Primary gastric lymphoma

This is a population-based review of 153 cases of primary gastric lymphoma. Sixty-seven (43 per cent) were histologically reviewed using the Kiel classification. There were no significant differences between reviewed and unreviewed cases. Ninety-seven per cent of all cases were of the non-Hodgkin's type. The annual incidence was constant at 1.2 per cent of gastric malignancies. The mean age was 60 years and the male to female ratio 1:8. Presenting symptoms were similar to those of gastric cancer. Twenty-one per cent had a palpable mass but one-third of these were amenable to a potentially curative resection. Some 66 per cent were resectable and 58 per cent had a macroscopic clearance of tumour. TNM stage and absolute tumour size were significant prognostic factors (P less than 0.005 and P less than 0.05 respectively) but the Kiel classification was not. The overall 5 year survival was 24 per cent. Apart from 10 patients whose only anti-tumour treatment was radiotherapy (5 year survival 36.9 per cent) no patient who did not have curative surgery survived 5 years. The 5 year survival for curative resection was 34 per cent and for curative resection plus radiotherapy was 43.5 per cent (45 and 73.4 per cent for the node negative cases respectively). A laparotomy is essential; 'curative' surgery possibly with adjuvant radiotherapy offers the best hope for cure.     

Ruptured abdominal aortic aneurysm presenting as buttock pain

This is the first case report of a ruptured aortic aneurysm presenting with acute right buttock pain. The patient was an 80 year old man. A literature search revealed one report of ruptured internal iliac artery aneurysm presenting with acute hip pain and another of an unruptured aortic aneurysm presenting with chronic hip pain. Thus the present case is another unusual presentation of ruptured abdominal aortic aneurysm and highlights the importance of careful history taking and clinical examination. A high index of clinical suspicion of aneurysm rupture should be maintained in elderly patients presenting with a history of collapse.     

The teacher and the cop: the role of 'private space' in increasingly transparent clinical practice

Education and enforcement have been two contrasting ways of managing clinical performance. Both are needed but recently health policy has placed greater emphasis on the latter, possibly to the detriment of the former. This paper examines the ways in which education and other formative aspects of clinical practice can be conducted. The boundary between education and enforcement involves a distinction between public and private space. Private space is the territory within which clinicians can review their performance and improve it from an educational perspective. The boundary between public and private space is fluid, particularly since the advent of systems to ensure clinicians' competence. The sensitive management of this boundary will determine whether the benefits of transparent clinical practice will be realized in terms of improved patient care.     

PRENATAL DIAGNOSIS OF DERMATOLOGICAL CONDITIONS*

During the years 1973 to 1980 fifty families with ectodermal defects out of a consecutive series of 1,556 were seen for genetic counseling. Arbitrary groupings were made into those with ectodermal dysplasias, icthyosiform and other related syndromes, hamartomas and those with an underlying mztabolic disorder. Eight of these families are discussed as they illustrate recent advances in prenatal diagnosis.     

Evaluation of a humidified nasal high-flow oxygen system, using oxygraphy, capnography and measurement of upper airway pressures

In this study, we evaluated the performance of a humidified nasal high-flow system (Optiflow, Fisher and Paykel Healthcare) by measuring delivered FiO, and airway pressures. Oxygraphy, capnography and measurement of airway pressures were performed through a hypopharyngeal catheter in healthy volunteers receiving Optiflow humidified nasal high flow therapy at rest and with exercise. The study was conducted in a non-clinical experimental setting. Ten healthy volunteers completed the study after giving informed written consent. Participants received a delivered oxygen fraction of 0.60 with gas flow rates of 10, 20, 30, 40 and 50 l/minute in random order FiO2, F(E)O2, F(E)CO2 and airway pressures were measured. Calculation of FiO2 from F(E)O2 and F(E)CO2 was later performed. Calculated FiO2 approached 0.60 as gas flow rates increased above 30 l/minute during nose breathing at rest. High peak inspiratory flow rates with exercise were associated with increased air entrainment. Hypopharyngeal pressure increased with increasing delivered gas flow rate. At 50 l/minute the system delivered a mean airway pressure of up to 7.1 cm H20. We believe that the high gas flow rates delivered by this system enable an accurate inspired oxygen fraction to be delivered. The positive mean airway pressure created by the high flow increases the efficacy of this system and may serve as a bridge to formal positive pressure systems.     

Finding bile duct injuries using record linkage: a validated study of complications following cholecystectomy.

Laparoscopic cholecystectomy was introduced to Western Australia in 1991 and has become the method of choice for this procedure, although there are concerns about complications, particularly bile duct injuries. Previous studies have investigated this problem but have not confirmed the accuracy of coded information. We used Record Linkage to link operative admissions to subsequent admissions for all people who underwent cholecystectomy between 1988 and 1994. Using ICD9-CM discharge codes, we identified patients with an associated complication. We validated these patients' medical notes to obtain the proportion of complications in the period encompassing the introduction of laparoscopic cholecystectomy. We found 48 bile duct injuries in 413 patients. Of these 43% were found using complication codes on the operative admission, 79% using linked records of subsequent admissions, and 90% by adding lists of complicated cases from the three teaching hospitals. Any epidemiological research that uses surgical complication codes from operative admissions, particularly in the absence of a specific ICD9-CM code, will lead to significantly underestimating the prevalence of complications. By using record linkage, and validating medical records, we captured a significant proportion of complications.     

Ventilator-associated pneumonia: current status and future recommendations

Objective  

Ventilator-associated pneumonia (VAP) is a common hazardous complication in ICU patients. The aim of the current review is to give an update on the current status and future recommendations for VAP prevention.     

Prevalence of intellectual handicap in Western Australia: a community study.

OBJECTIVE: To produce comprehensive community based data on individuals with intellectual handicap, the level of retardation, associated handicaps and demographic data. DESIGN: Multiple sources of ascertainment were used to identify all children in birth cohorts, 1967-1976 inclusive, who had an IQ less than 70. SETTING: The majority of cases were ascertained through Western Australian government agencies that provide services for the intellectually handicapped. Other sources included the support branch of the education department, private schools and the children's hospital. PATIENTS: In all, 1602 children, aged between 6 and 16 years, fitted the study criteria. RESULTS: The prevalence of intellectual handicap was found to be 8.9 per 1000 live male births and 6.3 per 1000 live female births with an overall rate of 7.6. The figures for mild, moderate, severe and profound retardation were 3.0, 2.4, 1.0 and 0.6 per 1000, respectively, with 0.8 per 1000 with an unknown IQ. Cerebral palsy occurred in 20% and epilepsy in 13% in addition to intellectual handicap. There was a significantly higher rate among those from rural compared with urban areas: 9.9 v. 6.5 per 1000 live births, respectively. CONCLUSIONS: This comprehensive epidemiological data on intellectual handicap in Western Australia will be of value in the planning of services, including screening and genetic counselling, and for the evaluation of care. The rural preponderance, in particular, is worthy of further evaluation.