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Analysis of on-line clinical laboratory manuals and practical recommendations.

CONTEXT: On-line clinical laboratory manuals are a valuable resource for medical professionals. To our knowledge, no recommendations currently exist for their content or design. OBJECTIVE: To analyze publicly accessible on-line clinical laboratory manuals and to propose guidelines for their content. DESIGN: We conducted an Internet search for clinical laboratory manuals written in English with individual test listings. Four individual test listings in each manual were evaluated for 16 data elements, including sample requirements, test methodology, units of measure, reference range, and critical values. Web sites were also evaluated for supplementary information and search functions. RESULTS: We identified 48 on-line laboratory manuals, including 24 academic or community hospital laboratories and 24 commercial or reference laboratories. All manuals had search engines and/or test indices. No single manual contained all 16 data elements evaluated. An average of 8.9 (56%) elements were present (range, 4-14). Basic sample requirements (specimen and volume needed) were the elements most commonly present (98% of manuals). The frequency of the remaining data elements varied from 10% to 90%. CONCLUSIONS: On-line clinical laboratory manuals originate from both hospital and commercial laboratories. While most manuals were user-friendly and contained adequate specimen-collection information, other important elements, such as reference ranges, were frequently absent. To ensure that clinical laboratory manuals are of maximal utility, we propose the following 13 data elements be included in individual test listings: test name, synonyms, test description, test methodology, sample requirements, volume requirements, collection guidelines, transport guidelines, units of measure, reference range, critical values, test availability, and date of latest revision.

Abstracting and Indexing↗

Three-dimensionality of contact forces during clinical manual examination and treatment: a new measuring system.

OBJECTIVE: Three-dimensionality (3D) of manual contact forces at the patient-practitioner interface. DESIGN: Description of a new hand/palm-held computerized 3D force measuring system. BACKGROUND: Up until now instrumented direct manual contact force measurement has been one-dimensional (1D).Methods. The system is built for interface (direct) measurement of 3D manual contact force with real-time data presentation. Static calibration was performed of the 3D force sensor with variable preloads to study their effect as well of the prototype system adapted for clinical manual examination and treatment. RESULTS: Calibration validity and reliability of the 3D force sensor under all but the 5 kN preload and of the new system showed systematic respective random errors in the order or smaller than one newton. CONCLUSIONS: The new system enables, for the first time, recording and presenting of 3D manual contact forces at the patient-practitioner interface. 3D direct manual contact force measures have the potential to give a more complete and differentiated characterization of patient and practitioner forces than 1D forces. Clinical validity of the prototype system will have to be investigated, and for studying specific clinical manual handling techniques, obvious limitations require further development. RELEVANCE: Manual techniques play a prominent role in chiropractic, manual-therapy and -medicine, massage therapy and osteopathy. The more complete 3D manual contact force description also can help practitioners and students to improve both manual force perception and delivery skills by providing higher standardization and real-time objective feedback about performance.

Calibration↗

Efficacy of manual therapy.

The use of manual therapy to treat somatic pain syndromes and associated disabilities is widespread. Yet, the efficacy of manual therapy has not been previously established because equivocal findings in the literature prevent definitive conclusions. The purposes of this article are (1) to establish objective criteria for judging the validity of manual therapy research, (2) to identify and discuss the results of those trials that were determined to be valid demonstrations of treatment efficacy or valid demonstrations of nonuseful therapy, and (3) to determine whether patients who benefit from manual therapy have common characteristics. The abstracts or full reports of 146 titles with appropriate key words were reviewed. Of these, 105 studies were not primary studies of manual therapy and were thus eliminated from review. In the 41 remaining studies, 18 did not utilize statistical comparisons or report blinded assessment of outcome measures. Nine controlled studies yielded negative results, but the statistical power or minimum sample size required to detect potential differences between manual therapy and control groups was not described. The 14 studies that met the efficacy criteria were categorized by the following factors: (1) the anatomical region of intervention, (2) pragmatic versus explanatory goals, and (3) primary intervention (manipulation, mobilization, combination). There was a paucity of valid explanatory research in all areas and a particular absence of controlled trials involving manual therapy applied to the peripheral joints. Manual therapy for low back pain, however, was studied extensively. The analysis of valid trials provided clear evidence that manual therapy, particularly manipulation, can be an effective modality when used to treat patients who have low back pain. A preliminary "profile" of the patient with low back pain who would likely benefit from manual therapy included acute symptom onset with less than a 1-month duration of symptoms, central or paravertebral pain distribution, no previous exposure to spinal manipulation, and no pending litigation or workers' compensation. Suggestions for future manual therapy research are discussed.

