A critical incident study in child health

The critical incident technique is an objective method of analysing doctors' professional behaviour. It extracts the skills which should be taught and assessed in any training programme. In such a study in child health, 438 incidents were collected from general practitioners, paediatricians and others, and analysed according to the problem, the disease, the setting, the skill and the attitude involved. Most of the problems concerned non-specific symptoms (e.g. 'unwell baby', 'fever') and the main skill categories (each with many subheadings) were clinical management (especially at home), the diagnostic process and interpersonal skills. Training of doctors in child health should emphasize the competencies highlighted in this study.     

喉罩全麻在颈动脉狭窄造影及介入治疗术中的应用

目的：观察喉罩全麻下行颈动脉狭窄的造影诊断及介入治疗术的临床效果。方法：择期DSA下颈动脉狭窄患者23例，年龄42-78岁，无明显肺部疾患及喉罩禁忌症患者，异丙酚（Pmpofol）泵入静脉全麻下插入喉罩完成手术，观察其不同时段的BP（MAP）、SpO2、HR、ECG（ST-Ⅱ）。结果：各时段的BP（MAP）、Sp02、HR、ECG（ST-Ⅱ）比较无显著性差异。结论：喉罩全麻在行颈动脉狭窄的造影诊断及介入治疗术的临床效果是肯定的。喉罩全麻颈动脉狭窄造影介入治疗     

Paediatric medulloblastoma: Patterns of care and radiotherapy quality assurance in Australia

The purpose of this study was to document how children in Australia with medulloblastoma are being treated and to evaluate the quality of radiotherapy (RT) delivered. The Radiotherapy Database of the Australian and New Zealand Children’s Haematology and Oncology Group was used to identify 46 children with medulloblastoma younger than the age of 15 years treated with radical intent by craniospinal irradiation between 1997 and 1999 inclusively. Twenty‐six patients had completely resected disease without evidence of disease spread. Of these, 16 patients received a craniospinal RT dose of <25 Gy in addition to chemotherapy. RT treatment immobilization methods varied, as did planning methods. RT dose to critical structures was recorded on treatment plans for only 15% of patients. The average systematic error in shield placement at the posterior orbit was 5.2 mm, and two‐thirds of patients were ‘overshielded’ at this site. Adequate coverage of the distal end of the thecal sac was achieved in fewer than 50% of on‐treatment verification films for 21 of 45 patients. With a reduction in RT dose to the craniospinal axis for paediatric medulloblastoma, greater attention is needed for patient immobilization, documentation of RT dose to critical structures and the placement and reproducibility of shielding.     

The effects of a 0.12% chlorhexidine-digluconate-containing mouthrinse versus a placebo on plaque and gingival inflammation over a 3-month period

Abstract Several previous studies have evaluated the effects of 0.12% chlorhexidine digluconate (ChD) mouthrinses on plaque and gingival inflammation. However, previously, none have been based in general dental practices. The aim of this study was to evaluate the potential to conduct controlled periodontal clinical trials in co-operation with general dental practitioners (gdps). The project took place in 5 general dental practices in the South of England. 121 healthy subjects (24 at 4 sites and 25 at the 5th). aged 18-65 years, mean 35 ± 12) years participated in a double-blind, randomised study during which they received full mouth assessments for plaque and gingival bleeding at baseline, 6 and 12 weeks. 60 subjects were randomly asigned to use the 0.12% ChD mouth wash and 6i the placebo. The assessments were carried out by 5 gpds, who had previously achieved inter-examiner κ scores of 0.78–0.85 (mean 0.81) for the plaque index (PlI), and of 0.73–0.94 (mean 0.87) for a modified gingival index (mGI), and who maintained κ scores of 0.51–0.90 for PII and of 0.73–1.00 for mGI during the 12 months required to complete the study. 98 subjects (48 ChD and 50 placebo) completed the study. Even though the baseline levels of plaque and gingivitis were low, by week 12, mean whole mouth piaque score of the ChD mouthwash users had fallen from 1.33 at baseline to 0.96 and was significantly lower (p < 0.001) than for the placebo users, 1.31 at baseline to 1.13. Whole-mouth gingival bleeding score fell from 0.56 to 0.42 in the ChD mouthwash group but was unchanged (0.54–0.55) in the placebo group. A subsidiary data analysis which considered the effects at sites indicated that within these overall differences, the ChD users experienced almost 2× the reduction from plaque score 2 at baseline at proximal molar sites over a 12-week period (50.6% ChD versus 27.6% placebo). It was concluded that 0.12% ChD mouthwash reduced plaque accumulation fay 28% and gingival inflammation by 25% over a 12–week period, that it is feasible for a group of gdps to maintain high levels of inter–examiner consistency in the use of PlI and mGI, that it is also feasible to carry out such a multicentre study in general dental practice, and that the use of mean mouth scores per subject to analyse the effects of mouthrinses may well mask variations in response throughout the mouth.     

