“Lytic” lesions in autologous bone grafts: demonstration of medullary air pockets on post mortem computed tomography

Donor bone grafts are an important aspect of orthopaedic surgery. The use of plain film as a pathological screening tool before donor bone dispatch has revealed “lytic” lesions in proximal humeri. Donor demographics did not support the diagnosis of myeloma and subsequent computed tomography (CT) scans of these bones identified the lesions as air, not pathology. In total, 27 long bones were scanned and 100% (27/27 cases) exhibited air within the trabecular bone. Three distinct patterns were found: ovoid, linear/branching, and broad channel. A longitudinal course of CT scans was performed to identify at which stage air appeared within the bone. Pre-retrieval, preprocessing, and postprocessing scans revealed that air originated between the retrieval and preprocessing stages of donor bone preparation. There may be multiple aetiology of this phenomenon, including bone retrieval and natural decomposition.     

Reconstructive options after temporal bone resection for squamous cell carcinoma.

Squamous cell carcinoma (SCC) of the temporal bone is a rare, aggressive and highly malignant tumour that requires specialised, multidisciplinary surgery for its treatment. Reconstruction of the defect is as crucial as the tumour ablation in terms of mortality and postoperative morbidity. METHODS: The experience of the East Anglian Skull Base Surgery Service from 1982 to 2004 in managing 42 consecutive patients (22 females; age range 37-80 years) undergoing extended and lateral temporal bone resection for SCC is presented. RESULTS: The overall 5-year survival was 31.0% (median follow up: 97 months) when both curative and palliative procedures were included. On multivariate analysis, the favourable prognostic factors were male sex, well-differentiated tumours and stage N(0) neck. The reconstructions in 38 patients were analysed. The majority (24/38) had free tissue transfer reconstructions and most of these were radial forearm free flaps. Later in the series, other free flap types such as anterolateral thigh flaps and lateral arm flaps were employed. Pedicled myocutaneous flaps and local flaps were also used. CONCLUSIONS: This paper analyses the outcomes of the various reconstructions and discusses the evolution of their care in our unit. The information obtained from the review of our data is extrapolated to offer guidance on the choice of reconstructive option in these patients.     

Evaluating clinical educators: an employer's perspective

An Australian school of nursing's attempt to introduce an evaluation process required by management for clinical educators involved in undergraduate preregistration education is discussed Reliance on student feedback and clinical agencies' perceptions of the quality of teaching were seen as inadequate mechanisms for evaluation The evaluation process adopted incorporated observation of the educators together with self-reflection on their performance We conclude that post-briefings were poorly used and generally not reflective Educators relied heavily on their clinical skills and used a limited range of teaching strategies Whilst evaluation of clinical educators was time consuming and therefore costly, it is argued that it is essential to the integrity of the course The evaluation process has provided direction for support and development of clinical educators within the context of the curriculum     

Making poverty a practice issue

Trends in poverty and changes in service provision are combining to make the promotion of health in poverty a particular challenge to health and welfare practitioners. The evidence suggests that practitioner groups have failed to respond adequately to this challenge. Factors concerned with professional perceptions of poverty, the nature of qualifying and post-qualifying education and the difficulties associated with taking research into practice all appear, in some way, to contribute to practitioners’ failure to incorporate a poverty perspective in their work. A team training approach appears to offer one way forward in the practice-setting. Using a team training approach, the‘Health Promotion in Poverty Project’ has sought to enable the lessons learnt from the broad base of poverty theory and research to be used by practitioners to build responsive and integrated support strategies for low-income families with dependent children.     

Term delivery in a woman with severe congenital neutropenia, treated with growth colony stimulating factor

The patient was diagnosed in childhood as having severe congenital neutropenia and had recurrent admissions with severe infections. In 1987, prior to getting married, she was sterilized. She continued to require i.v. antibiotics when she contracted a severe infection. On one occasion, she was treated with growth colony stimulating factor (G- CSF). Her increased neutrophil count was sustained following this treatment. In June 1993, she wished to start a family and underwent in- vitro fertilization (IVF) treatment. G-CSF was given prior to oocyte retrieval. She conceived on her first cycle and an ultrasound scan revealed a singleton pregnancy. Throughout the course of the pregnancy, her white cell count was monitored closely and remained at <1.0x10(9)/l. The pregnancy progressed uneventfully and at 37 weeks gestation she was admitted for G-CSF injections. At 38 weeks she was delivered of a boy weighing 3350 g, by elective Caesarean section. His white cell count was normal. This is the first case of G-CSF being used before conception and during pregnancy in a patient with congenital neutropenia. It shows that advances in cytokine therapy and close interdisciplinary liaison can lead to a successful outcome and help patients, who would otherwise remain childless, to achieve a family.      

The effectiveness of 'nursing beds': a review of the literature

A literature search was conducted to identify 'nursing led in-patient units' where the nurse is the designated leader of the clinical team. The review concentrates on studies which have attempted to measure the impact of nursing-led in-patient units and reviews both the methodology and outcomes. Three major bodies of work were identified. Lydia Hall's evaluation of the Loeb Center for Nursing and Rehabilitation (USA) is reviewed in some detail. This work was the model for 'nursing beds' at the two Oxfordshire Nursing Development Units (UK) in the 1980s. Studies evaluating these centres are reviewed and reports of similar UK units discussed. A third body of work evaluates a nurse-managed critical care environment. Common features include a case mix based on nursing need with nurses having authority to admit and discharge patients. While results are generally favourable, with improved patient independence, fewer readmissions, lower mortality and cost savings reported in some or all of the studies, all studies reviewed demonstrate the difficulties of applying an experimental model to real life clinical services. Methodological limitations render firm conclusions difficult. Techniques adopted from studies in field settings, the so-called 'quasi-experiment', are advocated as a remedy, as is further study of the process of care in investigating this model of care delivery.     

Cognitive behaviour therapy approach to disputing automatic thoughts: a two-stage model

Research shows that clients with automatic thoughts (dysfunctional thinking) often do not think of alternative explanations in relation to negative events. Furthermore, these automatic thoughts are characterized by a broad global, self-evaluative and ambiguous nature that could make disputing (or changing the ways they think) the most difficult part of the therapeutic process. This paper proposes a two-stage practise-based disputing model, guided by research, that aims to 'bring' an automatic thought to a specific, objective, quantifiable and concrete level at which not only is the particular aspect(s) of the automatic thought that causes emotional disturbances finely focused, but the disputing is also likely to be effective and manageable. Furthermore, it will also generate alternative explanations that are helpful in reducing emotional disturbances and in facilitating problem solving approach. In this paper, the authors use a case example to discuss the rationale that underpins the conceptualization of the model and to illustrate the process in which the strategies of the model are effectively used.