Biological data from a data-deficient shark: the Arabian smoothhound Mustelus mosis (Carcharhiniformes: Triakidae).

The present study provides information on length distribution, reproductive biology and diet of Mustelus mosis based on individuals caught in waters off the eastern Arabian Peninsula. Although ageing of vertebral centra was attempted, band pairs were of low clarity and counts could not be confidently assigned.

Self-reported prescribing for hypertension in general practice.

OBJECTIVE: To describe the self-reported management of hypertension in general practice and how this compares to national guidelines for hypertension. DESIGN: Analysis of self-reported cross-sectional clinical audit data. SETTING: Australian general practice for the years 1999, 2001, 2003 and 2004. STUDY POPULATION: A total of 5247 general practitioners who voluntarily participated in one of four hypertension clinical audits and provided data for 105,086 adult patients with a previous diagnosis of hypertension. MAIN OUTCOME MEASURES: Selection of blood pressure targets consistent with recommendation of hypertension guidelines, percentage of patients achieving target blood pressure and percentage of patients with selected co-morbidities treated with the preferred class of antihypertensive medications. RESULTS: In 2001, target blood pressures of 140/90 mmHg and 130/85 mmHg were being used for 38% and 55% of patients, respectively. In 2004, target blood pressures were 140/90 mmHg (39%), 130/85 mmHg (49%) and 125/75 mmHg (0.5%). In 2003 and 2004, 58% and 70% of patients were reported to have achieved a target blood pressure that was consistent with guidelines according to patient age and co-morbidities. However, only 54-62% of hypertensive patients with heart failure were prescribed an ACE inhibitor and 52% of patients with a history of myocardial infarction were receiving a beta-blocker or ACE inhibitor. CONCLUSIONS: The self-reported data from general practitioners participating in clinical audits show that these general practitioners are using blood pressures targets consistent with guideline recommendations for most patients and that more patients are reaching their target blood pressure. However, drug selection based on co-morbidities could improve.

Measuring angles on digitalized radiographic images using Microsoft PowerPoint / La medición de ángulos en las imágenes radiográficas digitalizadas, mediante el uso de Microsoft PowerPoint

OBJECTIVE: To introduce the " virtual goniometer" , a method of measuring angles on digital images using Microsoft PowerPoint, a readily available and inexpensive software programme. METHODS: Twenty-six X-rays of scoliosis curves were photographed with a digital camera. Six examiners measured the angles of curvature on their computers using the goniometer (Set 1). Under a blinded protocol, repeated measurements on these digitalized X-rays were done three weeks later (Set 2). Intra-observer differences were analyzed. To assess validity, four examiners also measured the angles using the Cobb method. Measurements achieved by both methods were analyzed by the paired samples t-test. To assess inter-observer differences, the Pearson correlation coefficient was calculated. RESULTS: Pearson correlation coefficients were significant, r (24) $ 0.975, p < 0.001. For intra-observer variability, the average 95% CI range was 2.23 degrees between Set 1 and Set 2. The average 95% CI range was 2.38 degrees for the difference between the digital and Cobb methods. CONCLUSIONS: Clinicians using this technique can reliably assume that repeated measurements of scoliosis curvatures will vary in the range of less than 3 degrees. The 95% CI range for intra-observer variability, an index of the technique’s repeatability, was $ 2.4 degrees. A high correlation of measurements can also be expected between different observers with the goniometer. This new technique allows practitioners to utilize an easily accessible computer programme to evaluate angular deformities on digitalized radiographic images accurately and hence reliably make clinical decisions based on these measurements.

