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INTRODUCTION Accurate clinical diagnosis depends on the reliable recognition of signs and symptoms. This expertise comes from experience in seeing patients which has been traditionally gained over a long training period. Shortened specialist training (Modernising Medical Careers) has led to a greater reliance on structured teaching and skills transfer programmes. The accuracy of clinical diagnosis and the rate at which diagnostic skills improve during training is important for the assessment of trainees, and the delivery of care. PATIENTS AND METHODS This study assessed the accuracy of clinical diagnosis of skin lesions by two junior plastic surgery trainees. They were asked to diagnose 120 consecutive skin lesions seen in a pigmented skin lesion clinic in 2005, with the histological diagnosis being confirmed following subsequent excision. The process was repeated a year later in 2006 to enable the rate of correct diagnosis to be compared. RESULTS Initially, 53.3% of diagnoses were correct. A year later, this had risen to 65.0%. Twenty-two different skin pathologies were present in excised specimens, and skin cancers comprised 30%. The trainees demonstrated 93.8% sensitivity in their initial diagnosis of malignancy (95% CI, 79.2–99.2) and 97.4% a year later (95% CI, 86.5–99.9). However, specificity was 69.3% (95% CI, 58.6–78.7) in 2005 and 71.6% (95% CI, 60.5–71.4) in 2006. CONCLUSIONS Accuracy in the diagnosis of the wide range of skin conditions presenting to an out-patient clinic was shown to increase over a 1-year period. We feel that this improvement resulted from regular clinical exposure supported by a structured learning programme. The shortening of the specialist training period may affect the acquisition of diagnostic skills by trainees and impact on the confidence with which they commence consultant practice.

To the Editor: Stroke patients who are managed in an organized (stroke unit) setting are more likely to make a good recovery than those who receive conventional care in general wards, an effect that has been attributed to the coordinated rehabilitation input.1 However, recent descriptive information from 2 Norwegian trials2 3 now indicates that some of the benefits of stroke unit care may also be due to acute medical interventions. In particular, these units employed early mobilization and the routine use of intravenous saline, plus selective use of antipyretic and antibiotic medication, oxygen, and insulin.2 3 4 We therefore wished to test the hypothesis that stroke patients who manage to maintain key physiological variables (osmolarity, temperature, oxygen saturation, blood glucose) within a narrow physiological range are more likely to enjoy an early recovery and better functional outcome. We carried out a case-control study, recruiting consecutive individuals admitted to a large, urban teaching hospital with a clinical diagnosis of stroke in the previous 24 hours that was confirmed on CT scan. Patients were assessed on admission, day 3, and day 7 after stroke with the Scandinavian Stroke Scale, Barthel Index, and modified Rankin scale.5 Physiological variables were …

Seven female patients (mean age 86 years) with proven biochemical primary hypothyroidism were enrolled in a single-blind randomized crossover study, of standard daily versus twice-weekly thyroxine therapy, with each phase of one month's duration. The median daily dose of thyroxine was 100 μg (range 75 – 100 μg). Serum levels of thyroid hormones and thyrotrophin were very similar during twice-weekly thyroxine therapy to those during daily therapy and there were no statistically significant differences between trough and peak serum total triiodothyronine, free thyroxine, or thyrotrophin levels or systolic time intervals during twice-weekly thyroxine. Administration of thyroxine twice-weekly to elderly patients with primary hypothyroidism gives effective biochemical thyroid hormone replacement, with no evidence from the systolic time intervals of tissue thyrotoxicosis at expected peak thyroid hormone concentrations. Supervised twice-weekly thyroxine should be considered in patients with primary hypothyroidism who comply poorly with daily dosing.