Adult↗

Interest in manual medicine among residents in physical medicine and rehabilitation. The need for increased instruction.

Manual medicine is an important part of the practice of physical medicine and rehabilitation (PM&R). Using a two-part questionnaire, we surveyed PM&R residents to determine their level of interest in manual medicine, their attitudes about this type of treatment, and the amount of formal training in manual medicine offered in PM&R residencies. Questionnaires were sent to all 75 PM&R residency training programs. Responses were received from 470 residents (41.6%) of 1126 potential respondents; this represented 55 (73%) of the programs surveyed. Of the 470 respondents, 363 (77.2%) believed that manual medicine should be a part of PM&R, 386 (82.1%) wanted more training in manual medicine, 389 (82.8%) believed that manual medicine is useful in the treatment of back/neck pain, and 392 (83.4%) would refer patients for manual medicine treatment. However, only 124 (27.3%) were receiving formal instruction in manual medicine during their PM&R residency training. Most of the 305 respondents who had received some exposure to manual medicine had done so through conferences (88.7%) and independent reading (66.9%). The results of this survey of PM&R residents demonstrate both a widespread interest in the use of manual medicine and an unmet desire for more instruction. Educational experiences in manual medicine should be provided so that, as residents become practicing physiatrists, they can either utilize this form of treatment or appropriately refer patients to other practitioners.

Adult↗

Texas passes first law for safe patient handling in America: landmark legislation protects health-care workers and patients from injury related to manual patient lifting.

On June 17,2005, Texas Governor Rick Perry (R) signed into law Senate Bill 1525, making Texas the first state in the nation to require hospitals and nursing homes to implement safe patient handling and movement programs. Governor Perry is to be commended for this heroic first stand for safe patient handling in America. The landmark legislation will take effect January 1, 2006, requiring the establishment of policy to identify, assess, and develop methods of controlling the risk of injury to patients and nurses associated with lifting, transferring, repositioning, and movement of patients; evaluation of alternative methods from manual lifting to reduce the risk of injury from patient lifting, including equipment and patient care environment; restricting, to the extent feasible with existing equipment, manual handling of all or most of a patient's weight to emergency, life-threatening, or exceptional circumstances; and provision for refusal to perform patient handling tasks believed to involve unacceptable risks of injury to a patient or nurse. Manually lifting patients has been called deplorable, inefficient, dangerous to nurses, and painful and brutal to patients; manual lifting can cause needless suffering and injury to patients, with dangers including pain, bruising, skin tears, abrasions, tube dislodgement, dislocations, fractures, and being dropped by nursing staff during attempts to manually lift. Use of safe, secure, mechanical lift equipment and gentle friction-reducing devices for patient maneuvering tasks could eliminate such needless brutality. Research has proven that manual patient lifting is extremely hazardous to health-care workers, creating substantial risk of low-back injury, whether with one or two patient handlers. Studies on the use of mechanical patient lift equipment, by either nursing staff or lift teams, have proven repeatedly that most nursing staff back injury is preventable, leading to substantial savings to employers on medical and compensation costs. Because the health-care industry has relied on people to do the work of machines, nursing work remains the most dangerous occupation for disabling back injury. Back injury from patient lifting may be the single largest contributor to the nursing shortage, with perhaps 12% of nurses leaving or being terminated because of back injury. The US health-care industry has not kept pace with other industries, which provide mechanical lift equipment for lifting loads equivalent to the weight of patients, or with other countries, such as Australia and England, which are more advanced in their use of modern technology for patient lifting and with no-lifting practices in compliance with government regulations and nursing policies banning manual lifting. With Texas being the first state to succeed in passing legislation for safe patient handling, other states are working toward legislative protection against injury with manual patient lifting. California re-introduced safe patient handling legislation on February 17, 2005, with CA SB 363, Hospitals: Lift Teams, following the September 22, 2004, veto of CA AB 2532 by Governor Arnold Schwarzenegger, who said he believes existing statutory protection and workplace safety standards are sufficient to protect health care workers from injury. Massachusetts HB 2662, Relating to Safe Patient Handling in Certain Health Facilities, was introduced December 1, 2004. Ohio HB 67, signed March 21, 2005 by Governor Bob Taft (R), creates a program for interest-free loans to nursing homes for implementation of a no-manual-lift program. New York companion bills AB 7641 and SB 4029 were introduced in April, 2005, calling for creation of a 2-year study to establish safe patient handling programs and collect data on nursing staff and patient injury with manual patient handling versus lift equipment, to determine best practices for improving health and safety of health-care workers and patients during patient handling. Washington State is planning re-introduction of safe patient handling legislation, after WA HB 1672, Relating to reducing injuries among patients and health care workers, was stalled in committee in February, 2005. Language from these state initiatives may be used as models to assist other states with drafting safe patient handling legislation. Rapid enactment of a federal mandate for Safe Patient Handling No Manual Lift is essential and anticipated.