OBJETIVOS: Introducir el " goniómetro virtual" , un método de medición de ángulos sobre imágenes digitales usando Microsoft Power Point, un programa de software no costoso y fácilmente disponible. MÉTODOS: Veintiséis rayos X de curvas de escoliosis fueron fotografiados con una cámara digital. Seis examinadores midieron los ángulos de curvatura en sus computadoras usando el goniómetro (Set 1). Bajo un protocolo ciego, se realizaron mediciones repetidas de estos rayos X digitalizados, tres semanas más tarde (Set 2). Se analizaron las diferencias intra-observador. Para evaluar la validez, cuatro examinadores también midieron los ángulos usando el método de Cobb. Las mediciones logradas por ambos métodos fueron analizadas mediante la prueba de t de muestras pareadas. Para evaluar las diferencias inter-observador, se calculó el coeficiente de correlación de Pearson. RESULTADOS: Los coeficientes de correlación de Pearson fueron significativos, r (24) $ 0.975, p < 0.001. Para la variabilidad intra-observador, el 95% promedio del rango del CI fue de 2.23 grados entre el Set 1 y el Set 2. El 95% promedio del rango del CI fue de 2.38 grados para la diferencia entre el método digital y el método de Cobb. CONCLUSIONES: Los clínicos que usen esta técnica, pueden con toda confiabilidad asumir que las mediciones repetidas de las curvaturas de escoliosis variarán en un rango menor de 3 grados. El 95% del rango del CI para la variabilidad intra-observador Â- un índice de la repetibilidad de la técnica Â- fue $ 2.4 grados. También puede esperarse una alta correlación de las mediciones, entre diferentes observadores con el goniómetro. Esta nueva técnica permite a los practicantes utilizar un programa de computación fácilmente accesible a fin de evaluar con precisión las deformidades angulares en imágenes radiográficas digitalizadas, y tomar por lo tanto decisiones clínicas de modo confiable a partir de estas mediciones.

Measuring angles on digitalized radiographic images using Microsoft PowerPoint.

OBJECTIVE: To introduce the "virtual goniometer", a method of measuring angles on digital images using Microsoft PowerPoint, a readily available and inexpensive software programme. METHODS: Twenty-six X-rays of scoliosis curves were photographed with a digital camera. Six examiners measured the angles of curvature on their computers using the goniometer (Set 1). Under a blinded protocol, repeated measurements on these digitalized X-rays were done three weeks later (Set 2). Intra-observer differences were analyzed. To assess validity, four examiners also measured the angles using the Cobb method. Measurements achieved by both methods were analyzed by the paired samples t-test. To assess inter-observer differences, the Pearson correlation coefficient was calculated. RESULTS: Pearson correlation coefficients were significant, r (24) > or = 0.975, p < 0.001. For intraobserver variability, the average 95% CI range was 2.23 degrees between Set 1 and Set 2. The average 95% CI range was 2.38 degrees for the difference between the digital and Cobb methods. CONCLUSIONS: Clinicians using this technique can reliably assume that repeated measurements of scoliosis curvatures will vary in the range of less than 3 degrees. The 95% CI range for intra-observer variability, an index of the technique's repeatability, was > or = 2.4 degrees. A high correlation of measurements can also be expected between different observers with the goniometer. This new technique allows practitioners to utilize an easily accessible computer programme to evaluate angular deformities on digitalized radiographic images accurately and hence reliably make clinical decisions based on these measurements.

National Prescribing Service: creating an implementation arm for national medicines policy.

Medicines make an essential contribution to the health of the community, but rapidly rising drug budgets have caused governments to seek ways of ensuring this expenditure results in value for money. The National Prescribing Service was established against this background to implement a quality use of medicines service as part of the National Medicines Policy. A range of programmes that attempt to use evidence-based strategies to deliver evidence-based messages have been established. These use multifaceted interventions, such as newsletters, prescriber feedback, clinical audit and educational visiting, that are provided both centrally, through the national office, and locally, through Divisions of General Practice. The work is underpinned by an evaluation strategy that incorporates strong qualitative elements as well as an emphasis on time-series analyses for changes in drug utilization. Some 80% of Australian general practitioners have voluntarily participated in activities such as educational visiting and clinical audit within the National Prescribing Service programmes. New programmes for the community and consumers will be coordinated with the work that has become well established within general practice.

Indicators for drug and therapeutics committees.

AIMS: This study describes development and field testing of a set of indicators for drug and therapeutics committees (DTCs) in hospitals. It was intended that these indicators should be accessible, useful and relevant in the Australian setting. METHODS: Candidate indicators were written following consultation and data collection. A framework of outcome, impact and process indicators was based on DTC goals, objectives and strategies. The candidate indicators were field tested over a 2 month period in teaching, city non-teaching, rural and private hospitals. The field tests provided response data for each indicator and evaluation of the indicators against criteria for accessibility, relevance, usefulness, clarity and resource utilisation. Consensus on which indicators to accept, modify or reject was reached at a workshop of stakeholders and experts, taking account of the field test results. RESULTS: Thirty-five candidate indicators were tested in 16 hospitals. Twenty-two had a response from >80% of sites, 23 had a mean relevance rating >3.5, 19 had a mean usefulness rating >3.5, 27 were correctly interpreted by > 90% of sites and 25 could be collected in an acceptable time. The most acceptable indicators required least data collection or provided data deemed useful for purposes other than the field test. At the consensus workshop 13 indicators were accepted with no or minor change, nine were accepted after major modification and eight were discarded. It was recommended that a further five indicators should be merged or subsumed into one indicator. CONCLUSIONS: This study has developed and field tested a set of indicators for DTCs in Australia. The indicators have been taken up enthusiastically as a first attempt to monitor DTC performance but require ongoing validation and development to ensure continuing relevance and usefulness.

