Consultation Period Research Articles

Protocol for the scientific opinion on the Tolerable Upper Intake Level of dietary sugars.

In June 2016, EFSA received a mandate from the national food competent authorities of five European countries (Denmark, Finland, Iceland, Norway and Sweden) to provide a dietary reference value (DRV) for sugars, with particular attention to added sugars. A draft protocol was developed with the aim of defining as much as possible beforehand the strategy that will be applied for collecting data, appraising the relevant evidence, and analysing and integrating the evidence in order to draw conclusions that will form the basis for the Scientific Opinion on sugars. As EFSA wished to seek advice from stakeholders on this draft protocol, the NDA Panel endorsed it for public consultation on 12 December 2017. The consultation was open from 9 January to 4 March 2018. A technical meeting with stakeholders was held in Brussels on 13 February 2018, during the consultation period. After consultation with stakeholders and the mandate requestors, EFSA interprets this mandate as a request to provide scientific advice on an Tolerable Upper Intake Level (UL) for (total/added/free) sugars, i.e. the maximum level of total chronic daily intake of sugars (from all sources) judged to be unlikely to pose a risk of adverse health effects to humans. The assessment concerns the main types of sugars (mono‐ and disaccharides) found in mixed diets (i.e. glucose, fructose, galactose, sucrose, lactose, maltose and trehalose) taken through the oral route. The health outcomes of interest relate to the development of metabolic diseases and dental caries. The final version of the protocol was endorsed by the EFSA Panel on Dietetic Products, Nutrition and Allergies on 28 June 2018.

Outcome of the public consultation on a draft protocol for the Scientific Opinion on dietary sugars

The European Food Safety Authority (EFSA) carried out a public consultation to receive input from the scientific community and all interested parties on a draft protocol for the Scientific Opinion on free sugars from all dietary sources, prepared by the EFSA Panel on Dietetic Products, Nutrition and Allergies (NDA Panel), supported by the ad-hoc Working Group on Sugars. The draft protocol was endorsed by the Panel for public consultation at its plenary meeting on 12 December 2017. The written public consultation was open from 9 January to 4 March 2018. A technical meeting with stakeholders was held in Brussels on 13 February 2018, during the consultation period. Stakeholders were encouraged to submit their comments in writing within the consultation deadline. EFSA received comments from 46 interested parties. EFSA and its NDA Panel wish to thank all stakeholders for their contributions. The present report summarises the outcome of the public consultation, and includes a brief summary of the comments received and how they were addressed. In particular, the report describes the revisions of the draft protocol that have been applied in light of the comments received. The protocol will be implemented in order to draft a Scientific Opinion on the Tolerable Upper Intake Level of dietary sugars. Another public consultation will be organised on the draft scientific opinion, which is foreseen to be endorsed by the NDA Panel at the end of 2019.

NICE outlines 1-month target for treatment of PTSD

On June 11, 2018, the National Institute for Health and Care Excellence (NICE) issued new draft guidance for post-traumatic stress disorder (PTSD). It recommended that adults at risk of developing PTSD should be offered individual trauma-focused cognitive behaviour therapy (CBT) within 1 month of experiencing a potentially traumatic event. For adults diagnosed with PTSD who are unable or unwilling to have face-to-face therapy or eye movement desensitisation and reprocessing (EMDR), the draft guidance suggested that computerised CBT be considered. A consultation period followed the publication of the draft guidance, which ended on July 23, 2018. The updated guidance is expected to be issued in December, 2018, replacing the 2005 version.

Effects of alertness management training on sleepiness among long-haul truck drivers: A randomized controlled trial

