The limerick leg-ulcer project: Early results

Nurse led clinics in joint hospital and community settings are now being advocated as the most effective and economic way of dealing with leg ulcers. However, little information exists on the profile and outcome of patients with venous ulcers treated either in the community or in the hospital setting. Over a 2 yr period we assessed 134 patients with leg ulcers of whom 122 were deemed suitable for compression bandaging therapy. Thirty-four patients (28 per cent) were treated by the newly developed community service and 88 (72 per cent) were treated at the hospital clinic. Our overall healing rate for venous ulcers was 50 per cent @ 40 weeks. This probably reflects the long duration (48 per cent >2 yr) and large size (0.5–600 cm²) of ulcer prior to treatment. There were no differences in outcome between hospital (50 per cent @ 40 weeks) and community (35 per cent @ 40 weeks) based treatment (p>0.05). We conclude that most venous ulcers can be effectively treated in the community and resources should be provided to achieve this goal.     

Maternal mortality in Papua New Guinea 1971 and 1972

Reports were received on 364 of the unknown number of maternal deaths that occurred in Papua New Guinea during the two years, 1 January, 1971 to 31 December, 1972. Postpartum haemorrhage accounted for 39 per cent of the deaths, puerperal sepsis for 19 per cent and associated conditions for 14 per cent. In 13 per cent of cases the cause of death could not be ascertained. Obstructed labour caused 4 per cent of the deaths, ruptured uterus 4 per cent, antepartum haemorrhage 3 per cent and abortion 3 per cent. Three deaths were due to miscellanous causes. It is possible that three of the deaths (0.8 per cent of the total) in the cause unascertained group were due to toxaemia of pregnancy. In the coastal districts the major cause of death was postpartum haemorrhage (53 per cent) and the major high-risk factor was grand multiparity (5 or more). In the highlands the major cause of death was puerperal sepsis (41 per cent) and the major high-risk factor was nulliparity. About 50 per cent of all pregnant women in Papua New Guinea are seen at antenatal clinic and about 25 per cent of all births occur in hospital or heath centre. Forty-four per cent of the women who died (abortion excluded) were seen at antenatal clinic and 18 per cent were delivered in hospital or health centre. High-risk factors were present in 87 per cent of women who were seen at antenatal clinic, but only 28 per cent of these high-risk women were delivered in hospital or health centre. Extension of the antenatal services will not result in a major reduction in maternal mortality unless high-risk factors are recognised and unless high-risk mothers can be persuaded to have their babies in hospital or health centre.     

Deaths from asthma in Victoria: a 12-month survey

The circumstances surrounding the death of all patients who died from asthma in the State of Victoria over a 12-month period from May 1, 1986 were investigated. Data were collected using an interviewer-administered questionnaire as soon as practicable after registration of the death. In 168 cases asthma was considered to be the cause of death and adequate data were obtained in 163; 75 of these were male (74 over 60 years of age). Thirteen per cent had a history of trivial or mild asthma, 22% of moderate and 65% of severe asthma. Thirty-four per cent had not been limited at all or only by active sport, while 39% had had no previous hospital admission for asthma. In only 18% had there been a previous admission to an intensive care unit. Forty-seven per cent were taking inhaled beclomethasone or sodium cromoglycate regularly and 27% were taking corticosteroids by mouth regularly. Death occurred outside hospital in 150 of 163 subjects. In the final attack 58% had a sudden onset and collapsed within minutes, 20% were found dead and 27% had an acute progression of an established attack. Twenty-nine per cent of the deaths were assessed as preventable: preventable factors included inadequate assessment or therapy of prior asthma (35%), poor compliance with therapy (33%) and delay in seeking help (43%). As a significant number of subjects in this survey could not be classified as "high risk", it is important that clinicians ensure that all patients are aware of optimal maintenance management and have a clear individualized plan of what to do in the event of deteriorating asthma.     

The identification and assessment of undernutrition in patients admitted to the age related health care unit of an acute Dublin General Hospital

Objectives: To profile those over 65 yr admitted to an acute geriatric medical service. To identify and assess their undernutrition risk and quantify the nutritional intervention they received. Methods: Forty-nine consecutive admissions were recruited, 23 various parameters were assessed. A diagnosis of undernutrition was made according to a specifically designed flow chart. Results: Eighty-four per cent of recruits were at risk of undernutrition on admission and 80 per cent were moderately to severely at risk. There was deterioration from baseline nutritional status in 29 per cent of previouslywell nourished patients with hospitalization. In the undernourished group, an improvement and/or stasis from baseline was achieved in 75 per cent, with intervention. Conclusions: The risk of undernutrition on admission to hospital and during treatment is an indicator of the need for nutrition services and nutritional screening for all acute medical services for older people.     