Back Injuries↗

An experimental study on the use of manual pressure to reduce pain in intramuscular injections.

To investigate whether the application of manual pressure to the injection site before intramuscular injection reduces pain. An experimental study with intrasubject comparison was conducted using manual pressure to reduce pain associated with intramuscular injection. Seventy-four subjects, participating in an immunization vaccination campaign, were recruited by convenience sampling from a university. They were required to receive two doses of vaccines via intramuscular injections. One was given in a conventional way, i.e. without manual pressure being applied prior to the injection (control condition). The other was given with manual pressure being applied prior to the injection (experimental condition) for 10 seconds. The two conditions were randomly allocated for each subject. The instrument for measuring the perceived pain intensity was the Pain Intensity Verbal Rating Scale (Cantonese). To ensure the consistency of manual pressure being applied to the injection site, a mechanical pressure sensor device was used to record the manual pressure being applied. The mean manual pressure applied was 190.82 mmHg (SD=5.25). Results demonstrated a significant difference in the perceived pain intensity for experimental and control conditions. Subjects with manual pressure applied before injections reported lower pain intensity scores, whilst those without the application of manual pressure before injections reported higher pain intensity scores. Applying manual pressure to an injection site before performing an injection could be an effective means of decreasing pain intensity.

Adult↗

Manual therapy: a critical assessment of role in the profession of physical therapy.

Interest in manual therapy appears to continue to grow among physical therapy clinicians and educators throughout the world even though the underlying concepts and techniques have not been justified by a knowledge base. The purposes of this article are to critically assess the role of manual therapy within the physical therapy profession and to provide an introduction to the other articles in this special issue. Eisner's model of explicit, implicit, and null curricula is used as a framework for our analysis and our discussion of manual therapy. The explicit area of manual therapy includes discussions of the definition and the role of manual therapy, the scientific rationale for manual therapy, and manual therapy in education and a comparison of manual therapy evaluative frameworks. The implicit area deals with the role of clinical decision making and critical thinking in manual therapy in education and rehabilitation. In the null (unaddressed) area of manual therapy, we suggest directions for future development and research.

Clinical Competence↗

Availability of operator manuals for used consumer products.

