Joint working. Local differences

The interface between social care and primary healthcare remains underdeveloped. Where joint working is effective, it is the result of co-operation, trust and mutual respect. Successful local networks take account of professional autonomy.     

A comparison of four ultraviolet sources to alter graft-versus-host responses

Graft-versus-host disease (GVHD) is a major contributor to the morbidity and mortality associated with allogeneic bone marrow transplantation. Direct ultraviolet B (UVB) irradiation of bone marrow and spleen cell allografts in mice using broadband lamps is known to abolish alloreactive responses which would normally cause GVHD. Using a histoincompatible murine model, we have extended these observations by comparing the physical spectrum of four UV sources (the Philips TUV8W, TL12 and TL01, and the Spectronics XX15B) with in vitro assessment of bone marrow progenitor cell damage and suppression of lymphocyte proliferation and in vivo comparison of the effect on GVHD of the TL12 and XX15B and on the rate of engraftment with the TL12. At doses of uv found to abolish lymphocyte proliferation (2.5, 7, 12 and 1000 J m(-2) with the TUV8W, XX15B, TL12 and TL01 lamps) colony-forming unit granulocyte-macrophage (CFU-GM) proliferation was reduced to 81%, 71%, 79% and 62%, respectively. At an optimal dose found to suppress GVHD (100 J m(-2) integrated radiant energy from 200-320 nm for the TL12 and XX15B) CFU-GM proliferation showed a reduction of 98% with the XX15B and 86% with the TL12. At this radiant energy with the TL12, the rate of bone marrow engraftment was impaired with 72% marrow cellularity at 2 weeks, decreasing to 48% after 200 J m(-2). Our results with this model demonstrate that broadband UVB irradiation of bone marrow permits transplantation across a major histocompatibility barrier. Furthermore we have provided in vitro evidence that narrowband UVB or UVC might potentially be applied to this model.     

Vagal Nerve Monitoring during Parapharyngeal Space Tumor Removal

The vagus nerve innervates the intrinsic and extrinsic laryngeal musculature as well as the complex pharyngeal plexus. Acute paralysis of this nerve results in dysfunctional speech, deglutition, and airway protection. These untoward effects, which lead to additional infectious and aerodigestive complications, may arise following manipulation of the vagus nerve during the surgical removal of a variety of neoplasms found in the parapharyngeal space.The vagal nerve has been intraoperatively monitored in an effort to maintain its anatomic and functional integrity. Bipolar hook-wire electrodes are introduced transcutaneously through the cricothyroid membrane and are guided into the vocalis muscle by an assistant performing direct laryngoscopy. Continuous, real-time monitoring of the vagal nerve is provided by audio and visual feedback to the operating surgeon. Potentially injurious stretching, heating, and compression of the nerve are easily detected, and monopolar stimulation of the nerve is used to map the nerve's course through the tumor bed.This presentation outlines our technique for vagal nerve monitoring in patients with tumors of the parapharyngeal space and intact preoperative vocal cord mobility. Selected cases are presented and illustrated through intraoperative and postoperative videotapes.     

Community care. Breaks in the chain

Tension and conflict between GPs and social services have dogged community care reforms. Bob Hudson suggests how the links can be strengthened.     

Rapidly available glucose in foods: an in vitro measurement that reflects the glycemic response

BACKGROUND: A chemically based classification of dietary carbohydrates that takes into account the likely site, rate, and extent of digestion is presented. The classification divides dietary carbohydrates into sugars, starch fractions, and nonstarch polysaccharides, and groups them into rapidly available glucose (RAG) and slowly available glucose (SAG) as to the amounts of glucose (from sugar and starch, including maltodextrins) likely to be available for rapid and slow absorption, respectively, in the human small intestine. OBJECTIVE: We hypothesize that RAG is an important food-related determinant of the glycemic response. DESIGN: The measurement of RAG, SAG, and starch fractions by an in vitro technique is described, based on the measurement by HPLC of the glucose released from a test food during timed incubation with digestive enzymes under standardized conditions. Eight healthy adult subjects consumed 8 separate test meals ranging in RAG content from 11 to 49 g. RESULTS: The correlation between glycemic response and RAG was highly significant (P < 0.0001) and a given percentage increase in RAG was associated with the same percentage increase in glycemic response. After subject variation was accounted for, RAG explained 70% of the remaining variance in glycemic response. CONCLUSIONS: We show the significance of in vitro measurements of RAG in relation to glycemic response in human studies. The simple in vitro measurement of RAG and SAG is of physiologic relevance and could serve as a tool for investigating the importance of the amount, type, and form of dietary carbohydrates for health.     

Medical complications during acute rehabilitation following spinal cord injury--current experience of the Model Systems

OBJECTIVES: To examine the frequency of common secondary medical complications during acute rehabilitation in persons with new spinal cord injury (SCI). DESIGN: Survey and analysis of data in the National SCI Statistical Center (NSCISC) database. SETTING: Eighteen Model System SCI Centers located in urban, public medical centers around the United States. SUBJECTS: A total of 1,649 persons with new SCI entered into the NSCISC database between 1996 and mid-1998. RESULTS: Since 1992, the number of days from injury to admission to rehabilitation has steadily decreased, resulting in the increased potential to develop common secondary medical complications during rehabilitation hospitalization. Pressure ulcers occur with high frequency and were found to have developed in 23.7% of patients during rehabilitation. In addition, autonomic dysreflexia and atelectasis/pneumonia also occur with relative frequency during rehabilitation. Conversely, deep vein thrombosis and pulmonary embolism have decreased, most likely because of greater awareness of their potential to develop, as well as improved methods of prophylaxis. Cardiopulmonary arrest and gastrointestinal hemorrhage occur with relatively small frequency. The frequency of renal complications is difficult to gauge because of the decreasing number of patients who have any renal testing performed during rehabilitation hospitalization. CONCLUSION: The continued declining lengths of acute care hospitalization after SCI have resulted in the occurrence in the rehabilitation setting of medical complications that were previously seen in acute care. Greater awareness and attention to these conditions are necessary to reduce their occurrence, so that obstacles to recovery and functional improvement after SCI are minimized.     

Acral dermatofibrosarcoma protuberans with metastases

Dermatofibrosarcoma protuberans (DFSP) is an uncommon cutaneous tumor that occurs rarely on the extremities. This tumor has a particular propensity for local recurrence following seemingly adequate excision. Metastases are rare, and usually follow repeated local recurrences. On rare occasions, fibrosarcomatous change may arise in a DFSP, and appears to affect adversely the prognosis. The adequacy of the initial resection is the most important prognostic factor; however, suggested margins vary between 1.5 and 5 cm. The ideal margin of resection on the foot is unknown. We report a patient with recurrent, acral DFSP with fibrosarcomatous change and pulmonary parenchymal metastases in a 48-year-old black male.