Diabetic retinal photographic screening: a model for introducing audit and improving general practitioner care of diabetic patients in a rural setting

ABSTRACT: This paper describes the addition of diabetic retinal screening using retinal photography to an existing immunisation audit by a General Practitioner (GP) Network in a semi-rural area 60-min drive from central Wellington, New Zealand. The employment of a nurse-facilitator who visited practices to assist the setting up of diabetic registers and the subsequent auditing of patterns of referral for retinal photography was seen as a first step in a process that would lead to audit of the care of diabetic patients by GPs in the Network. This should lead to a measurable improvement in health-care delivery to diabetic patients in this area and is a model that could be adapted by any group of rural or semirural GPs within a defined geographical area.     

The awesome Asthma School Days Program: educating children, inspiring a community

Program planners developed an educational program to improve the health of children with asthma in grades three to five in Milwaukee (Wis.) Public Schools. During 1997-1998, 1,400 students from 74 elementary schools participated in the Awesome Asthma School Days education program. In a cross-sectional survey, about 40% of children reported play interrupted and sleep disturbed by asthma, more than 50% of children reported exposure to smoke in their home, most children lacked asthma self-care tools, and most children with persistent symptoms did not use an anti-inflammatory inhaler. The educational program improved students' expectations about normal play and sleep and improved their understanding of asthma. Leaders in Milwaukee used the survey results to develop a community action plan. The educational program, surveys, community partnerships, and strategic plans can be replicated in other schools.     

Endoneurial microvascular abnormalities of sural nerve in non-diabetic chronic atherosclerotic occlusive disease

Neuropathic abnormalities are found in chronically ischaemic limbs associated with non-diabetic atherosclerotic peripheral vascular disease (PVD). In chronic ischaemic neuropathy, microvascular alterations play a key role in its development. We undertook morphometric assessment of endoneurial microvessels in the sural nerves, taken from severely ischaemic amputated legs in nine chronic non-diabetic PVD. These subjects had threatened ischaemic limbs and revealed clinical, physiological and pathological evidence of neuropathy. For comparison, sural nerves taken from amputated legs due to non-ischaemic disorders (n=4) and chronic PVD associated with diabetes (n=3) were also assessed. We evaluated the areas of vascular lumen, endothelial cells and whole vessel, as well as the percentage of closed capillaries. Endothelial area of sural nerve microvessels in non-diabetic PVD nerves was significantly greater than in non-ischaemic control nerves. Periendothelial cell area containing pericytes and basement membranes was also significantly increased in non-diabetic PVD nerves when compared with control nerves. Vascular lumen area was significantly less in non-diabetic PVD nerves than in non-ischaemic control nerves. Endoneurial microvessels in diabetic PVD nerves showed similar results: thickened vessel wall and smaller lumen. Periendothelial area in diabetic nerves was significantly greater than in non-diabetic PVD nerves. We demonstrated swollen endothelial cells and increased periendothelial area associated with narrowed lumen in sural nerve endoneurial microvessels of severe chronic PVD. Basement membrane reduplication of endoneurial capillaries was seen in non-diabetic PVD nerves. These microvascular abnormalities could play an important role in the development of chronic ischaemic neuropathy in PVD limbs.     

Critical thinking in health care supervision

Henry Ford is reputed to have said that thinking is the hardest work there is, which is probably why so few people engage in it. Perhaps many people have felt this way sometimes, especially when they viewed the foibles of the human race displayed prominently on the evening television news. Some people do stupid things; some people seem to be mindless in what they do. This applies also to some in managerial and supervisory positions in health care organizations. The percentage of these thoughtless managers and supervisors is probably comparable to the percentage of the thoughtless people in the general population. Fortunately every normal functioning human being is capable of becoming a more critical thinker. Of course, no amount of effort is adequate to the development of critical thinking when a person lacks fundamental good sense. On the other hand, no amount of genius suffices when someone does not put forth adequate effort to become a more critical thinker.     

Local secretion of a chimeric anti-CD4 antibody protects against graft rejection in the NOD mouse

BACKGROUND: Engineering a graft to secrete its own immunosuppressive antibodies may minimize the risks associated with current high dose systemic immunosuppression. METHODS AND RESULTS: A beta cell insulinoma cell line (NIT-1) was transfected with genes encoding a chimeric anti-CD4 antibody. The NIT-1 cells secreted functional chimeric anti-CD4 antibody that bound to the CD4 molecule on mouse thymocytes and inhibited in vitro proliferation of CD4+ve T cells. Both test and control transfected cell lines grew at a similar rate in immunodeficient mice. In immunocompetent NOD mice, NIT-1 cells are normally rejected by a cellular immune response against the SV40 T antigen. Although control transfected NIT-1 cells were rapidly rejected by NOD mice, anti-CD4 secreting NIT-1 cells grew significantly better and were able to form tumors at the site of injection. CONCLUSIONS: The local secretion of chimeric anti-CD4 antibody from transfected cells can contribute to graft survival in our transplantation model.     

Use of a computerised maternity information system to improve clinical effectiveness: thromboprophylaxis at caesarean section

An audit of the introduction of a protocol for thromboprophylaxis at caesarean section revealed over treatment of low risk women and the under treatment of high risk women. A routine computer generated risk assessment profile was introduced as part of a maternity information system. Reaudit showed a significant improvement in adherence to the thromboprophylaxis protocol in all risk groups.     

Randomized study of brachytherapy in the initial management of patients with malignant astrocytoma

Purpose: A randomized study was undertaken to assess the role of brachytherapy as a boost to external beam radiation therapy in the initial management of patients with malignant astrocytomas.

Methods and Materials: Inclusion criteria included the following: biopsy-proven supratentorial malignant astrocytoma of brain ≤6 cm in size, not crossing midline or involving corpus callosum, age 18–70, Karnofsky Performance Status (KPS) ≥70. Patients were randomized to external radiation therapy only delivering 50 Gray (Gy) in 25 fractions over 5 weeks or external radiation therapy plus a temporary stereotactic iodine-125 implants delivering a minimum peripheral tumor dose of 60 Gy. Patients were stratified to age ≤50 or >50, and KPS ≥90 or ≤80.

Results: There were 140 patients randomized between 1986 and 1996, 71 to the implant arm and 69 to external irradiation only. Pathologically 125 patients had necrosis noted in their tumor specimen. Factors associated with improved survival in univariate analysis were age ≤50, KPS ≥90, chemotherapy at recurrence, and reoperation at the original tumor site. The Cox proportional hazards model revealed the following significant factors: treatment at recurrence (chemotherapy or reoperation) with a relative risk (RR) of 0.6 (p = 0.004) and KPS ≥90 with a RR 0.6 (p = 0.007). Randomization to the implant arm was associated with a RR of 0.7 (p = 0.07). Median survival for patients randomized to brachytherapy or not were 13.8 vs. 13.2 months, respectively, p = 0.49.

Conclusions: We conclude that stereotactic radiation implants have not demonstrated a statistically significant improvement in survival in the initial management of patients with malignant astrocytoma.