This research investigates the availability of operator manuals for used (second-hand or resold) consumer products. One hundred people were solicited at a shopping mall and asked various questions about 20 common consumer products (e.g. car, computer, power lawn mower, bicycle, etc.). They were queried about: (a) whether they have ever purchased the products new and/or used and, if purchased used, whether it came with an operator manual or an instruction sheet, (b) whether they personally sold any of the products used, and if so, whether they transferred the operator manual to the receiver, (c) the desirability of having an operator manual; and (d) how much they would be willing to pay for a manual assuming they had to purchase it separately. Participants were also asked to rate each product on familiarity, hazard level, and difficulty of use, and to answer a set of general manual-related questions. A second survey solicited the opinions of 39 professional sellers (dealers) of used products. Findings from both surveys indicate that while operator manuals for some used products are transferred to purchasers at moderate frequencies, others are much lower. In general, participants believed that the inclusion of the operator manual would aid the sale of used products and they were willing to pay extra to have one (particularly for unfamiliar, more hazardous, difficult-to-use products). The results suggest that manufacturers ought to address ways that would make it more likely that consumers retain the operator manual and transfer it to subsequent purchasers at later resale. Additionally, convenient ways of obtaining replacement copies should be provided to ensure that important safety-related information reaches end users.

Adolescent↗

Paired comparison of manual and automated Pap test screening using the PAPNET system.

A paired-comparison study of manual and automated (PAPNET) screenings of cervico-vaginal smears (Pap tests) was conducted to determine whether primary PAPNET screening was a reliable alternative to manual screening. A series of 5,037 consecutive Pap tests was first screened by the manual method. Next they were scanned by the PAPNET system, the DAT tapes were reviewed, and using a nonspecific triage protocol, abnormal tests were identified for limited, manual rescreening. False-negative rates (FNR) for each method were calculated and analyzed for due cause. By manual and PAPNET screening, respectively, there were 436 (8.6%) and 250 (4.9%) abnormal results. Manual screening missed 18 abnormals (5 SIL) and PAPNET 202 (7 SIL). The primary, manual screenings relating to the PAPNET false-negative tests were reviewed and revised to normal in 30. Based on the changes in the other 172 tests, cellular features ostensibly missed by the PAPNET system were listed to form part of a specific triage protocol, and were used to scrutinize the companion 172 DAT tapes: 150 tapes were abnormal. The manual FNR for an abnormal (SIL) result was 4% and (8.8%), respectively. Equivalent FNR pre- and postreviews for the PAPNET system were 44.6% (10.6%) and 5.2% (1.3%), respectively. This study discovered that the evaluation of some cell features in monitor-based, video images was the most important factor limiting the application of the PAPNET system as a primary screener. When governed by a specific triage protocol incorporating these features, primary PAPNET screening has the potential to equal the laboratory threshold of manual screening and be a better detector of SIL.

Automation↗

Automated perimetry detects visual field loss before manual Goldmann perimetry.

PURPOSE: To determine if automated perimetry detects visual field defects before manual Goldmann perimetry. METHODS: Subjects with ocular hypertension without field loss on detailed manual perimetry were followed prospectively with annual automated and manual perimetry. Subjects with field loss on manual perimetry were age-matched post hoc to subjects who did not have field loss. The automated fields 1 year before the development of field loss on manual perimetry were compared between the two groups. Subjects were recruited from ophthalmologists' offices, eye clinics, and a population-based glaucoma survey in the Baltimore area. Abnormal results detected on the Humphrey Field Analyzer were defined using the glaucoma hemifield test, mean defect, and corrected-pattern standard deviation. RESULTS: Forty subjects who had field loss during 8 years of follow-up were compared with 145 control subjects with ocular hypertension who did not have defects. Seventy-five percent of converters had abnormal results of the glaucoma hemifield test 1 year before field loss on manual perimetry, whereas 22% of controls had abnormal results of the glaucoma hemifield test (odds ratio, 13.4). The odds ratio of field loss developing on manual perimetry within 12 months was 3.3 for those with borderline results of the glaucoma hemifield test relative to the control subjects. The odds ratio was 6.0 for corrected-pattern standard deviation (P < 0.05) and 3.9 for mean deviation (P < 0.05). CONCLUSIONS: Those with field loss on manual perimetry were more likely to have had an abnormal automated field 1 year before conversion than those who did not convert. However, 22% of subjects in whom definitive field loss did not develop on manual perimetry during the study had abnormal automated fields at one visit and 15% had abnormal automated fields on two consecutive visits.