Junior medical posts in the NHSSB: what the doctors think.

This survey of house officers in the Northern Health and Social Services Board in Northern Ireland demonstrated that they have complaints not just about the number of hours they work. Thirty-nine per cent noted poor standards of food and/or accommodation. Many complained about doing routine "non-medical" work and thought that their working conditions would be improved by nurses having more responsibility for managing intravenous medication and the employment of phlebotomists. Doctors expressed concerns about a lack of career counselling and availability of training in research methods in their posts.     

Advanced trauma and life support principles: An audit of their application in a rural trauma centre

In December of 1995 a system of trauma care based on Advanced Trauma Life Support (ATLS) principles was instituted to assess the impact of such principles on trauma care in a rural general hospital setting. This audit reviews the results over a 2 yr period to December 1997. All patients admitted with major trauma (i.e. with life threatening or potentially life threatening injuries) to Cavan General Hospital (CGH) were eligible for inclusion. This numbered 70 patients admitted (for at least 3 days), or who were transferred after resuscitation and stabilization as well as inpatient deaths. Twenty-seven patients who died prior to admission are also reviewed. The endpoints assessed were death, disability and survival 3 months post-accident. Based on injury severity scores 7 per cent of cases suffered fatal non-survivable injury, 20–30 per cent had very serious injury with an overall mortality rate of 17 per cent. The predicted mortality rate was 30 per cent. One-third had their full treatment at CGH with a 76 per cent survival rate. The other two-thirds were transferred for specialist intervention with an overall survival of 80 per cent, a disability rate of 16 per cent and a mortality rate of 4 per cent. No patient died during transportation.     

Symptoms of oesophageal reflux are more common following laparoscopic cholecystectomy than in a control population

Previous studies have shown that up to 40 per cent of patients have symptoms after cholecystectomy or laparoscopic cholecystectomy (LC). There are concerns, however, that these symptoms reflect those of the general population and are not a specific post-operative phenomenon. Abdominal symptoms of 212 patients following LC were compared to a healthy acalculous control population (n=62). Patients and controls were assessed by questionnaire. Age and sex profiles were similar in both groups. There was no significant difference in the incidence of abdominal pain, bloating or nausea between the 2 groups. Frequent heartburn was a symptom in 19.3 per cent of patients following LC as compared to 3.2 per cent of control patients (p=0.004, chi-squared 9.39, 1 d.f.). Furthermore 11.3 per cent of post-operative patients complained of dysphagia versus 6.4 per cent of the control group (p=0.08, chi-squared 1.245, 1 d.f.). One hundred and twenty (57.1 per cent) patients judged their operation to be a complete success, while 9 (4.3 per cent) were dissatisfied. Five of the latter group cited frequent heartburn as the cause of their dissatisfaction. We conclude that abdominal pain, bloating and nausea occur as frequently in the general population as in patients following LC. Patients are more likely to suffer from heartburn and dysphagia following LC than a normal population supporting a link between cholecystectomy and lower oesophageal dysfunction.     

Human immunodeficiency virus infections in teenagers. Seroprevalence among applicants for US military service. The Walter Reed Retrovirus Research Group

Between October 15, 1985, and March 31, 1989, serum specimens from 1 141 164 teenaged youths (aged less than 20 years) who applied for entry into the US military were tested for antibodies to the human immunodeficiency virus. Overall, 393 teenaged applicants were found to be seropositive (prevalence, 0.34 per 1000). Prevalences varied markedly in different geographic locales: less than 0.1 per 1000 throughout the north-central states, compared with greater than 2 per 1000 in urban counties in Maryland, Texas, New York, and the District of Columbia. Overall, rates among teenaged males (345/991 445; prevalence, 0.35 per 1000) and teenaged females (48/150 013; prevalence, 0.32 per 1000) were comparable. The prevalence among black teenaged applicants (1.06 per 1000) was greater than that among white (0.18 per 1000) or Hispanic (0.31 per 1000) teenaged applicants. Infections with the human immunodeficiency virus are not rare among teenaged Americans.     

Deciding not to resuscitate in Dutch hospitals.

