Basic standards for management of patients with common mental illnesses in primary care

At least 95% of mental health problems are dealt with entirely in primary care. The other 5% are referred to secondary care, but these will be dealt with jointly by primary care services and secondary care services. Mental Health problems provide a major burden to primary care services, the doctors who operate in those services- the General Practitioners-, and their staff Standards need to be set in order to clarify what an adequate primary care response should be to the provision of mental health care. We propose a set of standards which are evidence based and which are correlated with the recent WHO declaration on Mental Health in Europe.     

Quality control of slope-intercept measurements of glomerular filtration rate using single-sample estimates

OBJECTIVES: Measurement of glomerular filtration rate (GFR) using the slope-intercept technique determines the plasma clearance curve by fitting a straight line to the logarithm of sample count rate. When two samples are used there is no check on the validity of curve fitting. GFR may also be estimated from single-sample concentrations. This study describes a method of quality control for the two-sample technique using the agreement between the one-sample and two-sample estimates. METHODS: GFR measurements using Tc-DTPA were performed on 225 adults and 100 children using two samples taken between 2 h and 4 h post-injection. The two-sample values obtained using the British Nuclear Medicine Guidelines slope-intercept technique were compared to one-sample estimates obtained using a new general equation. Equations describing the variation of GFR error with GFR value were defined. These were used to determine action levels giving the limits of expected agreement between slope-intercept and single-sample values. The use of these action levels for quality control was demonstrated in a further 120 GFR measurements. RESULTS: The variation of single-sample error estimate with GFR depended both on the time of sample and body surface area. For specific sample groups, the error variation with GFR could be approximated using a truncated quadratic equation. Four studies were identified as failing quality control in the dataset used to define the error equations. Two studies failed in the test dataset. CONCLUSIONS: One-sample equations give reliable estimates of GFR, which may be used for quality control of slope-intercept GFR assessment.     

A general equation for estimating glomerular filtration rate from a single plasma sample

OBJECTIVES: Glomerular filtration rate (GFR) may be estimated from a single plasma sample measurement using empirical equations. This method forms the basis of international guidelines on GFR measurement. New guidelines have recently been recommended by the British Nuclear Medicine Society (BNMS). These use the slope-intercept technique in which several samples are obtained. Quality control of measurement may be achieved by comparison with the individual single-sample values. This paper compares international guideline single-sample estimates of GFR with the new BNMS method and derives an improved general single-sample equation. METHODS: GFR measurements using Tc-DTPA were performed on 180 adults and 100 children using samples at approximately 2 h and 3 h and a further 45 adults with samples at 2, 3 and 4 h. The two-sample values obtained using the BNMS guideline method were compared to one-sample estimates obtained using (1) international guidelines and (2) a new equation derived from the data. The new equation was evaluated in a further 145 subjects. RESULTS: The international guidelines technique had systematic differences between the one-sample and two-sample estimates of GFR. The new equation had minimal systematic error and reduced random error (standard error of the estimate 4.5 ml . min per 1.73 m). CONCLUSIONS: There were significant differences between GFR values obtained using the international guidelines single-sample method and the slope-intercept method described in the BNMS guidelines. The new equation described in this paper gave considerably improved agreement and is recommended if single-sample estimates are to be used as quality control for BNMS guideline measurements.     

Management of septic arthritis

Septic arthritis in children remains a serious disease with the potential for significant systemic and musculoskeletal morbidity. Staphlococcus aureus is the most common cause of bone and joint infections in all age groups. Microbial invasion of the synovial space occurs typically results from hematogenous seeding. Diagnosis in neonates and young infants can be difficult since the clinical signs are much less specific in these age groups. Early diagnosis by needle aspiration of the affected joint and prompt initiation of appropriate antimicrobial therapy in conjunction with drainage of the affected joint is critical to avoid destruction of the articular cartilage and prevent disability. Septic arthritis in infants and children should always be managed by a pediatrician in close consultation with an orthopedic surgeon. Empiric antibiotic regimens should always include adequate anti-staphylococcal coverage. Antibiotic treatment should be started with appropriate doses of intravenous antibiotics. Switch to oral antibiotic therapy can be made when patient demonstrates clinical improvement. A minimum of 3-4 weeks of therapy is recommended. Close follow-up is warranted to monitor the growth of the affected limb until skeletal maturity.     

Pseudosarcomatous fibrovascular proliferative tissue masquerading as a primary subglottic angiosarcoma

A unique case of pseudosarcomatous fibrovascular proliferative tissue causing biphasic stridor and simulating a primary subglottic angiosarcoma is reported. The patient presented with a wheeze and was diagnosed initially with asthma. He subsequently developed worsening biphasic stridor. Flexible nasendoscopy revealed a subglottic mass obstructing the airway. The mass was removed with a carbon dioxide laser and the patient's condition improved dramatically. The specimen was difficult to interpret histologically and was thought at first to be a novel case of a primary subglottic angiosarcoma. However, the slides were reviewed by expert soft tissue pathologists in the UK and USA, and a final diagnosis of a pseudosarcomatous fibrovascular proliferative lesion was made. This case highlights the important principle of seeking additional opinions before making a malignant diagnosis in an atypical site. Our report also emphasizes the importance of good clinico-pathological liaison, especially in difficult cases.     

Oral delivery of medications to companion animals: palatability considerations

There is an increased need for highly palatable solid oral dosage forms for companion animals, which are voluntarily accepted by the dog or cat, either from a feeding bowl or from the outstretched hand of the pet owner. Such dosage forms represent an emerging trend in companion animal formulations with major impact on medical needs such as convenience and compliance, particularly for chronically administered medications, and on marketing needs such as product differentiation. This review focuses on the science of taste, food and flavor preferences of dogs and cats, and palatability testing, in the context of applying these principles to the development of an oral palatable tablet for companion animals.