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Introduction: There has been significant growth in international tourism from South-East Asia. Travel medicine services are still quite limited in this region. Few data exists on the knowledge, attitudes and practices of travelers from South-East Asia regarding the prevention of travel-related health risks. The present study aimed to characterize the travel trends and risk reduction strategies of international travelers departing from a major Malaysian airport. Methods: We conducted a cross-sectional survey among international travelers at the Kuala Lumpur International Airport. A questionnaire recorded data on the demographic profile, travel patterns, travel health protective measures, sources of pre-travel health advice, personal perception of travel-related risk, and barriers to seeking health advice, travel vaccinations and malaria chemoprophylaxis. Results: 36.8% of respondents had sought pre-travel health advice, mostly (64.7%) from their doctor. 23.6% of the travelers had received travel vaccinations. 40% of travelers were uninsured and over 50% did not know how to access medical care overseas. The survey revealed deficiencies in the risk perception of travelers regarding endemic infectious diseases such as malaria, dengue, and rabies. A minority of the travelers reported an intention to avoid unsafe food and water, inform themselves of local disease outbreaks, pack a first-aid kit, and protect themselves from animal and mosquito bites. Conclusions: This study highlights areas of concern in relation to the knowledge and behavior of the travelers surveyed and points to the need for raising public awareness in South-East Asia of the risks associated with international travel and the most efficient means of mitigating those risks.

The purpose of this study was to examine the principal travel health priorities of travellers. The most frequently selected travel health concerns were accessing medical care abroad, dying abroad, insect bites, malaria, personal safety and travel security threats. The travel health risks of least concern were culture shock, fear of flying, jet lag and sexually transmitted infections. This study is the first to develop a hierarchy of self-declared travel health risk priorities among travellers.

Basic surgical skills modules in medical education are effective in teaching skills and increasing confidence among students approaching surgery. However, these modules are not delivered universally and their effect on the professional development of graduates has not been established. We aimed to assess the impact of a 10-week basic surgical skills module on attitudes and technical skills of first year medical students compared to interns. Eighteen students participated and were assessed using a 4-part questionnaire. Technical skills were assessed by observing students perform a basic interrupted suture, using the objective structured assessment of technical skills (OSATS) tool. Fourteen interns were recruited. Students were more confident in surgical scrubbing (mean score 4.0 vs. 2.86, p = 0.001), and performing a basic suture (4.05 vs. 1.93, p = 0.000), more enthusiastic about assisting with an operation (4.5 vs. 3.0, p = 0.001) and more likely to consider a career in surgery (4.16 vs. 2.28, p = 0.000). Technical skills were greater in the student group (mean score 30.8 vs. 19.6, p = 0.001). Five interns had taken part in surgical skills modules as undergraduates. Their technical skills were significantly higher compared to interns who had not (n = 9) (28.8 vs. 14.5, p = 0.006), and they were more likely to consider a career in surgery (3.6 vs. 1.5, p = 0.036). The introduction of surgical skills teaching to the undergraduate medical curriculum has a positive impact on students’ attitudes towards surgery and accelerates basic technical skills development. Consideration should be given to development of a standardised undergraduate core curriculum in basic surgical skills teaching.

Cardiovascular disease (CVD) is the primary cause of morbidity and mortality in Ireland and worldwide. Male sporting referees registered with the Gaelic Athletic Association (G.A.A.) represent the Irish male population due to the wide range of ages and CVD risk factors. Although G.A.A. referees, a predominately male population, play a pivotal part in the success of the game, there is a paucity of epidemiological evidence relating to their CVD health status. The purpose of this study was to assess the CVD risk factor profile of male G.A.A. referees in Ireland. An observational, cross-sectional study design was used to assess the CVD risk factor profile of the participants. A cluster and convenience sample method was used to recruit participants aged ≥ 18 years within the G.A.A. referee community throughout Ireland. CVD risk factor profiles were studied using questionnaires, blood pressure (BP) and anthropometric measurements. A total of 183 male G.A.A. referees were studied with a mean age of 39 years (± 6, p = 0.000) for inter-county and 47 (± 11) for club referees. Of the total population studied, 49% had pre-hypertension and 60% were overweight. The findings from this study demonstrate the presence of hypertension and negative lifestyle behaviours within this male population. This justifies the need to implement a policy on the pre-participation screening and risk reduction of CVD for male G.A.A. referees in Ireland. This health promotion intervention would assist in reducing the CVD epidemic within this specific population.