The use of do not resuscitate (DNR) orders in Dutch hospitals was studied as part of a nationwide study on medical decisions concerning the end of life. DNR decisions are made in 6 per cent of all admissions, and 61 per cent of all in-hospital deaths were preceded by a DNR decision. We found that in only 14 per cent of the cases had the patients been involved in the DNR decision (32 per cent of competent patients). The concept of futility is analysed as these findings are discussed. We conclude that determining the effectiveness of resuscitation is a medical judgement whereas determining the proportionality (burden/benefit ratio) of it requires a discussion between doctor and patient (or his or her surrogates). Since the respondents in the cases without patient involvement gave many reasons for their decision that went beyond determining effectiveness, we conclude that more patient involvement would have been desirable.     

The role of gallium scanning in the detection of bone and joint sepsis

The value of gallium (⁶⁷Ga) scanning in the diagnosis of septic disease of bone or joint was assessed in 34 patients. The results show a sensitivity of 60 per cent and specificity of 64 per cent. The low accuracy of this method for the detection of bone and joint sepsis (62 per cent) means that gallium scanning can be used only as an adjunct to other investigative techniques.     

A national model of care service for professionals dealing with Sudden Infant Death

Sudden Infant Death Syndrome (SIDS) is any death occurring in an infant or young child which is unexpected by history and in which a thorough post mortem examination fails to demonstrate an adequate cause of death. The National Sudden Infant Death Register collects information on all sudden unexpected deaths in infants and young children occurring in Ireland. In this study, a comparison was made between parent’s experience of professional services in the aftermath of their child’s death both before and after the implementation of a National Model of Care for professionals in 1995. In addition, a random sample of 105 professionals were surveyed about their knowledge of the Model of Care services. Results were grouped according to the parental experience of the emergency services, the hospital services, the community services and the bereavement support services offered to parents. Prior to the implementation of the Model of Care Service (MOC) (1992–1994), 14 per cent of families stated that they did not find the Gardai helpful. After the Model of Care, only 7 per cent of parents expressed such dissatisfaction. Prior to the MOC, only 3 per cent of Gardai provided families with an information booklet on sudden infant death but afterwards, 23 per cent of Gardai did so. After the MOC families were more likely to have been given the opportunity to hold their infant, were given more privacy and were offered more keepsakes of their infant. Only 46 per cent of families were offered momentos of their baby prior to the MOC as compared to 84 per cent after the implementation of the MOC. They were also more likely to perceive the ancillary services such as the Gardai in a more positive light, where 22 per cent of Gardai offered the family the ISIDA support booklet compared to a previous 3 per cent. Over 50 per cent of parents were provided with a special room in the hospital following the MOC as opposed to a previous 48 per cent. Twenty-one per cent of parents prior to the MOC described the conditions in the hospital as awful, poor or fair, however 31 per cent of parents stated this after the MOC. While there have been improvements in certain areas, there still remains considerable variation in the quality of service provided to all parents. Specifically, we need to address the fact that 16 per cent of parents still report a difficulty in obtaining post-mortem information. Almost 40 per cent said they had little input into how their child was dressed or laid out at this highly emotive time. Over one-third of parents stated they were concerned about how few of their primary health providers, namely general practitioners and public health nurses called to visit them in the aftermath of this tragic event.     

Canadian Applicants to Medical Schools in Canada for 1965-66

An examination of applicants to Canadian medical schools for 1965-66 revealed that 4660 applications were received by the 12 schools for approximately 900 places available; 2852 of these were from Canadians, but because many applicants applied to more than one school, these 2852 applications represented only 1767 individuals. Evaluations made by the schools concerning the acceptability of these applicants showed that only 36 persons rated as “acceptable” by one or more schools failed to gain admission to any Canadian school for 1965-66. Furthermore, 66 “marginal” applicants were accepted, as were 130 multiple applicants who were rated as “acceptable” by one school but “marginal” and/or “unacceptable” by one or more other schools. Of the 464 multiple applicants, only 40% received the same evaluation from all schools to which they applied. If those multiple applicants who were rated as acceptable by all schools to which they applied are added to single applicants rated as acceptable, the pool of these clearly acceptable candidates (40% of all Canadian applicants) is sufficient only to fill 78% of places available. It was thus concluded that it is erroneous to speak of a surplus of well-qualified Canadian applicants at the present time.     

Attitudes to research ethical committees.