Aged↗

Comparison of the clinical effects and gingival abrasion aspects of manual and electric toothbrushes.

AIMS: The clinical effects and gingival abrasion aspects of 2 electrical tooth-brushes (Braun Oral-B Plak Control Ultra and the novel development Braun Oral-B Plak Control 3D) were to be compared with conventional manual tooth-brushing. MATERIAL AND METHODS: In a cross-over study, 26 dental student volunteers participated and were assigned to 1 of 3 groups. Following instruction in the use of the electric as well as manual toothbrushes, the volunteers were timed for 2 min each day to apply one electric or the manual toothbrush, respectively, during 3 experimental phases of 2 weeks. No other methods of tooth cleaning were to be performed except the one specified for the respective test period. When brushing manually, the Bass toothbrushing technique was applied. Between each test period, a recovery period of 1 week was allowed during which no oral hygiene was performed at all. At the start and the end of each of the experimental periods, the extension of plaque deposits from the gingival margin in coronal direction was assessed using the Turesky et al. modification of the Quigley and Hein plaque index. Presence or absence of gingival inflammation was evaluated by bleeding and probing (BOP). The extent and severity of gingival abrasions were assessed by use of a modified method of Breitenmoser et al. and adapted by Danser et al. RESULTS: The plaque-reducing effect was similar in all groups with the same cleaning regime. For that reason, the result of the different experimental phases with the respective cleaning modalities were collapsed. Cleaning with the Braun Oral-B Plak Control Ultra electric toothbrush resulted consistently in the lowest plaque scores when compared to both the Braun Oral-B Plak Control 3D and the manual toothbrush. Although the differences in plaque reduction were statistically significant between cleaning with Braun Oral-B Plak Control Ultra and 3D, they were small and of questionable clinical relevance. No significant differences in plaque reductions were found between manual brushing and any of the 2 electric brushes. Gingival abrasions were least pronounced following brushing with the Braun Oral-B Plak Control 3D electric toothbrush. However, no significant differences in gingival abrasion were encountered following brushing with the Braun Oral-B Plak Control Ultra electric in comparison with the manual toothbrush. CONCLUSIONS: The results of the present study have shown that in a group of dental students trained in manual brushing technique, where efficacy was similar with the 3 toothbrushes tested, there is no evidence of greater gingival abrasion with either Braun Oral-B Plak Control Ultra or 3D when compared with a manual brush.

Adult↗

Root-canal shaping with manual and rotary Ni-Ti files performed by students.

AIM: To investigate root-canal shaping with manual and rotary Ni-Ti files performed by students. METHODOLOGY: Thirty undergraduate dental students prepared 150 simulated curved root canals in resin blocks with manual Ni-Ti files with a stepback technique and 450 simulated curved canals with rotary Ni-Ti files with a crowndown technique. Incidence of fracture, preparation length, canal shape and preparation time were investigated. Questionnaires were then issued to the students for them to note their experience of the two preparation methods. RESULTS: Zips and elbows occurred significantly (P < 0.001) less frequently with rotary than with manual preparation. The correct preparation length was achieved significantly (P < 0.05) more often with rotary files than with manual files. Instrument fractures were recorded in only 1.3% of cases with both rotary and manual preparation. The mean time required for manual preparation was significantly (P < 0.001) longer than that required for rotary preparation. Prior experience with a hand preparation technique was not reflected in an improved quality of the subsequent rotary preparation. Approximately 83% of the students claimed to have a greater sense of security in rotary than in manual preparation. Overall 50% felt that manual and engine-driven preparation should be given equal status in undergraduate dental education. CONCLUSIONS: Inexperienced operators achieved better canal preparations with rotary instruments than with manual files. No difference in fracture rate was recorded between the two systems.

Attitude↗

A comparison of manual and automated systems for soil CO2 flux measurements: trade-offs between spatial and temporal resolution.