Hypertension is a leading modifiable risk factor for premature cardiovascular disease. Research indicates a growing prevalence of hypertension among adults worldwide, with accompanying low levels of patient knowledge, and sub-optimal clinical management. This study aims to explore the impact of a structured hypertension educational intervention on patient knowledge, lifestyle behaviours and blood pressure control. An observational, prospective cohort design was selected. Participants were recruited through a public blood pressure screening event in a community-based setting. They were asked to complete a self-report questionnaire followed by an assessment of their blood pressure. Participants with high blood pressure were randomly assigned to either a control group or an intervention group. Those in the intervention group received an educational intervention on hypertension 4 weeks later. Both groups were recalled 4 months later for a repeat of the same initial assessment. Eighty-one participants with a mean age of 64 years were included in this study. There were no significant differences in the baseline measures between the two groups. Significant improvements were found in the intervention group compared with the control group in levels of hypertension knowledge and awareness (p =

Evidence-based travel medicine requires that research priorities reflect the wide knowledge base of this discipline. Bibliometric analysis of articles published in Journal of Travel Medicine yielded the following results: epidemiology (6%, n = 105); immunology/vaccinology (8.5%, n = 148); pre-travel assessment/consultation (30.5%, n = 533); diseases contracted during travel (48.3%, n = 843); other clinical conditions associated with travel (6.8%, n = 119); post-travel assessment (5.2%, n = 91) and administrative and general travel medicine issues (6%, n = 105).

Background Death during international travel and the repatriation of human remains to one's home country is a distressing and expensive process. Much organization is required involving close liaison between various agencies. Methods A review of the literature was conducted using the PubMed database. Search terms included: 'repatriation of remains', 'death', 'abroad', 'tourism', 'travel', 'travellers', 'travelling' and 'repatriation'. Additional articles were obtained from grey literature sources and reference lists. Results The local national embassy, travel insurance broker and tour operator are important sources of information to facilitate the repatriation of the deceased traveller. Formal identification of the deceased's remains is required and a funeral director must be appointed. Following this, the coroner in the country or jurisdiction receiving the repatriated remains will require a number of documents prior to providing clearance for burial. Costs involved in repatriating remains must be borne by the family of the deceased although travel insurance may help defray some of the costs. If the death is secondary to an infectious disease, cremation at the site of death is preferred. No standardized procedure is in place to deal with the remains of a migrant's body at present and these remains are often not repatriated to their country of origin. Conclusions Repatriation of human remains is a difficult task which is emotionally challenging for the bereaving family and friends. As a travel medicine practitioner, it is prudent to discuss all eventualities, including the risk of death, during the pre-travel consultation. Awareness of the procedures involved in this process may ease the burden on the grieving family at a difficult time.

