Working alongside the general practitioner: a child psychiatric clinic in the general practice setting

A monthly child psychiatric clinic was established in a primary health care centre in order to offer a more accessible service to patients, and to improve liaison with primary health care professionals. Compared with the base child guidance unit, at the health centre there was a better first attendance rate, a much higher proportion of referrals from health professionals especially general practitioners, and an increased proportion of younger children referred. If further follow-up was necessary at the child guidance unit the attendance rate was very good. The service provided, although not reducing the need for a main multidisciplinary base, offered an acceptable and accessible opportunity for children with psychological problems to be assessed and treated, and for the referring professionals to have easy communication with the child psychiatrist.     

Congenital rubella syndrome in Western Australia

Abstract The birth prevalence of congenital rubella syndrome (CRS) in Western Australia has been around 20 per 10 000 live births with peaks up to 100 per 10 000 in rubella epidemic years. The rate appears to be falling but it is still too soon to know whether the rubella vaccination programme in Western Australia has made a significant impact. The cohorts of young women who would have received the schoolgirl vaccination programme are only now entering the child bearing age groups. Observed falls may be due also to delayed diagnosis particularly of cases of deafness only. The proportion of nonimmune young women who would have been eligible for the programme in one maternity hospital has fallen.
This study needs to be repeated to ascertain whether further epidemics of rubella have resulted in peaks of CRS or whether the vaccination programme has started to have an effect.     

Shaping practice behaviour: novel training methodology

Context — Some studies that have used “pseudo‐patron” methods have provided the basis for criticism of pharmacists' performance and have stigmatised these methods in pharmacy research. Objective — To test and refine the use of pseudo‐patron methodology, with feedback to practitioners, as a means of implementing behaviour change. Method — In the studies reported in this paper practice behaviour was shaped by conducting a workshop and then providing ongoing training in the form of feedback and coaching immediately after a pseudo‐patron visit. The involvement of pseudo‐patrons was negotiated with pharmacists and their staff and embedded within their professional development. Results — An initial study showed that, compared with controls, pseudo‐patron trained pharmacists were significantly more likely to identify off‐label (not in accordance with label specifications) analgesic use (P<0.01) and were more likely to discuss the use of alternatives (P<0.02). The methodology was refined and in a subsequent study pharmacists were even more likely to identify misuse (P<0.001), assess readiness to change (P<0.001) and deliver an appropriate intervention (P<0.001). Conclusions — The results of the studies presented in this paper demonstrate that the inclusion of pseudo‐patron visits in pharmacist training is feasible and that a combination of workshops and performance feedback, including positive and corrective elements, can produce substantial protocol adherence in the natural setting. The use of pseudo‐patron methods as part of a training programme is effective in shaping behaviour of pharmacists and pharmacy assistants.     

The Heart Rate Response to Carotid Artery Massage in a Sample of Healthy Elderly People

Carotid artery massage was carried out in a cross-section of 95 healthy elderly subjects (51 men and 44 woman, mean age of 74 years) to assess the heart rate response and associated symptoms. These subjects were drawn from a larger group of randomly selected healthy elderly people living in Southampton. They had no history of myocardial infarction or stroke and were not taking any drugs that might enhance the carotid sinus reflex. A continuous distribution of response to carotid artery massage was seen with a median percent change in RR interval of 11.6% (IQR 22.9%); 66% had a percent change in RR interval of < 20%, 90% had a change of < 50%, and 9.5% a change of > 100%. Carotid sinus hypersensitivity (sinus arrest > 3 s) was found in 4 previously asymptomatic subjects; a prevalence of 4.2% (95% CI 1.2%–10.4%), and this was associated with dizziness in 2 of these 4 subjects. Dizziness also occurred in one other subject who had a change in RR interval of 178%, The definition of an abnormal carotid sinus reflex is arbitrary given the continuous RR interval response to carotid artery massage. In diagnosing carotid sinus syndrome, the RR interval response to carotid artery massage alone is not sufficient, as this maneuver must also reproduce the patient's presenting symptoms.     

Scoliosis repair in a teenager with Duchenne’s muscular dystrophy: who calls the shots?

In this exchange, a clinician (the first author) presents a case scenario for comment by an ethicist (the second author). The case concerns a 15-year-old boy with Duchenne's muscular dystrophy requested palliative surgical correction of a 60 degree thoraco-lumbar scoliosis. The surgical team were initially reluctant to offer surgery given their assessment of the perioperative and postoperative risks (anesthetic review suggested an 80% chance of surviving the surgery and 50% likelihood of returning home), but the operation proceeded. The case raises issues of the rights of patients to insist on nonfutile but high risk surgery, risk perception, resource allocation, autonomy, and the integrity of clinicians.     

Review article: Luminex technology for HLA antibody detection in organ transplantation

Since its inception in the early 1960s, the serologically based complement-dependent cytotoxicity (CDC) assay has been the cornerstone technique for the detection of human leucocyte antigen (HLA) antibodies, not only in pre-transplant renal patients, but also in other forms of organ transplantation. Recently, solid phase assays have been developed and introduced for this purpose, and in particular the Flow-based bead assays such as the Luminex system. This latter assay has proved to be far more sensitive than the CDC assay and has revealed pre-sensitization in potential transplant recipients not detected by other methods of HLA antibody detection. However, the clinical implications of this increased sensitivity have not been convincingly demonstrated until recently. This technology for HLA antibody detection permits the evaluation of the clinical importance of antibodies directed at, for example, HLA-DPB1 and HLA-DQA1, which has not been possible to date. There are Luminex issues, however, requiring resolution such as the ability to distinguish between complement fixing and non-complement fixing antibodies and determination of their relative clinical significance. Luminex technology will permit a re-evaluation of the role of HLA antibodies in both early and late antibody-mediated rejection.     

Extraction of Pacing Leads Jailed by a Stent in a Mustard Circulation

A case of successful lead extraction of atrial and ventricular pacing leads “jailed” by a stent in the superior limb of a Mustard baffle in a 40‐year‐old man with surgically corrected transposition of the great arteries and pacemaker pocket infection. Manual traction alone was sufficient to remove the jailed leads with no subsequent complications. (PACE 2010; e65–e67)