The application of adverse drug reaction data to drug choice decisions made by pharmacy and therapeutics committees. An Australian perspective.

Pharmacy and Therapeutics (P&T) committees undertake policy, regulatory and educational activities to promote rational use of medicines in their institutions with the aim of improving the quality of health and economic outcomes at these institutions. Formulary management is an important part of the P&T committees' activities and making drug choices is one of the committees' most difficult tasks. The 3 types of information most commonly identified by P&T committees as necessary for making drug choices are effectiveness, safety and cost data; usually in this order of importance. There is some evidence, however, that safety data are not considered by all committees when they make decisions about adding a new drug to a formulary. The role of adverse drug reaction (ADR) data in formulary decision-making (for registered drugs) occurs at several levels. First, ADR data obtained from pre-marketing studies of the drug are important and enable the committee to make an assessment of the risk of toxicity that should be anticipated for the drug. However, the limited nature of this information makes an absolute assessment impossible. Secondly, comparative safety information is necessary when deciding the place in therapy of a particular drug. Weighing up the comparative risks and benefits is a complex task which is a routine activity for most P&T committees whatever level of sophistication is applied. Thirdly, ADR data are an important ingredient of any economic assessment considered by a P&T committee. Calculation of the costs and consequences associated with the adverse effects of treatment demand careful assessment. Finally, aggregated adverse drug event reports which collate not only the consequences of adverse drug reactions but also medication incidents (medication errors) and which have been reported locally can be a useful quality assurance process for a P&T committee. This information will contribute to the identification of drugs for deletion from the formulary and less commonly in making decisions about additions to the formulary. As formulary management forms only part of a P&T committee's work, so the committee's interest in ADR is broader than the use of these data in making drug choices. The P&T committee may also be involved in promoting ADR reporting to either a central database or primary carers. Although often of limited availability, ADR information has an important role in the formulary management process of P&T committees.

Drug and Therapeutics Committees in Australia: expected and actual performance.

1. This study describes stakeholders' opinions on Drug and Therapeutics Committees (DTCs) and measures the composition, activities and perceived effectiveness of DTCs in Australia. 2. Focus groups explored the opinions of clinicians, consumers and administrators on the goals, objectives and strategies of DTCs. 3. A national survey was sent to 306 hospitals to collect data on the composition, committee processes, goals, objectives, educational activities, policies and decision making of DTCs. 4. Stakeholders believed the DTC should optimise therapeutic health outcomes for patients and economic outcomes for the hospital. Important objectives were availability of safe, efficacious and cost-effective medicines, affordability of medicines and quality use of medicines. 5. The national survey of DTCs found that over 92% of respondents had a DTC in their hospital. Composition was generally representational and most commonly included members from the disciplines of internal medicine, pharmacy and nursing. More than half the DTCs had executive authority although only 21% had an appeals mechanism. 6. The most commonly cited issues for DTCs in 1994-95 were quality drug use, drug policies and spending on high cost drugs. 7. While access to clinical pharmacologists and specialist drug utilisation evaluation (DUE) pharmacists was poor, 71% of DTCs had access to DUE data of some sort. Guidelines (61%), prescribing restrictions (60%) and pharmacist monitoring (63%) were the most commonly used strategies to implement DTC policies and decisions. Audit-feedback activities (61%) and drug bulletins (56%) were the most commonly used interventions. 8. Available information for formulary decision making varied with small rural hospitals having access to significantly less information. The most commonly used information was availability of a therapeutic alternative (87%), efficacy (83%), cost (80%) and estimated usage (78%). 9. On average DTCs reported an ability to implement 75% of decisions (range 0-95%) with teaching hospitals perceived to perform better than other hospital types. 10. This study reveals a high level of expectation for DTC activities and achievements. In Australia DTCs were involved in policy, education and management initiatives to promote best practice in therapeutics. Few committees appeared to have adequate resources to extend services to their wider community.

Pharmacokinetics of alcuronium in children with acyanotic and cyanotic cardiac disease undergoing cardiopulmonary bypass surgery.