Summary Background Stem cell therapies are advertised through online resources which describe a range of treatments with diverse clinical indications. Stem cell tourists may not be aware of the information they should seek when consulting these clinics, or of the potential risks involved. The aim of this study was to characterise the therapies offered by online stem cell clinics. Methods A web based search utilising five search terms was employed. The first twenty pages of each search result were screened against 340 variables. Results 224 out of 1091 websites advertised stem cell clinics. 68 eligible sites covering 21 countries were evaluated. The top five clinical indications for stem cell therapy were multiple sclerosis, anti-ageing, Parkinson's disease, stroke and spinal cord injury. Adult, autologous stem cells were the most commonly utilised stem cell, and these were frequently sourced from bone marrow and adipose tissue and administered intravenously. Thirty-four per cent of sites mentioned the number of patients treated while one quarter of clinics provided outcome data. Twenty-nine per cent of clinics had an internationally recognised accreditation. Fifteen per cent of clinics stated that their therapies posed no risk. Eighty-eight per cent of clinics claimed treatment effectiveness, with 16% describing their curative potential. Over 40% of sites did not specify the number or duration of treatments. Fifty-three per cent of clinics requested access to patients' medical records, and 12% recommended patients discuss the proposed therapy with their doctor. No clinic recommended that travellers consult a travel medicine specialist or receive vaccinations prior to their intended travel. One quarter of sites discussed contraindications to treatment, with 41% of sites detailing follow up patient care. Conclusions There is potential for stem cell tourists to receive misleading or deficient information from online stem cell clinics. Both the stem cell tourist and travel medicine practitioner should be educated on the potential risks associated with stem cell clinical services advertised online.

Travel medicine awaits formal specialty recognition in many jurisdictions. It is likely over time that higher specialist training pathways in this discipline will be established. Education in this dynamic field has focused on the postgraduate phase of medical and nursing education, with the development of postgraduate university programmes and membership examinations.1 The Certificate of Knowledge of the International Society of Travel Medicine assesses an agreed body of knowledge for practising travel health professionals.2 An analysis of the practice of 341 travel health clinics worldwide revealed that 40% of physicians providing travel health advice and vaccinations were not trained in infectious diseases or tropical medicine.3 A retrospective study of returned travellers’ case notes reported deficiencies in the documentation of travel histories in patients presenting to a teaching hospital with symptoms of tropical infectious diseases.4 The recommendations for the practice of travel medicine highlight the need for clinicians to maintain their knowledge and skills through continuing professional development.5 It is desirable to introduce all undergraduate healthcare students to travel medicine, since the majority of medical graduates subsequently train to become general practitioners or family physicians and there is hardly a medical or surgical specialty to which travel health issues are not relevant. These graduates will ultimately provide travel health advice to travellers in a primary care setting, or be required to recognize imported tropical infectious diseases in hospital emergency departments.6 …

Traditionally a small number of clinical specialties, such as obstetrics and gynaecology, have been regarded as particularly high-risk areas of medical practice in terms of medical negligence litigation. Increasing evidence is emerging to substantiate the view that clinical negligence litigation is becoming prevalent in primary and ambulatory care settings.1–3 In common with other specialist areas of clinical practice, travel medicine presents medico-legal risks. The potential for unrecognised medico-legal risk and a lack of risk management practices in travel medicine merit consideration. In order for an allegation of negligence to be proven, four principle facts must be individually established.4 In the first instance, the travel health professional must have a duty of care to the patient. Second, that professional must have failed to reach an accepted standard of practice in the course of providing that care. Third, the patient must have suffered physical, financial, psychological and/or another form of loss. Finally, the loss must have been legally caused by the failure to provide an accepted standard of care. The onus is upon the plaintiff (i.e. the patient) to prove that negligence has occurred, and unless evidence of all four aspects is accepted by the court, the allegation of negligence will not be upheld. Travel health professionals owe a duty of care to any patient who consults them. Within that duty of care, there is an obligation to provide a standard of care that must be approved by a reputable body of opinion within the specialist area of practice. In this way, variation in clinical practice and differences in opinion between practitioners are taken into account. If there is a reasonable body of opinion to support the course of action taken, then the professional will likely be considered to have provided an appropriate standard of care. Duty of care begins …

Few studies have examined emergency self treatment (EST) antimalarial prescribing patterns. 110 physician-members of the Travel Medicine Society of Ireland and British Global and Travel Health Association participated in this study. There was a trend towards the prescription of EST for travel to remote low-risk malaria areas; for long-term residents living in low-risk areas; and for frequent travellers to low-risk areas. This study provides insights into the use of EST in travellers' malaria.