A questionnaire on the attitudes towards the functions of research ethical committees was sent to members of selected research ethical committees in Wessex and some controls. Almost all respondents felt there was a need for ethical review of research projects; 42 per cent thought there was a need for some training before joining a committee; 67 per cent thought the system could be improved and 47 per cent thought that monitoring or follow-up procedures should be adopted. Ethical committees were thought to be purely advisory, as opposed to mandatory, by 33 per cent, and 63 per cent thought they should restrict their review to ethical problems as opposed to scientific or design problems. Views about the function of non-medical members ranged from 'none at all' to 'very important'. Of the 10 controls who were asked whether they would become a member of an ethical committee if asked, seven said that on balance they would and the reasons stated varied from the view that it was a 'very important committee' to the feeling that it was 'a necessary but irksome job'.     

Asthma in primary schools

Seven schools in the Lewes area were visited to identify which children were using inhalational treatment for asthma. The attitudes of the parents and schools were assessed, as was the children's skill in using inhalers. Five per cent of all children were receiving inhalational treatment with bronchodilator drugs. On average they had missed seven school days in the past year. The opinions of the parents about treatment appeared to be determined by the severity of the child's asthma. Most schools coped well with giving bronchodilators, though there was no real understanding of the nature of the disease or treatment. Most children who had received pressurised inhalers could not use them satisfactorily.     

Yag laser-assisted thermal balloon angioplasty. Our early experience at Charleston Area Medical Center

Laser thermal balloon angioplasty was performed in 22 arteries, including iliac, superficial femoral, and popliteal arteries. The length of the lesion varied from less than two cm. to 12 cm. The yag laser was used initially, followed by conventional balloon angioplasty. Initial failure to recanalize was noted in 27 per cent, and nine per cent failed within 24 hours, i.e. a primary failure rate of 36 per cent. Initial failure was noted in 67 per cent of lesions greater than five cm. The primary failure rate was 100 per cent in lesions greater than 10 cm. and 82 per cent in lesions. Greater than five to 10 cm. There was no primary failure in lesions less than or equal to five cm. The successfully treated group (14 lesions, 65 per cent of the series), were followed three to 13 months (mean seven months) with a success rate of 86 per cent. The combined primary and secondary failure rate was 45 per cent. The overall success rate was zero per cent for lesions over five cm., and 92 per cent for lesions less than or equal to five cm. Six complications occurred (27 per cent). Two of these were major complications (nine per cent). In conclusion, the primary and secondary failure rate was unacceptable for lesions greater than five cm. LTBA probably should be confined to lesions less than or equal to five cm., and these patients should be followed closely for their long-term success. The widespread application of LTBA cannot be justified without further long-term clinical and laboratory investigation. Conversely, the potential of this technique should not be dismissed out of band.     

HpSA: Assessment of a new non-invasive diagnostic assay for helicobacter pylori infection in an Irish population

Background  The diagnosis of Helicobacter pylori is an essential element in the management of many common gastrointestinal pathologies. Previously diagnosis was dependent on the availability of endoscopic biopsy samples. The advent of non invasive assays such as the C13Urea breath test and Elisa serology have enabled diagnosis, and treatment to be undertaken in the primary care setting. The isolation of Helicobacter pylori antigen from stool has led to the development of a new non-invasive test. Aim  A prospective study was designed to assess and compare the performance of Premier Platinum HpSA with current gold standard tests. Methods  Consecutive patients undergoing a gastroscopy for investigation of dyspepsia at the Meath and Adelaide hospitals were enrolled. At endoscopy gastric biopsies were taken for histology, microbiology and rapid urease testing. In addition all subjects had C13UBT, serology and stool tests performed. Individuals who were H. pylori positive received standard proton pump inhibitor based triple therapy. Following treatment all tests, apart from serology were repeated. Results  54 patients were enrolled, 46 per cent were H. pylori positive. HpSA had a sensitivity and specificity and positive and negative predicted values of 96 per cent, 75 per cent and 80.6 per cent, 75.8 per cent respectively and compared favourably with all other tests. The sensitivity and specificities of the other tests were, histology 79.2 per cent and 100 per cent, culture 68 per cent and 100 per cent, rapid urease test 75 per cent and 100 per cent, serology 75 per cent and 96 per cent and C13 urea breath test 100 per cent and 96.6 per cent. Conclusion  The detection of H. pylori antigen in stool by means of a HpSA assay is a new and effective non-invasive means of diagnosis which can be performed in a routine laboratory setting. It is simple to perform and has possible advantages over other non-invasive tests, detecting actual antigen indicating current active infection.     