Education is a frequently recommended remedy for driver sleepiness in occupational settings, although not many studies have examined its usefulness. To date, there are no previous on-road randomized controlled trials investigating the benefits of training on sleepiness among employees working in road transport. To examine the effects of an educational intervention on long-haul truck drivers’ sleepiness at the wheel, amount of sleep between work shifts, and use of efficient sleepiness countermeasures (SCM) in association with night and non-night shift, a total of 53 truck drivers operating from southern Finland were allocated into an intervention and a control group using a stratified randomization method (allocation ratio for intervention and control groups 32:21, respectively). The intervention group received a 3.5-hour alertness management training followed by a two-month consultation period and motivational self-evaluation tasks two and 4–5 months after the training, while the control group had an opportunity to utilize their usual statutory occupational health care services. The outcomes were measured under drivers’ natural working and shift conditions over a period of two weeks before and after the intervention using unobtrusive data-collection methods including the Karolinska Sleepiness Scale measuring on-duty sleepiness, a combination of actigraphy and a sleep-log measuring sleep between duty hours, and self-report questionnaire items measuring the use of SCMs while on duty. The data analysis followed a per-protocol analysis. Results of the multilevel regression models showed no significant intervention-related improvements in driver sleepiness, prior sleep, or use of SCMs while working on night and early morning shifts compared to day and/or evening shifts. The current study failed to provide support for a feasible non-recurrent alertness-management training being effective remedy for driver sleepiness in occupational settings. These results cannot, however, be interpreted as evidence against alertness management training in general but propose that driver education is not a sufficient measure as such to alleviate driver sleepiness.

A rare case of plantar lipoma

Plantar tumors of soft tissue are rare and are characterized by their slow evolution which delays the patient consultation period Lipomas are among the most common benign tumors which often serve in regions rich in fats often in the face of the hands and feet We report an exceptional case of plantar lipoma Surgical treatment has laid the histological diagnosis of certainty and restores a normal and painless plantar support Lipoma despite its exceptional location at the foot level should be mentioned as differential diagnosis of benign tumors of the foot

Ponatinib for Treating Acute Lymphoblastic Leukaemia: An Evidence Review Group Perspective of a NICE Single Technology Appraisal.

As part of its single technology appraisal (STA) process, the UK National Institute for Health and Care Excellence (NICE) invited the manufacturer (Incyte Corporation) of ponatinib (Inclusig®) to submit evidence of its clinical and cost effectiveness for previously treated Philadelphia-chromosome-positive acute lymphoblastic leukaemia (Ph+ ALL) and chronic myeloid leukaemia. This paper focusses on Ph+ ALL. The School of Health and Related Research Technology Appraisal Group at the University of Sheffield was commissioned to act as the independent evidence review group (ERG). This article presents the critical review of the company's submission by the ERG and the outcome of the NICE guidance. The clinical-effectiveness evidence in the company's submission was derived from a phase II, single-arm, open-label, non-comparative study. Given the lack of comparative evidence, a naïve indirect comparison was performed against re-induction chemotherapy comparing major cytogenetic response and complete remission. Best supportive care (BSC) was assumed to produce no disease response. Despite the limited evidence and potential for biases, this study demonstrated that ponatinib was likely to be an effective treatment for patients with Ph+ ALL. The company submitted a state transition model that analysed the incremental cost effectiveness of ponatinib versus re-induction therapy and BSC for the treatment of Ph+ ALL in patients whose disease is resistant to dasatinib, who are intolerant to dasatinib and for whom subsequent treatment with imatinib is not clinically appropriate or who have the threonine-315-isoleucine mutation. This population was further subdivided into those who were suitable for allogeneic stem cell transplant (allo-SCT) and those who were not. The company's revised economic evaluation, following the clarification process, estimated incremental cost-effectiveness ratios (ICERs) in those suitable for allo-SCT of £31,123 per quality-adjusted life-year (QALY) gained for ponatinib compared with re-induction chemotherapy and £26,624 per QALY gained compared with BSC. For those for whom allo-SCT was unsuitable, the company-estimated ICER compared with BSC was £33,954 per QALY gained. Following a critique of the model, the ERG undertook exploratory analyses that, when combined, produced a range in ICERs (due to uncertainty of the most appropriate overall survival function) of dominant (being less expensive and providing more QALYs) to £11,727 per QALY gained compared with re-induction chemotherapy and between £7892 and £31,696 per QALY gained compared with BSC for those in whom allo-SCT was suitable. For those in whom allo-SCT was not suitable, the ERG estimated that ponatinib was dominant. During the consultation period, the company agreed a revised patient access scheme (PAS) that reduced the ICER ranges to £7156 to £29,995 per QALY gained versus BSC and to less than £5000 per QALY gained versus re-induction chemotherapy. In people for whom allo-SCT was unsuitable, ponatinib dominated BSC. The NICE appraisal committee concluded that ponatinib is a cost-effective use of UK NHS resources in the considered population, subject to the company providing the agreed discount in the PAS.

