The role of the practice nurse in primary health care: managing and supervising the practice nurse resource

This paper, by drawing on material from a qualitative study funded by the Department of Health and Welsh Office, examines the supervision and management of the practice nurse in general practice. In doing so it explores the perspectives of practice nurses, the GPs who employ them, representatives from FHSAs, those responsible for commissioning community nursing services, and managers of community nursing provider units. Within this context the paper explores the nature of the supervisory relationship between GP and practice nurse, and the wider role of the FHSA, commissioners of community nursing services and managers of community nursing provider units.     

Neonatal subgaleal haematoma: Associated risk factors, complications and outcome

Objective : To describe the obstetric and perinatal factors, in particular the method of delivery, associated with development of a subgaleal haematoma (SGH) and to determine the outcome of survivors with this type of birth trauma. Methodology : Perinatal and obstetric data were retrospectively reviewed for 37 infants admitted to the neonatal unit of the sole tertiary paediatric referral hospital in Western Australia with an SGH, over a 24 year period from 1970 to 1993. These data were compared to data for all Western Australian births. The long-term outcome was obtained through medical and private paediatric records for 26 of these infants. Results : All except one of the neonates had instrumental deliveries; 89% had a vacuum extractor applied to the head at some stage of delivery compared to 10% of the general population of births in Western Australia. There was also a significantly increased risk of failure of attempted vacuum extraction. Of the cases where a vacuum extraction was attempted, 45% also had forceps applied to the head. Coagulopathy was associated with the severity of the SGH. There was also a high frequency of occurrence (40%) of associated head trauma such as intracranial haemorrhage, skull fracture and cerebral oedema, as well as neonatal encephalopathy (73%). The occurrence of these associated features did not correlate significantly with the severity of SGH. Minor complications of SGH included jaundice and facial bruising. There was an excess mortality associated with SGH; however, the long-term outcome for neonatal survivors with this disorder was good. None of the cases studied subsequently developed cerebral palsy or intellectual disability, and minor neurological sequelae only were documented in four infants. Conclusions : SGH is an uncommon type of birth trauma, and is associated with delivery or attempted delivery by vacuum extraction. The most commonly associated clinical problems were hypovolaemia and coagulopathy. The long-term outcome for neonates with this condition is good.     

Neuropilin-1 and VEGF correlate with somatostatin expression and microvessel density in ovarian tumours

Vascular endothelial growth factor (VEGF), is an angiogenic growth factor, expressed more highly in malignant than benign ovarian tumours. Neuropilin-1, which can act as a VEGF receptor has been shown to be associated with tumour angiogenesis in some cancer systems. Somatostatin (SST), a potentially anti-angiogenic factor, acts via somatostatin receptors that are expressed in ovarian cancer. We used immunohistochemistry to demonstrate expression of Neuropilin-1 in 63 malignant and 35 benign ovarian tumours and compared it to VEGF, Flt, Flk, SST expression and tumour microvessel density (MVD). Neuropilin-1 was expressed in 34/63 malignant and 22/35 benign lesions. VEGF, Flt, Flk and SST were expressed more highly in the epithelium of malignant and the vessels of benign lesions. VEGF expression correlated with SST expression in the epithelium (p<0.001) and the vessels (p<0.001), this co-expression was confirmed by dual immunostaining. The MVD for malignant lesions was higher than benign (p<0.001) and positively correlated to epithelial VEGF expression (p=0.001) and negatively correlated to vascular VEGF expression (p=0.025). These results show that Neuropilin-1 is expressed in ovarian tumours and also show that VEGF and SST are co-expressed in the same tissue compartments raising the intriguing possibility that SST may be important in angiogenesis in ovarian cancer.     

Malaria in the Nuba Mountains of Sudan: baseline genotypic resistance and efficacy of the artesunate plus sulfadoxine-pyrimethamine and artesunate plus amodiaquine combinations

Both northern and southern Sudan are deploying artemisinin-based combinations against uncomplicated Plasmodium falciparum malaria (artesunate+sulfadoxine-pyrimethamine [AS+SP] in the north, artesunate+amodiaquine [AS+AQ] in the south). In 2003, we tested the efficacy of 3 day AS+SP and AS+AQ regimens in vivo in the isolated, seasonally endemic Nuba Mountains region (the first study of AS combinations in southern Sudan). We also analysed pre-treatment blood samples for mutations at the P. falciparum chloroquine transporter (Pfcrt) gene (associated with CQ resistance), and at the dihydrofolate reductase (Dhfr) gene (associated with pyrimethamine resistance). Among 161 randomized children under 5 years, PCR-corrected cure rates after 28 days were 91.2% (52/57, 95% CI 80.7-97.1) for AS+SP and 92.7% (51/55, 95% CI 82.4-98.0) for AS+AQ, with equally rapid parasite and fever clearance. The Pfcrt K76T mutation occurred in 90.0% (144/160) of infections, suggesting CQ would work poorly in this region. Overall, 82.5% (132/160) carried mutations at Dhfr (N51I, C59R or S108N, but not I164L), but triple mutants (more predictive of in vivo SP failure) were rare (3.1%). CQ use should be rapidly discontinued in this region. SP resistance may propagate rapidly, and AS+AQ is likely to be a better long-term option, provided AQ use is limited to the combination.     

The evolution of an integrated State Trauma System in Victoria, Australia

The incidence of major trauma and associated fatalities in the State of Victoria, Australia, have declined over 20 years following the successful implementation of strategies to modify environmental and behavioural factors that contribute to motor vehicle injuries. However, several system deficiencies in the management of major trauma patients had remained unresolved. To investigate these shortfalls the State Government of Victoria established a task force in 1997 to review trauma and emergency services. The task force adopted the principle of "the right patient to the right hospital in the shortest time" and in 2000 began to deploy an integrated State Trauma System. Implementation of such a system required the designation of specific hospitals of various levels to care for trauma patients; the concentration of trauma expertise at these centres; integration and coordination between the service providers; development of agreed triage and transfer protocols and improved education, training and research programs. A statewide major trauma database was established to enable system monitoring and facilitate further enhancements. The Victorian experience with the development of an integrated trauma system should aid in the development of similar systems nationally and internationally and is described in this paper.     

Laparoscopic drainage of bilateral tuberculous psoas abscesses

Psoas abscess secondary to Mycobacterium tuberculosis infection is rare in industrialized countries. Standard treatment options for psoas abscess of any etiology include percutaneous drainage under radiographic guidance and surgery, which is reserved for failure of conservative therapy. A case of bilateral tuberculous psoas abscesses is reported and a surgical method of drainage utilizing a totally extraperitoneal laparoscopic approach is described.