Mapping the cortical representation of the lumbar paravertebral muscles.

OBJECTIVE: The aim of this study was to map the cortical representation of the lumbar spine paravertebral (LP) muscles in healthy subjects. METHODS: Transcranial magnetic stimulation (TMS) was employed to map the cortical representations of the LP muscles at two sites. Stimuli were applied to points on a grid representing scalp positions. The amplitude of motor evoked potentials (n=6) was averaged for each position. RESULTS: The optimal site for evoking responses in the contralateral LP muscles was situated 1cm anterior and 4 cm lateral to the vertex. Ipsilateral responses were evoked from sites lateral to the optimal site for evoking contralateral responses. Contralateral responses were also obtained from areas anterior to the optimal site. CONCLUSIONS: Maps of these muscles can be produced. The results suggest discrete contra- and ipsilateral cortical projections. Anterior sites at which excitation can be evoked may indicate projections arising in the SMA are involved. SIGNIFICANCE: This study provides normative data regarding the cortical representation of the paravertebral muscles and provides a technique for evaluating cortical motor plasticity in patients presenting with spinal pathologies.

A comparison of travel related ID admissions in Glasgow: (1985; 1998/99).

A comparative study was made of patients admitted over 12 months to the principal infectious diseases unit for Glasgow in 1985 and in 1998/99. During this interval UK travel statistics show a 135% growth in visits abroad and a 5% rise to 17% in destinations with a risk of malaria. Travel associated admissions rose by 96% to a total of 108. Patients of Asian/Oriental ethnicity declined from 55% to 18%, whilst Caucasians increased from 38% to 81%. Travellers aged 20-39 years formed the modal age groups (51% and 50%). Gastro-intestinal problems accounted for the largest single diagnostic category in both study periods, 38% and 40% respectively. In-patients diagnosed with malaria fell by 20%; these figures are cause for encouragement to those involved in the teaching and dissemination of advice on malaria prophylaxis. The findings re-enforce the need for the continuation and expansion of travel health education for both healthcare professionals and the public.

A comparison of the WHOQOL-100 and the WHOQOL-BREF in detecting change in quality of life following liver transplantation.

The World Health Organization has recently produced a generic quality of life measure--the WHOQOL-100, together with an abbreviated version, the WHOQOL-BREF. Preliminary data suggest that the WHOQOL BREF provides a valid and reliable alternative to the lengthier WHOQOL-100. In the present study, the sensitivity to change of both versions was tested pre- and 3 months post liver transplantation in fifty patients and also in twenty-one non-transplanted liver disease controls. Quality of Life domains on both measures were highly correlated, and were sensitive to change following transplant and remained stable on repeat assessment in non-transplanted control patients. However, the sensitivity to change was significantly reduced for the Social domain in the WHOQOL BREF. It is concluded that the WHO-QOL-BREF is a useful alternative to the WHOQOL-100 in evaluating quality of life improvement following major therapeutic interventions for Physical, Psychological and Environmental domains of life quality. However, researchers interested in measuring the Social aspects of life quality may be best advised to use the lengthier WHOQOL-100.

Gastrointestinal infections presenting in general practice in Scotland.

OBJECTIVES: To determine the incidence of gastrointestinal infections (GII) presenting to general practitioners (GPs) in Scotland, To record the demographic and clinical characteristics of persons presenting with GII, To determine the proportion and characteristics of GII investigated in the laboratory, To report on the microbiological aetiology of the GII. DESIGN: Descriptive epidemiological study. SETTING: Twenty three general practices in Scotland serving a total practice population of 152,471. SUBJECTS: Patients consulting their GPs for a 'gastrointestinal infection' which met the study case definition. RESULTS: These are presented for the 3872 patient consultations for GII between April 1996 and December 31st 1997 which met the survey case definition. The crude annual rate of new consultations recorded was 1.7 per 100 person years. The crude monthly consultation rate for new cases ranged between 11 and 18 per 10,000 patients. GPs notified 9% of the cases as 'food poisoning'. A request for microbiological testing of samples at the local laboratory for clinical reasons was documented for 34% of cases with diarrhoea. The study laboratory received faecal samples by post from 66% of these cases. About one in five of the samples tested revealed evidence of infection with a common gastrointestinal pathogen. The pathogens most frequently reported were Campylobacter sp and Salmonella sp. CONCLUSION: The incidence of consultations for GII in Scotland is similar to that recorded in a recent survey in England. The very low notification rate by GPs means that statutory notification by telephone or post is a poor basis for early warning of outbreaks. It is recommended that a pilot study of electronic notification using the NHS net is set up.