Soil respiration is affected by distributions of roots and soil carbon substrates and by temperature and soil water content, all of which vary spatially and temporally. The objective of this paper was to compare a manual system for measuring soil respiration in a temperate forest, which had a greater spatial distribution of measurements (n=12), but poorer temporal resolution (once per week), with an automated system which had poorer spatial distribution (n=3) but superior temporal frequency of measurements (hourly). Soil respiration was measured between 18 June and 21 August, 2002, at the Harvard Forest in central Massachusetts, USA. The fluxes measured within 1 h of each other by these systems were not significantly different. However, extrapolations of the mid-morning manual measurements to daily flux values were consistently lower (averaging 13% lower) than the daily estimates obtained from summing the 24 hourly measurements of the automated system. On the other hand, seasonal flux estimates obtained by interpolating between weekly manual sampling dates or by summing the hourly automated measurements were nearly identical. Underestimates by interpolated weekly manual measurements during some periods were cancelled by overestimates during other periods. Hence, a weekly sampling schedule may be sufficient to capture the most important variation of seasonal efflux of CO(2) from the soil. The larger number of chambers that could be measured with the manual system (larger n) resulted in a smaller 95% confidence interval for characterizing spatial variability within the study area on most dates. However, the greater sampling frequency of the automated system revealed rapid responses of soil respiration to wetting events, which permitted better empirical modelling of the effects of soil temperature and moisture on soil respiration than could have been achieved with the manual sampling system. Most of the positive residuals of a function that predicts soil respiration based on temperature were from fluxes measured within 12 h of a rain event, and the residuals were positively correlated with water content of the O horizon. The automated system also demonstrated that Q(10) values calculated for diel variation in soil temperature over a few days were not significantly different than Q(10) values for the entire 3 month summer sampling period. In summary, a manual system of numerous, spatially well-distributed flux chambers measured on a weekly basis may be adequate for measuring seasonal fluxes and may maximize confidence in the characterization of spatial variance. The high temporal frequency of measurements afforded by automation greatly improves the ability to measure and model the effects of rapidly varying water content and temperature. When the two approaches can be combined, the temporal representativeness of the manual measurements can be tested with the automated measurements and the spatial representativeness of the automated measurements can be tested by the manual measurements.

Carbon Dioxide↗

Multicenter comparison of manual and automated screening of AutoCyte gynecologic preparations.

OBJECTIVE: To compare AutoCyte SCREEN-assisted evaluation of AutoCyte PREP liquid-based preparations with manual microscopic screening of the same preparations in a masked, multisite trial. STUDY DESIGN: AutoCyte PREPs were made using the CytoRich automated, liquidbased method from the residual cellular material on the collection device after a conventional cervical smear had been made. The study involved 1,676 samples collected sequentially from high-risk patients at two medical centers. The AutoCyte PREPs were then screened manually by cytotechnologists at one of two laboratory sites. All abnormal slides were reviewed by the site pathologists for final diagnosis. The PREPs were then remasked and screened using the AutoCyte SCREEN automated, interactive screening system, designed to select potentially abnormal slides for manual review while allowing the direct sign-out of negative slides. The AutoCyte SCREEN-assisted practice result was determined by combining the interactive SCREEN result with manual evaluation for those cases selected by SCREEN for manual review. All slides deemed abnormal were manually reviewed by an independent reference pathologist. The original manual review results were then compared to the AutoCyte SCREEN-assisted practice results stratified by the Bethesda categories of abnormal diagnoses as determined by the reference pathologist. RESULTS: Of the 1,676 cases, 494 were determined to be abnormal (ASCUS+) by one or both of the study methods and also by the independent reference pathologist. Of these 494 abnormal cases, 312 had a reference diagnosis of LSIL+, and 139 had a reference diagnosis of HSIL or cancer. The remainder of these cases were ASCUS or AGUS. Sensitivities and false negative proportions were stratified by the reference pathologist based on Bethesda categories as "truth" and compared. For LSIL+ cases, manual screening alone had a sensitivity of 89% as compared to 98% for the AutoCyte SCREEN-assisted practice. Manual screening demonstrated 90% sensitivity to HSIL or greater abnormality as compared to 99% sensitivity by the AutoCyte SCREEN-assisted practice. CONCLUSION: There was a concurrent significant reduction in the false negative fraction using the AutoCyte SCREEN as part of screening practice. Specificity for both screening practices was equivalent.