To the Editor-in-Chief: We read with interest the review on hypoxia-related altitude illnesses.1 We would like to draw attention to the often overlooked dangers posed by lightning at altitude. The recent tragic death of an elite mountaineer on Mount Kilimanjaro2 highlights the importance of educating travellers about this phenomenon. The overall ratio of lightning injuries to deaths is 10:1, with a 76% chance of sequelae in survivors.3 Most lightning deaths are due to cardiorespiratory arrest. Neurologic sequelae include amnesia, paraesthesiae and traumatic spinal injury. Tympanic membrane rupture occurs in 50% of survivors.4 When thunder is heard, trekkers should seek shelter in a building with plumbing and electrical wiring or in a fully enclosed metal vehicle. Ungrounded structures such as huts and tents increase the risk of being struck.5 As electrically grounded shelter is often unavailable, thunder at altitude should compel the trekker to avoid high-risk areas such as ridgelines and summits, and to avoid tall objects such as isolated trees and …

Travel to altitudes above 2500 m is a popular recreational activity that presents a potential risk of high-altitude illness. Acute mountain sickness (AMS), for example, affects up to three-quarters of trekkers attempting to climb Mount Kilimanjaro in Tanzania, East Africa (5895 m). GPs should be able to provide practical advice on prevention of high-altitude illness.1 Travellers, especially those travelling in organised groups, may not allow adequate time for acclimatisation owing to pressurised itineraries, and administering chemoprophylaxis to accelerate this physiological response to hypobaric hypoxia may be indicated in some cases. This article summarises current recommendations in relation to high-altitude illness, its prevention, and the specific precautions that should be followed by patients with pre-existing chronic illnesses. ### Classification and diagnosis The single most important risk factor for the development of high-altitude illness is rate of ascent. There is significant heterogeneity with respect to the rate at which individuals can ascend without developing altitude illness. There is no reliable means to predict at sea level which travellers are more likely to be affected, and measuring capillary oxygen saturation with a pulse oximeter during ascent does not predict the development of AMS.2 All travellers to high-altitude environments should be able to recognise the symptoms of high-altitude illness. According to the Lake Louise consensus definition,3 AMS is characterised by the presence of a non-specific headache and at least one of the following symptoms: lack of appetite, nausea, vomiting, fatigue, disturbed sleep, or …

One of the most common procedures for junior medical doctors is peripheral intravenous cannulation (PIVC). Considering this, an understanding of the peripheral intravenous cannulation procedure is paramount. Aim: The objective of this study was to identify the level of understanding of interns regarding intravenous cannulation. Method: An anonymized structured questionnaire using a knowledge attitude and practices (KAP) format was distributed to 60 interns affiliated to a university college hospital in Ireland. Findings: This study suggests that interns are poorly prepared for one of the most common clinical skills they will perform. They showed poor understanding of whether peripheral cannulation is a clean or aseptic technique, and lacked knowledge of the potential side effects of peripheral cannulation and IV therapy. Recommendations: A structured learning module on peripheral intravenous cannulation is required. A rigid, evidence-based, Objective Structured Clinical Examination (OSCE) on peripheral cannulation is recommended. The reduction of junior doctors’ weekly working hours to 48 under the European Working Time Directive offers the potential for nurses to take ownership of IV cannulation. This will allow junior doctors to focus on other clinical skills and assessments, which can only be to the advantage of the patient.