Concerns that Linger: Medical School Perspectives on the UKMLA and Shared Assessment

The General Medical Council have closed their formal consultation process soliciting recommendations on how to develop a UK Medical Licensing Assessment (UKMLA). The output of this consultation goes a considerable way to identifying concerns about implementation of such an assessment. However, there is scope for more attention to detail in specifying concerns held by individual UK medical schools, even where these schools have indicated acceptance or approval of the UKMLA. There is therefore a need for increased transparency in identifying stakeholder viewpoints to ensure these lingering concerns can be addressed during the current development phase. The current study contributes to addressing this need through providing an overview of UK medical school views on introducing a UKMLA and relatedly, on shared assessment as a source of uniformity in competency across medical schools. Using a secure online survey system, response data were collected during 13-30 January, 2014 from recommended assessment specialists, representing their respective medical schools. Likert scale and free text response data were collected. Based on Likert sale data, more medical schools appeared accepting of these ideas than either those who expressed disapproval or those who expressed uncertainty. Nevertheless, concerns still lingered. Areas of concern included stifling of curriculum innovation, supporting students who fail the UKMLA and quality and administration of assessment. Eleven recommendations have emerged for addressing respondent concerns. In presenting these recommendations arising specifically from participant feedback, I invite responses from all categories of stakeholder in order to promote open discussion beyond the formal consultation period.

Therapeutic Itinerary and Causes of Delay in Specialized Consultation of Patients Admitted for Diabetic Foot

Introduction: Amputation remains a common practice in patients admitted for diabetic foot. The delay in consultation is one of the main reasons. The objective of this work was to analyze patients’ itinerary care and to identify the causes of delay in consultation in patients admitted for diabetic foot. Method: This is a descriptive cross-sectional study, including all patients hospitalized for diabetic foot. A wait of at least seven (7) days before consulting the Endocrinology department of Hubert Koutoukou Maga Teaching Hospital (CNHU-HKM) after the foot injury occurred was considered as delay in consultation. The data were recorded and analyzed in the EPI INFO software. The description of the sample was made according to the usual statistics (frequency, average, standard deviation). Results: Seventy-six (76) diabetic foot cases were admitted during the period of the study. The mean age of the patients was 56.64 ± 10.71 years with extremes of 29 years and 84 years. Patients were most often received at an advanced stage of the foot injury, 3D stage of Texas classification in 87% of cases and Wagner grades 4 and 5 in 52% of cases. The amputation rate was 38.16%. An analysis of the first care places reveals that 90.8% of patients had consulted conventional medicine, 13.2% in traditional medicine; 1.2% had religious practices and 18.7% had declared self-medication at home. Consultation period at CNHU HKM was more than 7 days in 80% of cases and less than 7 days in 20% of cases. The average consultation time was 44.08 ± 26.43 days with extremes of 1 and 480 days. The main reasons for the delay in seeking hospital care cited by diabetic patients were fear of amputation (47.8% of cases), economic difficulties (32.5% of cases) and awareness lack of the situation seriousness (22.4%). Conclusion: The therapeutic itinerary of patients with diabetic foot was particularly long. The main reasons of late appeal to specialized care were fear of amputation and economic difficulties. The implementation of universal health insurance and an information, education and communication program could certainly reduce the periods allowed for recourse to care and therefore to reduce the amputation rate.

Prise en charge du priapisme ischémique aigu à l’Hôpital National de Lamordé de Niamey

ObjectivesTo describe the clinical features of acute ischemic priapism and to assess the results of the management. Patients and methodsThis is a prospective study over a period of 19 months from June 2011 to December 2012, involving 29 patients treated for acute ischemic priapism in the service of surgical and urological emergencies of National hospital of Lamordé. The age, the consultation period, the etiology and results of the treatment were the variables studied. ResultsThe mean age was 19 years (range 5-43 years). The average time of consultation was 26 hours (range: 5 hours and 5 days). Sickle cell disease (18 cases) and self-medication (7 cases) were the main causes. De tumescence was complete (15 cases) after cavernous puncture and etilefrine administration. The erection was satisfactory (7 cases) with a mean of 3 months and 5 patients had erectile dysfunction. ConclusionSickle cell disease is the leading cause of acute ischemic priapism in our context. Winter's procedure is a simple treatment option, reliable and effective for the treatment of this condition.