False Negative Reactions↗

A survey of parent training manuals.

Twenty-six commercially available parent training manuals were surveyed with the goal of providing helpful information to the professional for selection of manuals. Included were manuals for parents as well as manuals for professionals for use in conducting individual or group treatment. The following information was given for all manuals: the characteristics of the target populations for whom the manuals were intended, readability levels, use made of technical language, provision of glossary, organization and format of the book, availability of supplementary materials such as leaders' guides, and references to reviews by other authors. In an additional section, the research literature dealing with evaluation of these manuals was reviewed and summarized as a means of acquainting the reader with the available scientific information on their effectiveness. A report on the status of each manual in terms of evaluation was provided in tabular form. The evaluation of manuals by conduct of empirical research to determine their usefulness to the consumer was emphasized.

Journal Article↗

Comparative study of haematological values using manual and automated techniques in apparently healthy adult Nigerians.

BACKGROUND: Many public medical laboratories use automated techniques for analysis of samples due to the few number of laboratory staff required and the speed at which it operates. This study was carried out to compare haematological values obtained from automated techniques and manual techniques. METHOD: A total of 86 apparently healthy adult Nigerians, aged 18-50 years comprising 50 males and 36 females who came for medical examination between June, 2004 and May, 2005 at Aminu Kano Teaching Hospital, Kano were used for the study. Standard manual methods and cell-dyn 3700cs system techniques were used to determine haematocrit, total and differential leucocyte counts. RESULTS: Statistically significant differences were found between automated and manual techniques in males with regard to haematocrit levels, total white cell counts, differential monocyte and basophil counts (0.45 +/- 0.031/1, 5.1 +/- 1.9 x 10(9)/l, 0.54 +/- 0.19 x 10(9)/l and 0.11 +/- 0.08 x 10(9)/l respectively) for automation and 0.42 +/- 0.041/l, 4.4 +/- 1.4 x 10(9)/1, 0.05 +/- 0.06 x 10(9)/l and 0.004 +/- 0.013 x 10(9)/l respectively for manual methods at P < 0.001, P < 0.05, P < 0.001 and P < 0.001 respectively while there were no significant differences in differential neutrophil, lymphocyte and eosinophil counts (2.1 +/- 0.7 x 10(9)/l, 2.2 +/- 0.7 x 10(9)/l and 0.14 +/- 0.16 x 10(9)/l respectively) of the automation when compared to 2.1 +/- 0.5 x 10(9)/l, 2.1 +/- 0.5 x 10(9)/l and 0.09 +/- 0.09 x 10(9)/l respectively using manual methods (P > 0.05). There were no statistically significant differences between automated and manual methods in females with regard to total white cell count, differential neutrophil, lymphocyte and eosinophil counts (5.8 +/- 2.3 x 10(9)/l, 2.6 +/- 0.9 x 10(9)/l, 2.4 +/- 0.8 x 10(9)/l and 0.1 +/- 0.1 x 10(9)/l respectively) of the automation when compared to 4.9 +/- 1.6 x 10(9)/l, 2.5 +/- 0.7 x 10(9)/l, 2.3 +/- 0.6 x 10(9)/l and 0.06 +/- 0.09 x 10(9)/l respectively of manual techniques (P > 0.05) while significant differences were observed in haematocrit, differential monocyte and basophil counts (0.39 +/- 0.03 l/l, 0.55 +/- 0.3 x 10(9)/l and 0.1 +/- 0.09 x 10(9)/l respectively) of automation when compared to 0.37 +/- 0.03 l/l, 0.03 +/- 0.04 x 10(9)/l and 0.002 +/- 0.01 x 10(9)/l respectively of the manual methods at P < 0.01, P < 0.001 and P < 0.001 respectively. CONCLUSION: The results have proven that differential monocyte and basophil counts from automation are unreliable and efforts should be made to carry out manual differential counts for confirmation.

Adolescent↗

Plaque removal using a battery-powered toothbrush compared to a manual toothbrush.