Aspects of imported malaria at a district general hospital in non-endemic Kuwait,Arabian Gulf

There is no indigenous mosquito-borne transmission of malaria in Kuwait. However, in a five year period at a district general hospital, the number of laboratory-diagnosed cases of malaria increased annually from 25 to 84, a rise of 336%. Except for two induced infections, all were imported, mainly from the Indian subcontinent. Plasmodium vivax was responsible for 87.29% of the cases; P. falciparum (12.05%), a mixed infection of P. vivax and P. falciparum (0.33%) and a case of P. ovale (0.33%) were also identified. Rapid preparation of acetone-fixed, Giemsa-stained thick blood films, a heightened awareness of the infection, examination of multiple samples of blood from patients and the general resurgence of malaria in endemic areas were some of the factors responsible for the high number of cases diagnosed. Most patients were young males and presented with clinical malaria due to P. vivax between May and October each year, an apparent seasonal peak. However, many were already resident in the country for a variable period. Patients with P. falciparum though, presented clinically within two weeks of arrival in the country. Parasite densities were calculated to monitor the progress of treatment and identify quickly any possible chloroquine-resistant P. falciparum strains. A policy of active prophylaxis is suggested to stem the tide of imported malaria.Corresponding author.     

FEASIBILITY OF CONDUCTING CARDIOVASCULAR OUTCOME RESEARCH IN AUSTRALIAN GENERAL PRACTICE: RESULTS FROM THE ANBP2 PILOT STUDY

1. The present study aimed to determine the feasibility of conducting a 5 year cardiovascular outcome trial of the treatment of 6000 elderly hypertensive patients in Australian general practices. 2. General practitioners (GPs) were invited to participate by mail and personal follow-up. Patient records were reviewed to identify subjects for a blood pressure (BP) screening programme. Blood pressure was measured on three occasions and eligible subjects were included if the average BP was 160 mmHg systolic or 90 mmHg diastolic if systolic BP was 140 mmHg. 3. Seven hundred and forty-one GPs were approached and 89 were enrolled in the study (12% of mail invites and 75% of those receiving a personal contact). In 16 practices where screening was completed, 82 000 records were reviewed to identify 4% patients eligible for screening. Twenty-two per cent of eligible subjects attended screening. Of 1938 subjects screened, 180 (9%) had BP 5=160/90 mmHg. Forty-seven percent of subjects (n = 916) were receiving antihypertensive therapy and 184 (20%) were withdrawn from therapy. One hundred and sixteen (63%) of these subjects had BP return to study entry levels within 6 weeks. Fifty-seven newly diagnosed and 81 previously treated subjects were randomized (7% of the screened population). 4. Based on the high participation rate of GPs, the response rate of patients to attend a BP screening programme and the 7% randomization to screening ratio for entry into the study, the ANBP2 pilot study has demonstrated that it is feasible to recruit subjects from Australian general practices to a cardiovascular outcome trial.     

Cardiovascular collapse during anesthesia in a patient with preoperatively discontinued chronic MAO inhibitor therapy

We describe a patient in whom long-term monoamine oxidase (MAO) inhibitor therapy was discontinued 20 days before surgery with general anesthesia. This patient developed severe perioperative hypotension after administration of 10 mg of bupivacaine through an epidural catheter, which was corrected only after potent vasopressor therapy. We attribute this hemodynamic instability to attenuation of this patient's sympathetic tone based on several mechanisms: (1) residual effect of long-term administration of MAO inhibitor that caused a decrease in the number of β-adrenergic receptors (adrenergic subsensitivity due to receptor down-regulation), (2) recovered MAO activity causing effective degradation of sympathetic amines, and (3) combined attenuating effects of general and epidural anesthesia on sympathetic tone.     

Gastric contents and pH after oral premedication

Forty women, aged 26-40 years, were investigated with regard to gastric contents and pH before general anaesthesia. The patients were divided into two groups (20 in each). Group 100 received 0.3 mg kg-1 diazepam orally with 100 ml of water 2 h before surgery. Group 50 received 0.3 mg kg-1 diazepam with 50 ml of water 2 h before surgery. The amount of gastric content was significantly greater in Group 100 than in Group 50 (P less than 0.05). There was no statistical difference in pH values between the groups. The number of patients with both gastric pH less than 2.5 and gastric volume greater than 25 ml was significantly higher in Group 100 compared to Group 50 (P less than 0.05). We cannot recommend the use of oral premedication using these amounts of water, considering the increased risk of aspiration of gastric contents.     

综合医院医务人员感染SARS情况对比分析

目的：分析在防治SARS工作初期、后期医务人员感染SARS的差异和采取的对策，为减少综合医院内医务人员SARS的感染提供参考。方甚：对本院自2003年3月24日至6月2日SARS诊断治疗任务中发生的医务人员的感染原因和采取的对策进行回顾性分析。结果：防治SARS工作初期，急诊科交叉感染和在SARS隔离病房等与SARS患者密切接触的工作岗位，共有17名医务人员感染，及时隔离治疗，均已痊愈，未造成医护人员的进一步交叉感染：经加强防护培训，改善工作条件，在防治SARS工作后期，仅发生2名护工感染，亦已痊愈，派出非典医疗队实现零感染。结论：综合医院内医务人员感染SARS的问题严峻，加强医院内的全员防护培训，按岗分区管理，改善医务人员的工作条件和病人的隔离观察环境，做好监督检查，积极应对，可以减少医务人员的SARS感染。     

Introducing expert systems to medical students using esta, Expert System Teaching Aid

Medical students are allocated little curriculum time for exposure to expert systems. ESTA, a computer model of an expert system, was developed to make best use of this time. The nature of the students' interaction with ESTA is described, and their reactions to the expert system concepts and the place of expert systems in medicine are presented. A discussion of these reactions draws some conclusions about teaching expert systems in particular, and computers in general, in the basic medical course.