Synopsis: Lyme Disease in Canada - A Federal Framework.

The Federal Framework on Lyme Disease Act required the federal government to develop a Federal Framework on Lyme Disease. To do this, the Public Health Agency of Canada held a conference with a wide variety of stakeholders who shared their experiences with Lyme disease, and discussed current knowledge and research. A draft version of the Framework was publicly posted on Canada.ca for a 30-day public consultation period. The final report, Lyme Disease in Canada: A Federal Framework was released in May 2017. The Framework includes the three pillars of surveillance; education and awareness; and guidelines and best practices. Implementation will require the involvement and collaboration of all stakeholders and all levels of government, with the Government of Canada committed to collaborating with domestic and international partners to exchange best practices in the prevention, diagnosis and treatment of Lyme disease.

An Authentic Learning Environment Based on Video Project among Arabic Learners

Role playing is among the language activities that stimulate language learners to use the language they are learning. However, a successful activity is always challenging especially when the learners are beginners. Therefore, a special arrangement needs to be carried out by instructors. This article explores the use of storyboards, or ‘PCVA’, to help Arabic learners prepare for their video project based on role playing. Blended methods were used to collect data, namely surveys, interviews, and observations. The target participants were among degree students from second level (TAC451) and third level (TAC501) of Arabic course. The total number of the participants is 87 respondents. Interview and observation were conducted during consultation period and then, related information was documented for the purpose of the study. Descriptive analysis was implemented to interpret the data. The findings showed a positive feedback from the learners who were involved in the experiment.

The art and science of community relations: Procedural fairness at Newmont's Waihi Gold operations, New Zealand

Community relations are an integral part of successful and socially acceptable mining operations. Effective interactions between a mining company and a host community tend to foster mutual understanding and trust, leading to higher levels of acceptance of those operations. The Waihi gold mining operations in New Zealand, which consist of an open pit, several underground operations, a processing facility and waste storage facilities, are well known for their close proximity to their host community. In 2011, the company Newmont Waihi Gold announced a potentially controversial extension to their existing underground operations, which for the first time proposed to extend directly beneath homes in residential Waihi. At the time of this announcement, the company had made no consent application nor held permission to extend their operations. The announcement was the first stage in an extensive three year consultation period with the community to negotiate whether and how the extension might proceed. This paper provides a case study of community relations practice that draws on both quantitative and qualitative research methods to examine the drivers of community acceptance of this extension. This includes results of a survey of community members undertaken prior to the announcement of the proposed extension, which identifies why community members regarded the company as a positive member of their community, and how this contributed to their acceptance of the company. These findings are supported by a series of interviews with key stakeholders from both company and community that interrogate the community relations process and how the mine's extension was negotiated after the initial proposal was announced. Based on these findings, a number of initiatives that were jointly developed by the company, community and other stakeholders through a voluntary, facilitated negotiation process within the legal consenting regime are identified. It is also observed that these negotiations ultimately allowed this complex operation to proceed. Our findings highlight how community relations function in practice, how trust in the relationship between company and community is underpinned by procedural fairness in those interactions, and provide examples of how fair processes are negotiated in context.

National Funding Formula: An analysis

Understanding the National Funding Formula, its limitations and how it will affect your school is vitally important. As the second consultation period draws to a close, Julia Harnden analyses the current proposals

Presumptive diagnosis of leptospirosis before seroconversion: a review of 338 cases in Wallis and Futuna 2008 to 2015.

Leptospirosis is a common condition in Wallis and Futuna, and the definitive diagnosis needs to be established urgently at the first patient consultation, which is usually one to two days after the onset of clinical signs. As a diagnostic aid, a composite index was established based on data from 338 patients seen by the Wallis and Futuna admissions services between 2008 and 2015. The data taken into account include: age and sex of the patient, their home island, the consultation period and the results of leukocytes, platelets, CRP, creatinine and GGT tests combined with 2 major clinical signs, headache and conjunctival suffusion. Then 5 threshold limits were defined for this index, which indicates from very low risk to almost certain biologically confirmed leptospirosis. Other febrile diseases responsible for thrombocytopenia are not found in Wallis and Futuna, which probably explains the good statistical qualities of this index with a value of area under the curve equal to 0.821.