Assessments of nutritional status frequently incorporate a measure of height to evaluate a person's relative thinness or fatness. Because height is often difficult to quantify, it may be predicted from alternative anthropometric measurements, including ulna length. Little information is available about the accuracy of these predictions in an ethnically diverse population. The present study aimed to evaluate published equations for predicting height from ulna length in adults from different ethnic groups. Ulna length and standing height were measured in a gender-stratified sample of 60 Asian, 69 Black and 65 White healthy volunteers, aged 21-65 years. Height was predicted from ulna length using the Malnutrition Universal Screening Tool (MUST) equations and compared against the measured values. Linear regression analysis was used to develop equations to estimate height from ulna length and to explore the relationship between height and ulna length in subgroups. The mean (SD) age for Asian, Black and White in men was 31.7 (11.0), 32.0 (10.3) and 38.6 (12.5) years and in women was 26.2 (5.4), 32.6 (8.9) and 35.7 (11.7); the mean (SD) height in men was 170.9 (5.2), 178.1 (7.3) and 176.3 (7.7) cm and in women was 157.7 (4.7), 164.0 (5.9) and 163.7 (6.2) cm. Ulna length and measured height were significantly correlated among all subgroups, except Asian women (r=0.11, P=0.57). The mean (SD) difference between predicted and measured height showed significant overestimates for Asian and Black men [4.0 (4.8) and 6.7 (5.3) cm] and Asian and Black women [6.4 (4.9) and 4.4 (4.9) cm] but not for White men and women. The MUST equations for predicting height from ulna length in healthy adults should be used with some caution among ethnically diverse populations, particularly in Asian women.

For large scale follow up studies with non-demented patients in which cognition is an endpoint, there is a need for short, inexpensive, sensitive, and reliable neuropsychological tests that are suitable for repeated measurements. The commonly used Mini-Mental-State-Examination fulfils only the first two requirements.In the PROspective Study of Pravastatin in the Elderly at Risk (PROSPER), 5804 elderly subjects aged 70 to 82 years were examined using a learning test (memory), a coding test (general speed), and a short version of the Stroop test (attention). Data presented here were collected at dual baseline, before randomisation for active treatment.The tests proved to be reliable (with test/retest reliabilities ranging from acceptable (r=0.63) to high (r=0.88) and sensitive to detect small differences in subjects from different age categories. All tests showed significant practice effects: performance increased from the first measurement to the first follow up after two weeks.Normative data are provided that can be used for one time neuropsychological testing as well as for assessing individual and group change. Methods for analysing cognitive change are proposed.

To compare the conventional virus isolation method for diagnosis of influenza infection with reverse-transcription polymerase chain reaction (RT-PCR) in prospectively collected nose and throat swabs from elderly patients during the winter influenza season. The use of a denaturing buffer as an alternative to viral transport medium (VTM) for submission of combined nose and throat swabs to the laboratory for PCR was then investigated in a second study.Virus was cultured in microtitre plates using two different cell lines and detected using monoclonal antibody staining. A multiplex, matrix gene PCR assay was optimized to increase the sensitivity and specificity of detection of influenza A (H3 and H1) and B nucleic acid.The multiplex assay detected all viruses with equal sensitivity to individual assays. In a large, multicentre field study PCR detected twice as many influenza infections compared with virus isolation. No positive culture was missed. PCR has a rapid turn around time (36 h) vs. a minimum of 7 days for virus isolation. Greater sensitivity and specificity in the PCR were achieved using a 'hot-start' method. Although the numbers were small, the detection rate using PCR was greater for swabs submitted in denaturing buffer than in VTM.PCR significantly increased the sensitivity and clinical utility of influenza A (H3 and H1) and B diagnosis. There were a number of advantages in using denaturing buffer for submission of samples, including high sensitivity, rapidity, ease of use and no requirement for the virus to be viable on arrival at the laboratory. Therefore, PCR is a rapid, sensitive and user-friendly alternative for influenza diagnosis. Virus isolation technology should be limited to referral centres for further epidemiological characterization.