The aim of this study was to determine the pharmacokinetic parameters for alcuronium in children with cyanotic or acyanotic congenital cardiac disease undergoing cardiopulmonary bypass surgery and to compare these parameters with previously reported values in children and adults with normal cardiac function. Seven children with acyanotic disease and seven with cyanotic disease were studied. Alcuronium (base) was administered in an initial dosage of 0.25 mg.kg-1 with additional doses as needed to maintain paralysis. Using time averaged data, cyanotic children had lower mean clearance, elimination half-life and volume of distribution at steady state than the acyanotic children; none of these differences was, however, statistically significant. In this study, children with acyanotic and cyanotic cardiac disease undergoing bypass, had a diminished clearance (P < 0.05) and a smaller volume of distribution (P < 0.05) than normal children and a shorter elimination half-life (P < 0.05) than adults. Onset of cardiopulmonary bypass caused an immediate marked decrease in alcuronium plasma concentrations which remained low in the acyanotic children at the completion of bypass.

Who is ordering all those cyclosporin concentrations and how do they use them? An audit of cyclosporin therapeutic drug monitoring.

Therapeutic drug monitoring is used for the immunosuppressant drug, cyclosporin, even though it is often unclear what concentration should be targetted. At St. Vincent's Hospital, Sydney, a polyclonal, whole blood immunoassay is used to measure cyclosporin and metabolites. The objective of the present study was to audit how the concentration results produced by the laboratory were actually used to adjust dosage. Each transplantation unit was asked about their policy for dosage adjustment and which therapeutic range was used. The audit criteria were considered to be passed if the action taken based on a concentration result was (a) predictable based solely on the concentration and its relationship to the stated therapeutic range (e.g., dosage increased if concentration was below therapeutic range) or (b) based on clinical considerations (e.g., dosage decreased because of increased serum creatinine). Data were collected for the actions taken following 347 concentration results over a 6-week period. Audit criteria were fulfilled for 246 (71%) of the results. The majority of the cyclosporin concentrations (75%) were determined for the cardiopulmonary unit; 66% of these fulfilled audit criteria. Approximately two-thirds of all the cyclosporin concentrations requested were followed up by appropriate action based on stated therapeutic ranges or documented clinical reasons.

Burkitt's lymphoma of the ovaries.

A case of Burkitt's lymphoma involving both ovaries of a 15-year-old Guatemalan girl is presented along with a brief review of the pertinent literature.

Disseminated intravascular coagulation.

Disseminated intravascular coagulation (DIC) is not uncommon in the obstetric patient, but DIC of sufficient severity to be of clinical importance is unusual. Treatment of DIC is directed primarily at its cause. Replacement of depleted blood components with packed red blood cells, fresh frozen plasma, cryoprecipitate, and platelets is sometimes required for treating hemorrhage. Heparin should be used only rarely, and only to help control life-threatening hemorrhage because DIC is refractory to vigorous and adequate blood-component therapy. With careful planning of treatment, adherence to a few general principles, and the combined approach of an obstetrician and a coagulationest, fatalities and major morbidity should be rare.

Ruptured spleen as a differential diagnosis in ruptured tubal pregnancy.

Two cases of traumatic biphasic or secondary splenic rupture are presented to demonstrate the clinical picture of an entity the obstetrician-gynecologist will be encountering more commonly in the future. The signs and symptoms of this condition figured prominently in the differential diagnosis of ruptured tubal pregnancy.

The role of the obstetrician-gynecologist in the management of breast lesions.

This paper is based on the author's frequent experience in the diagnosis of breast masses in his everyday practice as an obstetriciangynecologist. It appears that gynecologists, by the very nature of their practices, are in an excellent position to head the case-finding expedition for breast lesions. Furthermore, the obstetrician-gynecologist can use acquired surgical skills to great advantage in the management of benign lesions and assist surgical associates in the management of the malignant lesions.

Cesarean section: a seven-year study.

This paper reports a seven-year study of cesarean section practices at the Queen of Angels Hospital, Los Angeles, California. Indications for this procedure are listed in detail and an attempt is made to explain its increasing frequency. Practicing physicians were interviewed and testimony seemed to indicate, as was suspected, that fear of malpractice suits was one of the reasons for cesarean section. The conventional wisdom of "once a section always a section" is questioned with regard to an increasing number of trials of labor and vaginal deliveries, when they are considered feasible and safe. The federal government is manifesting serious interest in this increased number of operative deliveries in the light of cost effectiveness.