The General Medical Council encourages the integration of complementary and alternative medicine (CAM) teaching into basic medical education. We wished to explore the attitudes of medical students to CAM and its inclusion in their undergraduate curriculum. Medical students were invited to complete the validated Integrative Medicine Attitude Questionnaire (IMAQ) and to state whether they considered it appropriate for them to learn about CAM in medical school. The questionnaire was completed by 308 students (65.8% response rate). CAM had been received by a majority of respondents and their families. Participants believed that doctors with knowledge of CAM provide better patient care and that it is desirable for physicians to exploit the placebo effect. Most students expressed the view that doctors should be able to answer patients' questions about herbal medicines. There was a belief that patients should be warned to avoid using supplements which have not undergone rigorous testing. Students who were current or previous users of CAM or whose family members used CAM had higher total IMAQ scores and openness subscale scores than those who did not report use of CAM. Two-hundred and nine (68%) students expressed a desire to study CAM as part of their medical curriculum. This study reveals a positive attitude towards a holistic approach to patient care which embraces CAM. Medical students believe that integrative medicine should be taught in medical school.

International travel presents a risk of sexual violence. In recent years, several high profile incidents, including the gang rape of an Indian woman aboard a bus in New Delhi in 2012, have heightened the awareness of this risk. The British Foreign and Commonwealth Office currently advises female travelers to India to “exercise caution when traveling there, even if they are traveling in a group,” on the basis that British women have been the victims of sexual assaults in Goa, Delhi, Bangalore, and Rajasthan.1 The international travel advice provided by the British Foreign and Commonwealth Office also highlights recent serious sexual attacks involving female Polish, German, and Danish travelers in 2014, and the kidnapping and sexual assault of a Japanese woman in January 2015.1 In the latter incident, a 22-year-old Japanese tourist was allegedly captured in Kolkata, India, by a tour guide using the pretence of bringing the traveler to visit a Buddhist shrine.2 It is reported that she was then locked in a secluded basement and repeatedly raped for one month before she managed to escape.3 In addition to these high profile media reports, there is also increasing research evidence demonstrating that sexual violence is frequently experienced during international travel. The European Institute of Studies on Prevention conducted a cross-sectional airport survey of more than 6,000 young people (aged 16–35 years) who were returning home from holidays in Southern European tourist resorts including Greece, Cyprus, Italy, Portugal, and Spain.4 A total of 1.5% of participants reported having had sex against their will during their holidays …

A positive learning environment in which postgraduate doctors are supported, supervised and nurtured, is likely to lead to enhanced professional satisfaction and improved patient care. The aims of the current study were to use the PHEEM inventory to determine the aspects of their current learning environment which junior doctors rate most and least positively. The PHEEM questionnaire was administered to all junior doctors working in medical subspecialties at Galway University Hospitals in Ireland. A response rate of 60 % (n = 61) was obtained. The mean total PHEEM score was 82.88 ± 18.99, corresponding to an educational environment with more positive than negative aspects but with room for improvement. The mean total PHEEM score (±standard deviation) of registrars (89.65 ± 20.92) exceeded that of Interns (84.00 ± 15.26) and SHOs (75.12 ± 18.09). Over half (55 %) of the individual items were rated by the junior doctors as more positive than negative. Nineteen items (48 %) pointed to areas in need of enhancement, whilst 3 items were rated as satisfactory or better. Analysis of qualitative data confirmed that deficiencies exist in various aspects of the educational climate, including protected educational time, access to suitable learning opportunities, the nature of tasks performed by junior doctors, the hospital bleep protocol, implementation of the European Working Time Directive, feedback and career guidance. Recommendations stemming from this study should lead to improvements in the quality of the educational environment of junior doctors and may stimulate similar evaluations in other teaching hospitals.