Traitement des hématomes maculaires compliquant la DMLA par vitrectomie, injection sous-rétinienne r-TPA, injection intravitréenne de bévacizumab associé à un tamponnement par gaz : à propos de 4 cas

The occurrence of a subretinal hematoma in age-related macular degeneration (AMD) is a serious complication that can impact the visual prognosis with a poor functional recovery. The management of this complication remains controversial. Several therapeutic methods have been described. We report the results of four patients treated with a protocol combining: vitrectomy, subretinal injection of r-TPA 0.025mg/0.3ml, intravitreal injection of 0.05ml of bevacizumab and retinal tamponade with 20% SF6 gas. Our series consists of four patients with a submacular hematoma complicating AMD, included in succession between October2013 and October2014 and treated with the same treatment protocol and by the same surgeon. All patients underwent surgery within eight days after the onset of the macular hematoma. Patients with a consultation period longer than eight days did not undergo this treatment. Face down postoperative positioning was then carried out for seven days by the patients. We observed a shift in the macular hematoma in the four patients, which allowed the identification of secondary neovascularization responsible for the bleeding. The visual acuity improved in three patients from hand motion (HM) preoperatively to 2/10 at one month postoperatively. One patient maintained visual acuity 1/20 during the entire follow-up despite almost complete resorption of the subretinal hematoma. These visual acuities were stable at 6months postoperatively. Macular subretinal hematoma can cause severe visual loss by several mechanisms. The blood accumulates between the neurosensory retina and the retinal pigment epithelium, which causes a toxic effect on the surrounding tissues, thus resulting in a loss of photoreceptors and cellular destruction in the pigment epithelium and choriocapillaris, evolving into a fibroglial scar. The therapeutic evaluation of this protocol in our series of four patients gives a favorable result. We observed an improvement in visual acuity in 3/4 of cases. This surgical technique appears to be effective in the treatment of this complication of AMD. However, a study on a larger scale is needed to confirm these results.

Aspects épidémiologiques, cliniques et judiciaires des violences physiques faites aux femmes dans la région de Tambacounda (Sénégal)

IntroductionTo contribute to the fight against physical violence against women, this work aimed to make a 10-year review of cases treated at the Regional Court of Tambacounda. MethodologyThis observational, retrospective, descriptive and analytical study was conducted from 15 October 2014 to 15 April 2015. It covered all the court records of victims of intentional injury from 2006 to 2015. The data was entered and analyzed using Epi info 3.3.2 software. ResultsIn all, 113 cases were treated. The mean age was 26.5±10.08 years for victims versus 32.5±13.8 years for the aggressors. The victims were all female, and 77.9% of offenders were male. The assaults took place mostly during the day (57.5%), and especially in the homes of victims (61.0%), in the street (16.8%) in the bush (12.4%). The consultation period was less than 24hours for 54.9% of the victims. Clinical examination differentiated: fractures (15%); contusions (13.5%); penetrating wounds (10.6%); bruises (9.7%); eye injuries (7.9%); broken teeth (7.9%); diffuse pains (7.1%), 6.2% polytrauma (6.2%), and 5.3% of trauma on pregnancies. Among the violence, 33.6% were domestic; 11.5% were associated with rape (7.1%); psychological violence (3.6%); rape and death threat (1.8%). Rape was statistically more common among child victims [OR=10.7 (3.2–35.5)] and/or educated victims [OR=5.8 (1.7–19.9)] and aggression in the bush [OR=7.5 (2.2 to 14.2)]. The attackers were lonely and imprisoned in 94.7% and 73.5% of cases respectively. The sentence was firm imprisonment for 89.2% of cases. ConclusionIn Tambacounda, health and judicial authorities should enhance public awareness concerning the risk of violence. The extension of this type of study to the national level would have enabled better orientation of control strategies against this scourge.