The PROspective Study of Pravastatin in the Elderly at Risk (PROSPER) is a randomized, double-blind, placebo-controlled trial designed to test the hypothesis that treatment with pravastatin will diminish risk of subsequent major vascular events in a cohort of men and women (70 to 82 years old) with preexisting vascular disease or significant risk of developing this condition. Five thousand eight hundred four men and women in addition to receiving advice on diet and smoking, have been randomized equally to treatment with 40 mg pravastatin/day or matching placebo in 3 centers (Cork, Ireland, Glasgow, Scotland, and Leiden, The Netherlands). Following an average 3.5-year intervention period, a primary assessment will be made of the influence of this therapy on major vascular events (a combination of coronary heart disease, death, nonfatal myocardial infarction, and fatal and nonfatal stroke). A number of additional analyses will also be conducted on the individual components of the primary end point, on men, on women, and on subjects with and without previous evidence of vascular disease. Finally, an assessment will be made of the effects of treatment on cognitive function, disability, hospitalization or institutionalization, vascular mortality, and all-cause mortality.

OBJECTIVE: To compare the effects on renal function of captopril and enalapril in elderly patients with chronic heart failure. DESIGN: A multi-centre double-blind parallel-group comparison of the two angiotensin-converting enzyme (ACE) inhibitors, captopril (12.5 mg bid) and enalapril (2.5 mg bid). SUBJECTS: 80 elderly patients with chronic heart failure (41 in the captopril group, 39 in the enalapril group). MAIN OUTCOME MEASURES: The blood pressure and pulse rate response to the first dose of ACE inhibitor was assessed in all patients. Glomerular filtration rate (GFR) was measured radioisotopically by 99mTcDTPA or 51CrEDTA clearance after three and six months of each treatment. Subgroups were assessed for effective renal plasma flow (33 patients), exercise tolerance (25 patients) and by a symptom-oriented questionnaire (45 patients). RESULTS: No serious adverse effect on GFR was noticed. There was no significant difference between the two treatments in the mean baseline GFR or in changes from baseline at three and six months (captopril mean baseline GFR 49.6 ml min-1 1.76 m-2, enalapril 54.7 ml min-1 1.76 m-2; mean change (95% confidence interval) at three months captopril 12 ml min-1 (+3.0, +21.0), enalapril -2 ml min-1 (-13.0; +9.0); mean change at six months, captopril 3.7 ml min-1 (-6.7; +14.2), enalapril -6.0 ml min-1 (-21.0; +9.4). Significantly more patients given captopril had an improvement in GFR during the study period (26/31 compared with 20/31 enalapril-treated patients at three months, p = 0.0096, and 23/30 compared with 15/27 at six months, p = 0.021). There were no significant changes in effective renal plasma flow. Three patients treated with enalapril developed symptomatic hypotension within three days of starting treatment. Quality of life questionnaires revealed more gastrointestinal symptoms in the enalapril group (p = 0.039). CONCLUSIONS: Captopril seems marginally preferable to enalapril in the treatment of chronic heart failure in elderly patients.

Recent reports have suggested an association between terodiline hydrochloride and cardiac arrhythmias. We report 4 patients presenting over a six month period who developed polymorphic ventricular tachycardia (polymorphic VT) while receiving treatment with this agent. In each case there was prolongation of QT interval on electrocardiogram (ECG). Two patients had hypokalaemia associated with diuretic therapy. In the 3 cases in which follow-up ECG was available, QT interval returned to normal after discontinuation of terodiline. In order to define the effects of terodiline on corrected QT interval (QTc) and heart rate in the elderly, a prospective study was performed in 8 elderly in-patients treated with terodiline for urinary incontinence. After 7 days treatment with terodiline 12.5 mg twice daily, there was a significant increase in QT by a mean of 29 ms, QTc by 15 ms and a decrease in resting heart rate by a mean of 6.7 beats.min-1. Terodiline increases QTc and reduces resting heart rate in elderly patients. Both these effects may be associated with polymorphic VT, a potentially life threatening arrhythmia. This drug should be avoided in patients with other known risk factors for polymorphic VT, particularly hypokalaemia and cardiac disease.