Health surveillance of Glasgow medical undergraduates pursuing elective studies abroad (1992-1998).

BACKGROUND: An integral part of the training for many UK medical undergraduates involves a period of elective study abroad. There is concern about the health risks this poses to the students, and uncertainty regarding the responsibility this places on medical schools. METHODS: Annually since 1992, medical undergraduates at Glasgow University have been asked to complete and return a confidential questionnaire on return from their elective studies. This records personal demographic details, the countries visited, and information about illnesses experienced. Analyses were conducted on the students' health experiences, lifestyle, the health precautions taken, and the climates experienced. RESULTS: Global statistics were compiled on 750 respondents. A subset of 267 completed a more extensive, post-1996, questionnaire enabling detailed study of comparative illness rates. A majority took pretravel health advice, visited only one country, stayed for 1 to 2 months, and experienced a tropical climate. Forty-five percent reported symptoms of illness, and alimentary symptoms predominated (77% of those ill). Higher illness rates were reported in those who experienced a hot desert or tropical climate compared with those who did not. There was correlation between taking professional pretravel health advice and exposure to a more hazardous climate. CONCLUSIONS: The attack rate for medical students on electives compares favorably to that for package holidaymakers; similarly the attack rate for students staying in the tropics compared with other travelers. A preexisting health problem did not predispose to a higher attack rate. Attack rates can be minimized by avoiding climatically extreme locations. This surveillance provides a focus of interest to the students, insight on minimizing avoidable health problems, evidences social responsibility by the Medical Faculty, and has the potential for expansion to other medical schools. Current Scottish medical school policies on HIV risk management would be strengthened by a more coordinated approach.

Sensitivity to Change Following Liver Transplantation: A Comparison of Three Instruments that Measure Quality of Life.

There is an increasing focus on the importance of quality-of-life (QOL) factors in evaluating the efficacy of medical and surgical interventions. There are a wide number of instruments currently available, and the aim of the present study was to evaluate the relative sensitivity to change of three widely used QOL measures, the WHOQOL-100, the SF-36 and the Rotterdam Symptom Checklist, focusing on psychological and physical components of life quality. Fifty patients were assessed pre- and 3 months post-liver transplantation. In addition, 21 patients with liver disease but who were not transplanted were assessed twice, separated by a 3-month interval, in order to serve as a comparison group. All QOL measures showed significant improvement following liver transplantation, whereas the control group showed no significant within-subject change on any measure. We employed the Standardised Response Mean (SRM) effect size as our index of clinically meaningful change in QOL measures. Large SRM effect sizes were obtained following liver transplantation for WHOQOL-100 and SF-36 summary measures, and for the Rotterdam physical subscale. In contrast, the traditional SF-36 scale scores and Rotterdam psychological subscale exhibited only moderate sensitivity to change.

Variceal haemorrhage and post-traumatic stress disorder.

OBJECTIVE: Post-traumatic Stress Disorder (PTSD) is thought to be relatively common following extremely distressing life-threatening events. Patients with liver cirrhosis can experience severe brisk variceal haemorrhage during which they vomit litres of blood and may exsanguinate. We predicted that a significant proportion of survivors would suffer from PTSD. DESIGN: PTSD assessment of 30 patients who had a haematemesis of more than four units of blood secondary to variceal bleeding and were fully conscious at the time of the bleed. METHOD: Structured Clinical Diagnostic Interview (SCID-DSM-III-R) and self-report measures. RESULTS: Most found the experience distressing, but only 1 out of 30 patients fulfilled DSM-III-R diagnostic criteria for PTSD. CONCLUSIONS: PTSD in a sample of patients who survived life-threatening variceal haemorrhage is much rarer than might reasonably have been anticipated. Possible reasons for this low prevalence of PTSD are discussed.

Heterologous biopharmaceutical protein expression in Streptomyces.

The commercial production of human proteins in recombinant microorganisms for therapeutic use is well established. Systems have been developed to exploit the natural ability of certain bacteria to secrete properly folded, bioactive proteins into the extracellular medium. The streptomycetes are a relatively well-characterized group of nonpathogenic filamentous bacteria that have the capacity to secrete large amounts of protein. In particular, Streptomyces lividans has the ability to secrete human proteins at a commercially viable level, thanks to relatively well-established plasmid-based expression system, a high-biomass fermentation process and a low level of endogenous protease activity.

Benzodiazepine-like substances and hepatic encephalopathy : implications for treatment.