Hypertension and the risk of ischaemic heart disease

The magnitude of the effect of hypertension as a risk factor for acute myocardial infarction (AMI) was estimated in 250 patients who presented with a first AMI who were aged 35-64 years (199 survivals and 51 deaths within 24 h), whose names were obtained from a community-based register of myocardial infarctions in the Hunter Region of New South Wales. The cases were matched by sex, age and residential area, and control subjects were obtained from a random population sample from the same region. A history of hypertension (odds ratio, 5.5; 95% confidence limits, 3.4 and 8.9) and treatment for hypertension (odds ratio, 4.2; 95% confidence limits, 2.5 and 7.2) were each significantly (P less than 0.0001) associated with an increased risk of AMI--persons with treated or untreated hypertension were four to five times more likely to develop AMI than were persons without hypertension. Adjustment for smoking did not affect the association between hypertension and the incidence of AMI. Cigarette smoking appears to have had less influence on the incidence of AMI (odds ratio, 1.7; 95% confidence limits, 1.1 and 2.4; P less than 0.01) than did a history of hypertension. Twenty-four per cent of the first AMIs that occurred in the study population were attributable to hypertension (after adjustment for smoking) and twenty-seven per cent were attributable to smoking (after adjustment for hypertension).     

Prevalence of abnormal thyroid function tests in a Down’s syndrome population

As thyroid function has been documented to be of a higher prevalence in individuals with Down’s syndrome, a study was set up to assess the thyroid status of these individuals. Thyroid function tests (T.F.T.s) were initially reviewed on 100 individuals with Down’s syndrome in the community and on 36 individuals who were residentially based. Abnormal T.F.T.s were then reviewed 3 yr later. In total sample of 136, initially 13 per cent [n=18] of individuals with Down’s syndrome had abnormal T.F.T.s, 5 per cent [n=7] were established cases of thyroid disease and 8 per cent [n=11] were newly identified cases who had abnormal T.F.T.s. Three yr later 6.5 per cent [n=9] of the group who had had abnormal T.F.T.s continued to have abnormal T.F.T.s, 5 per cent [n=7] had thyroid disease and 1.5 per cent [n=2] still had biochemical evidence of thyroid dysfunction. There was a statistically significant increase in abnormal T.F.T.s in the residential sample compared to the community sample on both occasions. The incidence of thyroid dysfunction has been found to increase with age, particularly over the age of 40, however in this study the majority were under the age of 40 with an age range between 28.3 yr and 33.8 yr. The results in this study, coupled with the variability of T.F.T.s over time, highlights the need for regular monitoring of the thyroid status of individuals with Down’s syndrome.     

马尾口岸港区与居住区媒介生物分布情况调查及对比分析

目的了解马尾口岸港区媒介生物分布情况及对居住区媒介生物分布的影响,为媒介生物控制以及国境口岸传染病监测工作提供科学依据。方法根据马尾口岸地理分布和港口类型,随机抽取4个港口和1个居民点实施为期1年、每月1次的调查,按照《中国出入境检验检疫行业标准》制定鼠、蚤、蚊、蝇、蜚蠊、蜱、螨、蠓8种媒介生物监测方法。结果(1)港区平均鼠密度(2.18%)、总染螨率(9.33%)、染蚤率(2.84%)及平均蝇密度[94.06/(笼.日)]明显低于居住区[分别为5.59%,28.95%,6.67%及149.5/(笼.日)],差别有统计学意义;蚊、蜚蠊密度港区与居住区差别无统计学意义;未捕获到蜱、蠓。(2)鼠、革螨、蝇、蚊在港区与居住区的种群组成基本一致。(3)居住区的各媒介生物优势种与港区不同。(4)135份肺和肝标本,经检测流行性出血热抗原阳性标本10份,阳性率为7.4%,阳性标本60%来自居住区;鼠疫抗体均阴性。结论(1)各媒介生物种群组成均属福建省普遍存在的种类,未发现新的品种,(2)居住区媒介生物的种群构成受港区影响。     

Inappropriate antibiotic use and the development of Clostridium difficile colitis

A three-year, retrospective, community-wide study reviewed all patients (n = 60) with positive Clostridium difficile stool cytotoxin assays. The appropriateness of antibiotic administration in hospitalized patients (n = 48) who developed antibiotic-associated colitis (AAC) was studied. Only 25 per cent had antibiotics used appropriately with positive culture results and organisms susceptible to the antibiotic(s) given. Another 25 per cent of cases had positive cultures, but the organisms were not susceptible to the antibiotics used. Cultures exhibited no growth or were not obtained in 50 per cent of cases, but empiric antibiotic administration led to the development of AAC. Our results point toward inappropriate antibiotic use as being a major factor in the development of AAC. AAC is rarely fatal but has significant morbidity, and is expensive to treat. Judicious use of antibiotics may decrease the incidence of AAC.