Valuable orthopaedic operating time is frequently lost because patients are found to be medically unfit for surgery on admission. One hundred and forty seven consecutive patients aged 60 years or older, who had been accepted for major joint replacement and who lived within 15 miles of the Western Infirmary, Glasgow were screened at a preadmission clinic. The screening protocol had been agreed by orthopaedic and anaesthetic staff involved in major joint replacement surgery. Some 42 patients had medical illnesses which would have resulted in surgery being postponed and a further five had their surgery cancelled. Six patients passed fit for surgery at the pre-admission screening clinic were unfit for surgery on admission. Two patients in this group had their surgery cancelled. Using the guidelines suggested, pre-admission screening could be carried out by the patient's general practitioner (GP) or by a member of the medical staff when the patient attends the orthopaedic out-patient clinic. By following a simple protocol the amount of valuable operating time lost through unrecognised or poorly controlled medical illness could be greatly reduced. Pre-admission screening should result in more efficient use of scarce hospital resources and improved patient care.

Functional capacity and mental status were assessed in 821 patients in long-term care in West Glasgow. In geriatric medical long-term care only five (1.3%) out of 387 patients were independent in activities of daily living (walking, transfers from bed and chair, dressing, toileting, urinary and faecal continence) and were not severely mentally impaired (AMT score greater than 6/10); in psychogeriatric care n = 6/143 (4.2%) in private nursing homes n = 6/66 (9.1%) and in residential care n = 100/235 (42.6%). Patients in geriatric medical care had a greater prevalence of immobility and urinary incontinence but less mental impairment than those in psychogeriatric care. Nearly all patients placed in geriatric medical or psychogeriatric care had major functional disability or mental impairment. The level of disability was less in private nursing than in geriatric medical care. Although 57% of those in residential care required some assistance or supervision in activities of daily living or had severe mental impairment, 86% were independent in walking and 83% were continent of urine. The implications of these findings for the provision of care for physically and mentally frail elderly are discussed.

EDITOR,—By applying American guidelines on neuroleptic use within nursing home facilities, Alice McGrath and Graham Jackson have deemed the prescription of these drugs for Glasgow nursing home residents to be potentially inappropriate in most cases.1 Their interpretation of the findings may be incorrect. No data are provided on the extent of behaviour problems among the patients studied. Previous research in similar settings suggests that a high prevalence of behaviour problems can be anticipated.2 3 Neuroleptic use may seem inappropriate in many cases because the …

We have given the selective 5 HT2 antagonist ritanserin in a dose of 10 mg twice daily for 4 weeks in a double-blind, randomized, placebo-controlled, parallel group study of 18 patients with untreated essential hypertension. The fall in single platelet count due to 5 HT-induced platelet aggregation was significantly reduced by ritanserin compared with placebo (p less than 0.05). There were no significant changes in supine or erect blood pressure or heart rate after ritanserin compared to placebo. Forearm blood flow, measured by mercury-in-strain gauge venous occlusion plethysmography, was not significantly altered by ritanserin. Ritanserin caused prolongation of the QTc interval by 41 (SEM 11) ms (p less than 0.05 compared to placebo) but had no detectable effect on QRS duration, features suggestive of Class III antiarrhythmic activity. These findings do not support an independent role of the 5 HT2 receptor in maintaining raised arterial pressure in essential hypertension.

We have studied eight adult atopic asthmatic patients in a randomized double-blind, placebo-controlled, cross-over trial in order to examine the effects of the 5 HT2 antagonist ketanserin on airways function (FEV1, FVC, V50(chi), and V25(pi]. Ketanserin did not significantly change resting bronchomotor tone. Treadmill exercise caused a similar maximal percentage fall in FEV1 after both drug [16.8 (3.7)%] and placebo [19.2 (4.2)%]; ketanserin did not significantly attenuate bronchoconstriction, measured over a 20-min period after exercise. These results suggest that 5 HT2 receptors do not play a major role in the control of resting bronchomotor tone or in exercise-induced bronchoconstriction in adult atopic asthmatic patients.