Background The acquisition of procedural skills is an essential component of learning for medical trainees. The objective of this study was to assess which teaching method of performing urinary catheterisation is associated with most efficient procedural skill acquisition and retention. We evaluated factors affecting acquisition and retention of skills when using simulators as adjuncts to medical training. Methods Forty-two second year medical students were taught urinary catheter insertion using different teaching methods. The interactive group (n = 19) were taught using a lecture format presentation and a high fidelity human urinary catheter simulator. They were provided with the use of simulators prior to examination. The observer group (n = 12) were taught using the same method but without with simulator use prior to examination. The didactic group (n = 11) were taught using the presentation alone. Student characteristics such as hand dexterity and IQ were measured to assess for intrinsic differences. All students were examined at four weeks to measure skill retention. Results Catheter scores were significantly higher in the interactive group (p

Dear Sir, We read with interest the article by Heidbuchel and colleagues in this journal, presenting a comprehensive curriculum in sports cardiology, which may be suitable for physicians seeking higher specialist training in this evolving subspecialty. We would like to relate our experiences in providing educational programmes in the prevention and management of cardiovascular disease, together with the development of a core undergraduate curriculum in preventive cardiology. The newly established National Institute for Preventive Cardiology has as a central mission the generation of scholars and leaders in cardiovascular disease prevention. Our multidisciplinary clinical team has reported findings from a community-based, lifestylecentred cardiovascular disease prevention programme, demonstrating that managing cardiovascular diseases as a single family of diseases with common antecedents represents a new paradigm for cardiovascular disease prevention. Our postgraduate taught programmes in preventive cardiology, delivered in partnership with our university, introduce graduates from diverse professional backgrounds to the practical clinical application of evidence-based prevention guidelines. Healthcare team members, who are honorary clinical fellows of the university, also deliver a range of student selected components to undergraduate medical students, including modules in sports cardiology, cardiovascular nutrition, stroke prevention and preventive cardiology. Healthcare graduates should serve as positive role models for health promoting lifestyles, and undergraduate exposure to preventive cardiology has been demonstrated favourably to affect knowledge, attitudes and dietary behaviour of medical students. Furthermore, with a shift in healthcare policy towards disease prevention, there is a pressing need to ensure that all graduates of healthcare courses are equipped with the core knowledge, skills and attitudes to enable them to effect meaningful changes in patients’ lifestyles that modify their cardiovascular disease risk. We propose that a standardised inter-professional undergraduate curriculum in preventive cardiology be developed on an e-learning platform, which could ensure consistency of teaching across Europe. A precedent exists with the development of the European Society of Cardiology e-learning platform for cardiology education. Table 1 outlines the modular structure of such a programme, which may be delivered to medical, nursing and other healthcare students as an online certified, interactive study programme, comprising narrated lecture slides, core reading material, video consultations and self-assessment activities. Previous research supports the potential for e-learning and blended learning approaches in the development of inter-professional team knowledge, attitudes and skills. Our proposed syllabus emphasises cardiovascular disease risk estimation using the SCORE tool, and the integration of health behaviour change, lifestyle and pharmacological approaches to cardiovascular disease risk modification. We believe that, if implemented on a Europe-wide level, a standardised core undergraduate healthcare curriculum in preventive cardiology has the potential to support the translation of evidence-based prevention guidelines to clinical practice, address health inequalities, improve quality of life and reduce premature mortality from cardiovascular disease.

The aim of this observational, descriptive study is to evaluate the impact of an intensive, evidence-based preventive cardiology programme on medical and lifestyle risk factors in patients at high risk of developing cardiovascular disease (CVD).Increased CVD risk patients and their family members/partners were invited to attend a 16-week programme consisting of a professional multidisciplinary lifestyle intervention, with appropriate risk factor and therapeutic management in a community setting. Smoking, dietary habits, physical activity levels, waist circumference and body mass index, and medical risk factors were measured at initial assessment, at end of programme, and at 1-year follow up.Adherence to the programme was high, with 375 (87.2%) participants and 181 (84.6%) partners having completed the programme, with 1-year data being obtained from 235 (93.6%) patients and 107 (90.7%) partners. There were statistically significant improvements in both lifestyle (body mass index, waist circumference, physical activity, Mediterranean diet score, fish, fruit, and vegetable consumption, smoking cessation rates), psychosocial (anxiety and depression scales and quality of life indices), and medical risk factors (blood pressure, lipid and glycaemic targets) between baseline and end of programme, with these improvements being sustained at 1-year follow up.These findings demonstrate how a holistic model of CVD prevention can improve cardiovascular risk factors by achieving healthier lifestyles and optimal medical management.