OBJECTIVE: To evaluate the effectiveness of battery-powered tooth brushing in removing plaque in Kuwaiti children. METHODOLOGY: The subjects were 30 boys, aged 9-11 years. Prior to the start of the study, the children had never used a battery-powered toothbrush. At baseline, plaque accumulation was assessed for manual tooth brushing and battery-powered tooth brushing (Oral-B Kids battery-powered). All subjects then used the battery-powered toothbrush for two weeks at home. Plaque accumulation was again assessed for both manual and battery-powered tooth brushing. Plaque accumulation was assessed using the Soparkar modification of the Quigley-Hein Plaque Index. Differences in pre- and post-tooth brushing plaque, and change from baseline, were the outcome measures evaluated. RESULTS: At baseline, there was no difference in plaque removal between battery-powered tooth brushing and manual tooth brushing, either in difference between pre- and post-tooth brushing plaque measures (p = 0.44) or in percentage change (p = 0.51). After two weeks of use, there was a statistically significant difference in plaque removal between battery-powered tooth brushing and manual tooth brushing, both in the difference between pre- and post-tooth brushing plaque measures (p = 0.01) and in percentage change (p = 0.006). Mean plaque removal by manual tooth brushing was 0.97 +/- 0.45, and mean plaque removal by battery-powered toothbrush was 1.23 +/- 0.56. Mean percentage change in plaque removal by manual tooth brushing was 33.5 +/- 16.05, and mean plaque removal by battery-powered tooth brushing was 43.0 +/- 18.82, which represented a 9.5% improvement for battery-powered tooth brushing compared to manual tooth brushing. CONCLUSION: After two weeks use of a battery-powered toothbrush, the plaque removal was enhanced compared to baseline and to manual tooth brushing. Battery-powered tooth brushing also enhanced manual tooth brushing ability.

Child↗

A randomized clinical trial of manual therapy and physiotherapy for persistent back and neck complaints: subgroup analysis and relationship between outcome measures.

OBJECTIVE: To study the efficacy of manual therapy and physiotherapy in subgroups of patients with persistent back and neck complaints. The second objective was to determine the correlation between three important outcome measures used in this trial. DESIGN: Randomized clinical trial (subgroup analysis). SETTING: Primary health care in the Netherlands. PATIENTS: Two hundred fifty-six patients with nonspecific back and neck complaints of at least 6 wk duration who had not received physiotherapy or manual therapy in the past 2 yr. INTERVENTIONS: At the discretion of the manual therapists, physiotherapists and general practitioners. Physiotherapy consisted of exercises, massage and physical therapy (heat, electrotherapy, ultrasound, shortwave diathermy). Manual therapy consisted of manipulation and mobilization of the spine. Treatment by the general practitioner consisted of drugs (e.g., analgesics), advice about posture, home exercises and (bed)rest. Placebo treatment consisted of detuned shortwave diathermy (10 min) and detuned ultrasound (10 min). MAIN OUTCOME MEASURES: Changes in severity of the main complaint and limitation of physical functioning measured on 10-point scales by a blinded research assistant and global perceived effect measured on a 6-point scale by the patients. RESULTS: Improvement in the main complaint was larger with manual therapy (4.3) than with physiotherapy (2.5) for patients with chronic conditions (duration complaint of 1 yr or longer). Also, improvement in the main complaint was larger with manual therapy (5.5) than with physiotherapy (4.0) for patients younger than 40 yr (both were measured after 12-mo follow-up). Labeling of patients by the treating manual therapists as "suitable" or "not suitable" for treatment with manual therapy did not predict differences in outcomes. Generally, there was a moderate to strong correlation between the three outcome measures, although a considerable number of patients gave a relatively low score for perceived benefit, while the research assistant gave a high improvement score for the main complaint and physical functioning. CONCLUSIONS: The subgroup analysis suggests better results of manual therapy compared to physiotherapy in chronic patients (duration of present complaints of 1 yr or longer) and in patients younger than 40 yr old). Differences for other subgroups were less clear. The explorative findings of these subgroup analyses have to be investigated in future research.

Adult↗