We have studied the acute effects of the serotonergic type-2 (5-HT2) antagonists ketanserin and ritanserin given as single oral doses to patients with essential hypertension. Ketanserin has alpha 1-antagonist properties, whereas ritanserin is largely devoid of alpha 1-receptor binding affinity. Ketanserin (40 mg orally) caused a significant reduction (p less than 0.03) of sitting mean arterial pressure over the 8-h period following drug administration by an average of 15.4 +/- 3.2 mm Hg (mean +/- SEM) as compared to a reduction of 8.5 +/- 2.2 following placebo. In contrast, ritanserin had no significant effect on blood pressure compared to placebo; sitting mean arterial pressure was reduced by 9.0 +/- 2.6 and 10.8 +/- 1.8 mm Hg after administration of 10 and 20 mg, respectively, of ritanserin. There were no significant differences in pulse rate among placebo, ketanserin, or ritanserin phases. Ritanserin caused a reduction in the hostility score (p less than 0.05) as measured by the Multiple Affect Adjective Check List; ketanserin had no significant effects. The highly selective 5-HT2 antagonist ritanserin, given in a dose which caused measurable alteration of psychological function tests, had no acute effects on blood pressure. The acute antihypertensive effects of ketanserin are not caused by 5-HT2 antagonism alone, but are likely to be dependent on its alpha 1-antagonistic properties.

Serotonin is a naturally occurring amine with vasoactive and platelet aggregating properties. It may be involved in the pathogenesis of hypertension. Almost all the serotonin circulating in blood is stored in platelets. Serotonin and other platelet contents are released from platelets during platelet aggregation, which occurs in a stepwise manner. Initially there is a reversible change in platelet shape from a disc to a spiny sphere, and then platelet clumping, and finally a release of platelet contents (Holm sen 1977). The contents of the dense granules, including serotonin, adenosine diphosphate, adenosine triphosphate, calcium and inorganic pyrophosphate, are released before the contents of the a granules, which include ~-thromboglobulin, platelet factor 4, acid hydro lases and fibrinogen (DeClerck 1986; Holmsen et al. 1977). Serotonin released during platelet aggregation could cause vasoconstriction, increased blood pressure and further platelet aggregation. The object of this study was to compare serotonin-induced and spontaneous platelet aggregation in whole blood, platelet serotonin content and plasma ~-thromboglobulin in patients with untreated essential hypertension and in a normotensive control group.

While no consensus over the treatment of essential hypertension has been reached, three recent major trials offer guidance to the clinician. The results of these trials and the role of new and old drugs in the treatment of hypertension are discussed.

The mechanism of blood pressure reduction by ketanserin in hypertensive patients is still not fully understood. It can occur in the absence of evident alpha 1-adrenergic blockade. However, particularly with prolonged therapy, features of alpha 1 blockade appear. There are both similarities and differences between the pattern of effects caused by ketanserin and prazosin. A central mode of action of ketanserin contributing to the blood pressure reduction is not excluded. It appears unlikely, however, that inhibition of aldosterone secretion makes a substantial contribution to the antihypertensive effect of ketanserin in humans.

Ketanserin reduces blood pressure effectively, but without inducing tachycardia. Its precise mode of action is unclear but under some circumstances it attenuates the rise in blood pressure caused by infusion of the alpha 1-agonist phenylephrine, suggesting that it acts at least partly as an alpha 1-adrenoceptor antagonist. However, the specificity of this attenuation has been questioned. We have therefore examined the effects of ketanserin on the blood pressure and heart rate responses to angiotensin II (a vasoconstrictor agent largely devoid of alpha 1-agonist properties). The blood pressure response to infused angiotensin II, in contrast to that of phenylephrine, was not attenuated by ketanserin. Ketanserin appeared not to increase cardiac efferent parasympathetic activity. At a dose used in the treatment of hypertension, ketanserin produces alpha 1-antagonism in man, which may partly explain its antihypertensive effect.