the epidemiologic surveillance of congenital anomalies covering approximately one quarter of births in the European Union. Down syndrome constitutes approximately 8% of cases of registered congenital anomaly in Europe, with over 7000 affected pregnancies in the 15 current member states of the European Union each year. In this paper, we aim to examine trends in the live birth prevalence of Down syndrome in Europe in the light of trends in maternal age and in prenatal diagnosis. METHODS: Descriptive analysis of data from 24 EUROCAT registries, covering 8.3 million births 1980-99. Cases include live births, stillbirths and terminations of pregnancy following prenatal diagnosis. RESULTS: Since 1980, the proportion of births to mothers of 35 years of age and over has risen quite dramatically from 8 to 14% for the European Union as a whole, with steeper rises in some regions. By 1995-1999, the proportion of "older" mothers varied between regions from 10% to 25%, and the total prevalence (including terminations of pregnancy) of Down syndrome varied from 1 to 3 per 1000 births. Some European regions have shown a more than twofold increase in total prevalence of Down syndrome since 1980. The proportion of cases of Down syndrome which were prenatally diagnosed followed by termination of pregnancy in 1995-1999 varied from 0% in the three regions of Ireland and Malta where termination of pregnancy is illegal, to less than 50% in 14 further regions, to 77% in Paris. The extent to which terminations of pregnancy were concen trated among older mothers varied between regions. The live birth prevalence has since 1980 increasingly diverged from the rising total prevalence, in some areas remaining approximately stable, in others decreasing over time. CONCLUSION: The rise in average maternal age in Europe has brought with it an increase in the number of pregnancies affected by Down syndrome. The widespread practice of prenatal screening and termination of pregnancy has in most of the regions covered by EUROCAT counteracted the effect of maternal age in its effect on live birth prevalence. Under the joint influences of maternal age and prenatal screening the pattern of geographic inequalities in Down syndrome live birth prevalence in Europe has also been changed.

The epidemiology of Down syndrome in four counties in Ireland 1981-1990.

BACKGROUND: We conducted a descriptive epidemiological study of Down syndrome (DS) in the four Irish counties (Dublin, Kildare, Wicklow and Galway) covered by EUROCAT registries of congenital malformations for the years 1981-1990. METHODS: EUROCAT registries, which cover defined populations, use multiple sources for case ascertainment. All DS cases born between 1 January 1981 and 31 December 1990 to mothers resident in the four counties were identified. Crude birth prevalence rates and maternal age-standardized rates (SPRs) were calculated for each county and for each year in the study period. The prevalence of DS by maternal age grouped in five-year periods and the risk for each five-year group were also estimated. RESULTS: The crude birth prevalence for the four counties was 18.5/10 000 for all births and 18.3 for live births. There was a fall in the total number of DS births over the decade, but less change in the crude birth prevalence owing to an increase in the proportion of mothers aged 35+. Galway had the highest crude birth prevalence of DS (23.5/10 000) but the SPR was within average for the four counties as a whole - 110.3, 95 per cent confidence interval (CI) 86.7-139. The risk of having a DS child increased 70-fold from 1:1841 at age 15-19 to 1:26 at 45 years or older. Nearly half of all DS cases (47.4 per cent) had at least one additional anomaly. CONCLUSIONS: The parts of Ireland covered by EUROCAT have a high birth prevalence of DS births as compared with some other countries, but the maternal age-specific rates are not substantially different from those in large international studies.

Hemodynamic patterns and duration of post-dynamic exercise hypotension in hypertensive humans.

We investigated: 1) the mechanism of the hypotensive effect of a single bout of dynamic exercise in hypertensive subjects by measuring hemodynamic parameters before and for 2 h after treadmill exercise, and 2) the duration of the effect using ambulatory blood pressure (BP) monitoring once the subjects left the test site. Ten minutes after exercise there was a significant decrease from baseline systolic pressure (SP; -14 +/- 3 mm Hg), mean arterial pressure (MAP; -7 +/- 2 mm Hg), total peripheral resistance (TPR; -3.7 +/- 1.2 units), calf vascular resistance (CVR; -25.4 +/- 4.1 units), and an increase in HR (19 +/- 2 bpm). The changes in SP, DP, MAP, and HR were maintained during the 2 h of post-exercise monitoring; CVR remained decreased for 1 h; TPR returned to baseline within 20 min and then tended to be slightly elevated. CO was significantly decreased at 50, 60, and 120 min after exercise. We conclude that the early decline in BP after dynamic exercise in hypertensive subjects follows a biphasic pattern: 1) an initial decrease in total and regional vascular resistance with maintained CO, 2) followed by increasing resistance and decrease CO. Pre-exercise hypertensive BP values returned during subsequent ambulatory monitoring.

Infant feeding practices.

This study was done on a population of 877 mothers over a five month period. Interviews were held on the first day after delivery and on the day of discharge. Mothers were questioned on their infant feeding practice and on the influences which led them to their choice of feed types. Follow up studies were done in subsequent months on randomly selected populations of breast feeders (103) and bottle feeders (170) to determine duration of breast feeding after discharge from hospital; the factors contributing to cessation of breast feeding; the measure of satisfaction with the brand initially chosen and the factors which caused mothers to change from one brand to another. The salient finding is that 36% breast feed initially and that up to 10% of the total are still doing so five months later. The other findings are discussed and their significance stated.

Ventricular ectopy in cardiac rehabilitation patients on exercise training and nonexercising days.

We evaluated the effect of routine exercise training sessions on the frequency of ventricular ectopic activity (VEA) in 18 coronary artery disease patients (mean age = 60 years) who were active participants in a cardiac rehabilitation program. Nine patients were classified as high risk and nine patients were low risk according to clinical status and cardiac catheterization criteria. Five patients in each group were on beta blockade, but none were on antiarrhythmic agents. Serial 24-h ECG monitoring was obtained on a routine supervised exercise day and nonexercise control day. VEA were compared during three time periods: (1) exercise training and recovery (4 h) and the corresponding 4 h during control, (2) activities of daily living (12 h), and (3) sleep (8 h). Both groups showed a moderate increase in total VEA during the three activity periods from control day to exercise day. However, this increase was only significant (p less than 0.05) in the high-risk group during the 12-h activity of daily living period postexercise. VEA was significantly greater (p less than 0.05) in the high-risk group during all activity intervals except the sleep period on the exercise day. We conclude that VEA occurs with similar frequency during exercise training or corresponding control periods. High-risk patients have significantly greater VEA on exercise and control days and show additional increased in VEA during activities of daily living (eating and driving) on exercise days.