Adenopathies in Internal Medicine Etiological Profile and Diagnostic Limits

INTRODUCTION: An adenopathy is a pathological hypertrophy of a lymph node of various etiologies requiring a rigorous approach. Thus we proposed in this work to study the etiological particularities of patients admitted for adenopathy in order to identify their specificities. METHODS: This was an observational study of a transverse and descriptive type, which took place from 1 July 2015 to 30 June 2016 in the internal medicine department of the Aristide Le Dantec national hospital in Dakar. RESULTS: We identified 84 patients, consisted of 46 male and 38 female. The sex ratio was 1.2. The mean age was 37.5 years. The consultation period was on average 2 months with extremes of 1 month and 1 year. The mean hospital stay was 29. 2 days with extremes of 1 week and 2 months. The etiologies found were classified into 6 groups. Hemopathies (30.9%) were dominated by acute leukemia in 8 patients (9.52%), non-Hodgkin’s lymphoma in 9 patients (9.5%), Hodgkin’s disease in 5 patients (5.9%). Chronic lymphocytic leukemia was retained in 3 patients (3.5%) and Castleman disease in 1 patient. Systemic diseases (11.9%) were divided into lupus disease in 4 patients and rheumatoid arthritis in 4 patients, one case of Sj?gren’s syndrome and one case of sarcoidosis. Infections were very frequent in our study, found in 34 patients (40.4%). Tuberculosis was more frequent (27.3%). The association with HIV was noted in 4 patients. The other infections were pyogenic in 3 patients (3.5%), HIV in 6 patients (7.1%), Borrelia and toxoplasma in 1 patient respectively. Cancers (8.3%) were metastatic of primary tumors including the esophagus, lung, prostate, cavum, stomach, pancreas and breast, one case each. One patient presented lymphadenopathy with inguinal localization, the etiology of which was found to be thrombophlebitis of the right lower limb. The hystiocytic pathologies (3.5%) were all related to lymphohystiocytic activation syndrome (LHAS) secondary to tuberculosis in 2 patients and pyomyositis in 1 patient. The difficulties encountered were mainly the inaccessibility of certain complementary examinations and the delay in obtaining the results. CONCLUSION: Adenopathies are a very common reason for consultation in internal medicine. This study allowed us to draw up the etiological profile of adenopathies in our practice but also to identify the main difficulties which are among other things the inaccessibility of certain complementary examinations.

Thoracic Wounds by Firearm at the University Hospital Yalgado Ouedraogo (YO)

Introduction: Thoracic wounds by firearms are frequent and severe. They may involve the patient’s prognosis. Objective: To study the epidemiological, clinical, paraclinical, therapeutic and evolutionary aspects of the thoracic wounds by firearms. Material and method: This was a cross-sectional, descriptive study of all patients over the age of 15 who consulted in the university hospital-YO in the department of general and digestive surgery over a period of 5 years. Results: We collected 50 cases of thoracic wounds by firearms on 183 thoracic wounds with a prevalence of 27.3%. There were 48 men (96%). The average age was 30 years. The patients came from urban areas in 66% of cases; the informal sector accounted for 44% of the cases. The pistol was the most involved firearm (46.9%). The consultation period was less than 6 hours in 78% of patients. An unstable hemodynamic state was found in 42% (n = 21). A fluid and mixed pleural effusion syndrome was found in 46% and 26% of patients, respectively. Associated lesions were diaphragm involvement, and lesions of intra-abdominal hollow organs. Thoracic drainage was performed in 24 patients (48%) and was associated with a laparotomy in 8 patients. The average hospital stay was 7.5 days. Mortality was 14%. Conclusion: the thoracic wounds by firearms are frequent in civilian practice. The thoracic CT allows mapping of the lesions and thoracic drainage constitutes the essential part of surgical treatment. The fight against the proliferation of weapons deserves to be promoted.

Experience of Women Diagnosed with a Pre-cancerous Cervical Lesion during the Consultation Period

Experience of Women Diagnosed with a Pre-cancerous Cervical Lesion during the Consultation Period

Sts’ailes Mental Wellness Clinic: Description of the First 15 Months of a Service Development Journey on a St’olo First Nation in British Columbia, Canada

The Sts’ailes community is a First Nation close to Chilliwack in British Columbia, Canada where a mental wellness clinic was launched in January 2015. Presented here, in addition to description of the development and structure of the clinic are the sources of referral, demographics, diagnoses and other characteristics of all patients seen over a 15 month period (January 2015 to April 2016). By way of context, the paper begins with an overview of the cultural and historical background of Sts’ailes. It then describes the health services that were in existence at Sts’ailes prior to the mental wellness clinic as well as the values that were held to be important for the mental wellness clinic to embody. Emphasized in this paper too is the fact that a significant time period of consultation and relation-building as well as organizational commitment between First Nations representatives as well as representatives of the local health authority preceded the inception of the clinic.