Hepatic encephalopathy is a neuropsychiatric syndrome that can complicate acute and chronic liver disease. Recent research has focused on the role benzodiazepine-like substances play in the pathogenesis of this disorder. It has been proposed that potentiation of the action of the neuroinhibitory transmitter γr-aminobutyric acid (GABA) through the binding of endogenous benzodiazepine agonists to the benzodiazepine receptor binding site accounts for the clinical and biochemical features of this condition.Increased levels of endogenous benzodiazepine-like substances have been noted in animal models of hepatic encephalopathy. In human studies, levels of these substances of up to 10 times those found in the body fluids of nonencephalopathic controls have been reported. The existence of such markedly elevated levels cannot be satisfactorily explained with reference to possible pharmaceutical or dietary origins.Further support for the role of benzodiazepines in the mediation of hepatic encephalopathy comes from the therapeutic effect reported after administration of the benzodiazepine receptor antagonist flumazenil. Improvements in the severity of hepatic encephalopathy have been documented in rats with fulminant hepatic failure given flumazenil, although results have been inconsistent according to the dose of flumazenil used and the procedure employed to induce the encephalopathy. Transient, but distinct, improvements in the grade of hepatic encephalopathy have also been documented in several human studies. In a placebo-controlled study involving patients with mild hepatic encephalopathy, a low dose of flumazenil (0.2 mg/kg) resulted in a significant improvement in reaction time.Research now needs to identify whether the beneficial effect of flumazenil is due to its antagonistic or inverse agonistic properties, and also to clarify the mechanisms by which the differential response to the drug in animal models of fulminant hepatic failure is mediated.

Mobility of Scottish injecting drug users and risk of HIV infection.

Nine hundred and nineteen injecting drug users (IDUs) were interviewed in Glasgow, Scotland during 1990 and 1991, as part of a wider study of HIV risk behaviour, about their injecting and sexual behaviour outside the city in the previous two years. Forty-five percent of respondents injected outside Glasgow, 6% shared needles and syringes (n/s) and 20% had sexual intercourse. Much activity occurred outside Scotland but mainly within the UK, particularly London. Predictors of n/s sharing outside Glasgow during the previous two years included current injecting with and passing on of used n/s and sexual intercourse with casual partners. Predictors of sexual behaviour outside Glasgow included passing on used n/s, having sexual intercourse with casual partners and, for females, engaging in prostitution. Glasgow IDUs are a highly mobile group and although HIV prevalence remains low within this population, considerable potential for importation/exportation of HIV and other bloodborne and sexually transmitted infections exists. Further work is required to establish why IDUs travel to, and engage in high-risk activities in locations outside their home environment, and detailed data about activities such as frequency of condom usage and n/s cleaning practices need to obtained. While there is a widespread network of services for IDUs in the UK, information provided usually relates to local services and may not fully address the needs of this mobile population. Therefore, we recommend that IDUs be provided with details of facilities such as n/s exchange schemes and drug-treatment establishments in centres to where they most commonly travel.

Epidemiology of travel.

The unprecedented scale and speed of contemporary international travel means that ever increasing numbers of travellers are exposed to unfamiliar infections and other hazards. Since 1973, surveillance has been conducted at the Communicable Diseases (Scotland) Unit on illnesses affecting returning travellers. This has helped define the perspective of illness associated with travel, to evaluate the effectiveness of pre-travel health advice and to develop a computerised data base designed to give advice on the prevention of travellers' illnesses. These and other epidemiological studies suggest that: (a) younger travellers experience more illness (b) the greater the climatic and cultural contrast between the traveller's country of origin and the destination country, the higher the risk (c) by far the commonest afflictions the traveller is likely to experience are diarrhoea and vomiting (d) the cost of travel-related illness in the UK is in excess of pounds 11 million.

Immunisation and health advice for travellers: the role of the general practitioner.

More and more travellers go to ever more widespread destinations. Diverse sources of advice exist on the protection of travellers against medical hazards encountered abroad. This study attempts to show that the General Practitioner (GP) is the best person to give pre-travel health advice on immunisation and malaria prophylaxis. A postal questionnaire was sent to all 681 GPs in the Greater Glasgow area, to assess their views on the provision of health advice for travellers; in addition we asked whether they knew about the free access to a computerised database on travel health advice (Travax) provided by the Communicable Diseases (Scotland) Unit, and what their view was of the usefulness of this service. The overwhelming majority (87%) of responding GPs felt that pre-travel health advice was best provided in the primary care setting. This group of GPs appear enthusiastic about providing health advice for travellers, in accord with the apparent preference of travellers themselves, and 85% indicated that they would find the travel health advice service a useful aid.