Modern travel is highly reliant on technology, with online flight and hotel reservations, tourist blogs, e-Visa applications and satellite navigation becoming the norm for travellers. Many functions previously ascribed to desktop computers have migrated to mobile smartphones and it is commonplace to witness the majority of passengers on some international flights presenting their Quick Response code on a handheld device instead of a paper-boarding pass. Mobile technology has been comfortably adopted by all age groups. Global wireless infrastructure has tried to keep pace with this increase in demand from the traveller who increasingly chooses to be ‘on the grid’. According to the International Telecommunication Union, 95% of the world’s population live in an area served by a mobile-cellular network, with mobile-broadband networks of 3G or higher reaching 84% of the global population and 67% of rural dwellers.1 There are currently over 7 billion mobile-cellular telephone subscriptions worldwide.1 A recent analysis of mobile applications for travellers and their healthcare providers concluded that there is scope for the development of more reliable and more frequently updated ‘apps’ that consolidate travel health information from multiple sources.2 Social media have opened up new opportunities for travellers to interact with … To whom corresponding should be addressed. Phone: +353-91495469, Fax: +353-91494540, Email: gerard.flaherty{at}nuigalway.ie

Few studies have examined emergency self treatment (EST) antimalarial prescribing patterns. 110 physician-members of the Travel Medicine Society of Ireland and British Global and Travel Health Association participated in this study. There was a trend towards the prescription of EST for travel to remote low-risk malaria areas; for long-term residents living in low-risk areas; and for frequent travellers to low-risk areas. This study provides insights into the use of EST in travellers' malaria.

Risk assessment relies on the accuracy of the information provided by the traveller. A questionnaire was administered to 83 consecutive travellers attending a travel medicine clinic. The majority of travellers was uncertain about destinations within countries, transportation or type of accommodation. Most travellers were uncertain if they would be visiting malaria regions. The degree of uncertainty about itinerary potentially impacts on the ability of the travel medicine specialist to perform an adequate risk assessment, select appropriate vaccinations and prescribe malaria prophylaxis. This study reveals high levels of traveller uncertainty about their itinerary which may potentially reduce the effectiveness of their pre-travel consultation.

The chondroepitrochlearis is an extremely rare muscular anomaly. Bergman et al. (1988) in their book on anatomical variations refer to ‘costoepitrochlearis, chondroepitrochlearis, or chondrohumeralis’ and describe the anomaly as a muscular slip which arises from one or more ribs, crosses the axilla, and inserts into the median intermuscular septum or medial humeral epicondyle. The phylogenetic significance of the muscle has received attention (Landry, 1958; Chiba et al. 1983; Bergman, 1991), and case reports with ulnar nerve entrapment and restriction of arm movements (FitzGerald, 1935–1936; Voto & Weiner 1987; Lin, 1988; Spinner et al. 1991) have emphasised its clinical relevance.

Primary leiomyosarcomas of the pulmonary artery are very rare tumours with 30 cases reported in the English literature. Herein, we report the first case with evidence of a renal metastasis.The tumour was discovered at autopsy in a 61-year-old woman who had presented with shortness of breath and chest pain. It was located in the pulmonary trunk with extension into the adjacent pericardial cavity. Separate nodules were found in the pulmonary valve, the left pulmonary artery and the left kidney.On microscopic examination, the tumour was composed of spindle cells with cigar-shaped nuclei immunoreactive for vimentin, desmin, CD68 and α-smooth muscle actin.Primary pulmonary artery leiomyosarcoma is easily confused clinically with pulmonary thromboembolism and most cases are diagnosed post mortem. Most tumours arise in the pulmonary trunk and metastases are only rarely described. The management of patients with this rare tumour depends on early surgical resection and the prognosis is unfavourable.

