Off-the-shelf audit: is it feasible?

Increasing interest in audit in the health service has focused attention on the tools and methods used to achieve it. These can be extremely expensive, so a tendency to opt for off-the-shelf packages has developed. This article reviews how one such instrument, The Central Nottinghamshire Psychiatric Nursing Audit, has been used in two settings over the past three years, with particular emphasis on its cost-effectiveness.     

A comparison of presenting characteristics of patients with intracapsular and extracapsular proximal femoral fractures.

The presenting characteristics of 1423 consecutive admissions with proximal femoral fractures were prospectively studied, to determine any differences that may exist between patients, dependent on the radiological site of the fracture. Patients with intracapsular fractures were of a lower average age, more mobile, less likely to use walking aids or live in residential accommodation, they also had a considerably shorter length of hospital stay than for those patients with extracapsular fractures. Comparison against previous series shows that the average age of hip fracture patients and the proportion of trochanteric fractures is increasing.     

Through a glass darkly: the disutility of the DSM nosology of depressive disorders.

OBJECTIVE: To demonstrate that the dimension-weighted DSM-IV model for classifying the depressive disorders lacks utility. METHOD: The logical flaws in classifying the depressive disorders with any severity-based model (which underpin both the DSM-IV and ICD-10 systems) are noted. Integral definitional limitations to the DSM-IV definition of key depressive disorders are identified. It is argued that the DSM-IV classificatory system lacks utility for providing information on etiology and preferential management strategies. An alternative subtyping model is considered. RESULTS: It is asserted that, in practice, the DSM-IV model and criteria lack explanatory power and compromise research and clinical practice. CONCLUSIONS: It is hoped that this article evokes wider debate about modelling and classifying the depressive disorders.     

Activated, HTLV-1-specific cytotoxic T-lymphocytes are found in healthy seropositives as well as in patients with tropical spastic paraparesis.

In human T cell lymphoma/leukemia virus (HTLV-1)-infected people with tropical spastic paraparesis (TSP), there are activated HTLV-1-specific cytotoxic T lymphocytes (CTL) in the circulation and lymphocytic infiltrates in spinal cord lesions that are rich in CD8+ T cells. These observations suggest a role for virus-specific CTL in the pathogenesis of TSP. We have examined the anti-HTLV-1 cytotoxic activity of freshly isolated CD8+ T cells from peripheral blood lymphocytes of eight subjects seropositive for HTLV-1. Four of five subjects with TSP had circulating activated anti-Tax CTL. However, two of three seropositive subjects without TSP also had activated anti-Tax CTL. These observations show that such activated CTL are not confined to patients with TSP and raise some uncertainty about their significance in the pathogenesis of the disease. In cultures of CD8+ T cells from two TSP subjects, we detected CTL with other HTLV-1 specificities, without exogenous antigenic stimulation. A CTL epitope in the middle region of Tax and one in the C terminus of Pol have been mapped at the peptide level and the HLA Class 1 molecules restricting their recognition have been defined.     

Assessment of intracardiac shunts with gadolinium-enhanced ultrafast MR imaging.

Dye dilutional techniques are widely accepted for the assessment of intracardiac shunts, but current techniques require arterial access or radioisotope injection. Ultrafast (less than 500 msec) magnetic resonance (MR) imaging is ideally suited for the evaluation of an indicator during passage through the heart. Twenty patients were studied, including 13 with shunts. Four-chamber, T1-weighted images were obtained during bolus injection of gadopentetate dimeglumine. A single image was obtained in 420 msec, with repetitive images acquired after each QRS complex. After the contrast material was injected, there was pronounced signal intensity enhancement in the right atrium, followed by the right ventricular cavity, left atrium, left ventricular cavity, and descending aorta. Patients with substantial intracardiac shunts demonstrated early recirculation. First-pass contrast material-enhanced MR imaging is a promising new technique for the rapid assessment of intracardiac shunts. Combined with anatomic and functional MR imaging techniques, it can help provide a comprehensive noninvasive evaluation of suspected intracardiac shunts or provide follow-up in patients with known shunts.     

Parental representations of melancholic and non-melancholic depressives: examining for specificity to depressive type and for evidence of additive effects.

Several studies have suggested that 'anomalous parenting', as measured by the Parental Bonding Instrument (PBI), may be a differential risk factor to subsequent depression in adulthood--being irrelevant to melancholia but over-represented in non-melancholic depressive disorders. Such a 'specificity' effect is confirmed in our current sample of 65 melancholic and 84 non-melancholic depressed patients. Secondly, we examine the risk to depression effected by exposure to one parent with an anomalous parental style, and the extent to which that risk is modified by characteristics of the other parent. We find clear evidence of additive effects with the risk to non-melancholic depression being raised by exposure to 'anomalous parenting' from two parents. Of the varying parental styles measured by the PBI, low parental care from both parents provided the highest risk to non-melancholic depression (being 4-7 time higher in one sample and 13-27 times higher in the other).     

Fulminant systemic necrotizing arteritis: CT findings

Fulminant necrotizing arteritis can be a rapidly fatal disease with protean manifestations often suggesting other diagnoses. We present two cases with angiographic and CT correlation and discuss CT findings that are suggestive of the diagnosis.     

Fatal haematemesis due to benign retrosternal goitre.

The development of a goitre in the retrosternal space may result in many different symptoms due to local compression. We describe a case in which such a goitre resulted in full-thickness ulceration of the oesophagus, which presented as a fatal haematemesis. We believe that such a complication has not been previously reported.     

The period evoked potential: a rapid technique for acquisition of phase-locked responses to continuous pure-tone stimulation.

In view of the current audiological need to obtain rapidly recorded and objective threshold information, particularly for frequencies below 1 kHz, we have developed an evoked potential technique based on the frequency following response. The technique involves the acquisition of a single captured epoch of EEG containing phase-locked responses to 1000 cycles of a continuous pure-tone stimulus. The captured epoch is partitioned into segments representing the responses to single cycles of the stimulus. The segments are then averaged to produce the period evoked potential. The process takes less than five seconds.