Introduction Deaths due to cardiovascular disease (CVD) number 4 million annually in Europe with significantly higher mortality rates seen in Central and Eastern Europe. Large numbers of citizens from these regions migrated to Ireland in the last decade with those of Polish nationality now comprising the largest minority ethnic group in the country. The health status of these immigrants and the potential impact of migration on national CVD risk levels has not been studied. There is no guidance from the European Society of Cardiology (ESC) to date as to which SCORE chart to use in the case of an individual from a high risk country who has immigrated to a low risk nation. Methods Immigrant adults over 18 years and from any of the high risk countries of Europe (according to the SCORE risk estimation tool) were recruited via convenience sampling in Limerick city. Screening was offered in occupational and community settings; a non-fasting lipid profile, blood pressure (BP) measurements, subjective questioning regarding physical activity levels, alcohol consumption and smoking status. The SCORE risk tool and relative risk categorisation were used to calculate CVD risk. Results 81 participants (mean age 41 years) took part in this study. The majority were Polish (n = 72, 89%) and 54% (n = 44) were male. Subjects were divided into two groups for data analysis; those aged ≥40 years (n = 38, 46.9%, mean age 52 years) and younger subjects (n = 43, 53.1%, mean age 30 years). Very high levels of hypertension (55%) and hypercholesterolaemia (61%) were observed in those aged ≥40 years and 42% (n = 16) of the older subjects displayed a high or very high ten-year risk of death due to CVD. SCORE was strongly correlated with age (r = 0.70, p Conclusions This study demonstrates that CVD risks inherent in a high risk population are preserved following immigration into a low risk area. As no current guidance exists from the ESC, the authors feel this cohort of people should undergo targeted risk factor modification in line with recommendations for high risk individuals. We have highlighted a deficiency in the SCORE risk charts, and feel further work is required to accurately assess the disease burden in this unique patient group.

Pathologic specimens acquired by anatomy departments may be of fundamental anatomical and clinical interest. In this report we describe a true aneurysm of the left ventricle and we review the relevant clinical records of the patient. A detailed review of the literature on ventricular aneurysms is presented with emphasis on particular aspects of cardiac anatomy. Clin. Anat. 5:363–368, 2001. © 2001 Wiley-Liss, Inc.

Background The reliability of clinical examinations is known to vary considerably. Inter-examiner variability is a key source of this variability. Some examiners consistently give lower scores to some candidates compared to other examiners and vice versa – the ‘hawk- dove’ effect. Stable examiner characteristics, such as personality factors, may influence examiner stringency. We investigated whether examiner stringency is related to personality factors. Methods We recruited 12 examiners to view and score a video-recorded five station OSCE of six Year 1 undergraduate medical students at our institution. In addition examiners completed a validated personality questionnaire. Examiners’ markings were tested for statistically significant differences using non-parametric one way analysis of variance. The relationship between examiners’ markings and examiner personality factors was investigated using Spearman correlation coefficient. Results At each station there was a statistically significant difference between examiners markings, confirming the presence of inter-examiner variability. Correlation analysis showed no association between stringency and any of the five major personality factors. When we omitted an outlier examiner we found a statistically significant negative correlation between examiner stringency and openness to experience with a correlation coefficients (rho) of – 0.66 (p = 0.03). Conversely there was a moderate positive correlation between examiner stringency and neuroticism with a correlation coefficient (rho) of 0.73 (p = 0.01). Conclusions In this study we did not find any relationship between examiner stringency and examiner personality factors. However, following the elimination of an outlier examiner from the analysis, we found a significant relationship between examiner stringency and two of the big five personality factors (neuroticism and openness to experience). The significance of this outlier is not known. As this was a small pilot study we recommend further studies in this field to investigate if there is a relationship between examiner stringency in clinical assessments and personality factors.