Clinical aspects of pelvic inflammatory disease

Pelvic inflammatory disease (PID) is a common and poorly managed condition. Untreated or inadequately treated, it leads to tubal infertility, ectopic pregnancy and chronic pelvic pain. Diagnostic difficulties are compounded by the wide variety of clinical presentations and the insensitivity and poor specificity of laboratory tests. Better recognition of mild and atypical disease needs a high index of suspicion whenever young, sexually active women present with gynaecological symptoms. Laparoscopy supplemented by microbiological tests and fimbrial minibiopsy should be regarded as the diagnostic 'gold standard' for research studies; new studies are required to identify techniques which might reduce under- and over-diagnosis. Early treatment reduces the risk of an adverse effect on fertility. Any therapeutic regimen selected should be effective against the common aetiological agents Chlamydia trachomatis, Neisseria gonorrhoeae, genital mycoplasmas and aerobic and anaerobic bacteria. Since at least 60% of cases of PID can be attributed to infection with a sexually transmitted organism, partner notification forms an essential part of management.      

Teaching symptom management in end-of-life care: the didactic content and teaching strategies based on the end-of-life nursing education curriculum.

Relief of symptoms for patients and families throughout the illness trajectory requires that palliative care practitioners have knowledge and skill, both in assessment and use of pharmacologic and complementary therapies. This article presents the didactic content of symptom assessment and management, and the experiential experiences used in a nondrug laboratory within the End-of-Life Nursing Education Consortium (ELNEC) curriculum.     

Predictors of response of antisocial patients to hospital treatment

Although clinicians generally agree that patients with antisocial personality disorder should not be treated on general psychiatry units, little is known about the response to hospital treatment of personality disorder patients who have antisocial features or traits. In a study to identify predictors of positive and negative response to hospitalization, charts of all patients discharged from a private hospital with diagnoses of antisocial personality disorder or antisocial features over 52 months were reviewed. As a group the 33 patients did not respond well to treatment, and 70 percent left treatment prematurely. Significant predictors of negative response were histories of felony arrest and conviction; a history of repeated lying, aliases, and conning; and an unresolved legal situation at admission. Positive response was related to the presence of anxiety and an axis I diagnosis of depression. The authors believe that antisocial personality disorder is often underdiagnosed and that countertransference can present a significant obstacle to treatment of antisocial patients.     

Age differences in primary organization or processing variability? Part II: Evidence for processing variability

Young and older adults were compared on their ability to organize letter sets into "opaque" memory codes (letters were either transposed within or between imposed chunk boundaries on a secondary memory, recognition task). Also, processing variability (i.e., internal noise) was examined via signal detection methods. The data indicated that there were no qualitative age differences in the manner in which both groups organized opaque memory codes, although older adults did take significantly longer to respond. The results from the signal detection theory portion of the present experiment demonstrated that older adults' memory operating characteristic curves exhibited significantly more variability than those of the young. This suggested that an age difference in processing variability existed, rather than any appreciable age difference in the primary organization (i.e., the forming of opaque memory codes) of item order information.     

Incidence and determinants of moderate COPD (GOLD II) in male smokers aged 40–65 years: 5-year follow up

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a major health problem with an estimated prevalence of 10-15% among smokers. The incidence of moderate COPD, as defined by the Global Initiative for Chronic Obstructive Lung Disease (GOLD), is largely unknown. AIM: To determine the cumulative incidence of moderate COPD (forced expiratory volume in 1 second/forced vital capacity ratio [FEV1/FVC] <0.7 and FEV1 <80% predicted) and its association with patient characteristics in a cohort of male smokers. DESIGN: Prospective cohort study. SETTING: The city of IJsselstein, a small town in the Netherlands. METHOD: Smokers aged 40-65 years who were registered with local GPs, participated in a study to identify undetected COPD. Baseline measurements were taken in 1998 of 399 smokers with normal spirometry (n = 292) or mild COPD (FEV1/FVC <0.7 and FEV1 >or=80% predicted, n = 107) and follow-up measurements were conducted in 2003. RESULTS: After a mean follow-up of 5.2 years, 33 participants developed moderate COPD (GOLD II). This showed an estimated cumulative incidence of 8.3% (95% CI = 5.8 to 11.4) and a mean annual incidence of 1.6%. No participant developed severe airflow obstruction. The risk of developing moderate COPD in smokers with baseline mild COPD (GOLD I) was five times higher than in those with baseline normal spirometry (one in five versus one in 25). CONCLUSIONS: In a cohort of middle-aged male smokers, the estimated cumulative incidence of moderate COPD (GOLD II) over 5 years was relatively high (8.3%). Age, childhood smoking, cough, and one or more GP contacts for lower respiratory tract problems were independently associated with incident moderate COPD.     

Lobular carcinoma in a mammary hamartoma.

Mammary hamartomas are uncommon breast lesions, sometimes presenting as mammographic abnormalities which require pathological clarification. Previous cases have all been benign. A unique case of mammary hamartoma containing atypical lobular hyperplasia (ALH), lobular carcinoma in situ (LCIS), and foci of microinvasive lobular carcinoma is presented. The need for adequately sampling macroscopically innocuous breast lesions is emphasised.     

Chest radiography in general practice: indications, diagnostic yield and consequences for patient management

BACKGROUND: Chest radiography (CXR) is frequently performed in Western societies. There is insufficient knowledge of its diagnostic value in terms of changes in patient management decisions in primary care. AIM: To assess the influence of CXR on patient management in general practice. DESIGN OF STUDY: Prospective cohort study. SETTING: Seventy-eight GPs and three general hospitals in the Netherlands. METHOD: Patients (n = 792) aged > or =18 years referred by their GPs for CXR were included. The main outcome was change in patient management assessed by means of questionnaires filled in by GPs before and after CXR. RESULTS: Mean age of the patients was 57.3+/-16.2 years and 53% were male. Clinically relevant abnormalities were found in 24% of the CXRs. Patient management changed in 60% of the patients following CXR. Main changes included: fewer referrals to a medical specialist (from 26 to 12%); reduction in initiation or change in therapy (from 24 to 15%); and more frequent reassurance (from 25 to 46%). However, this reassurance was not perceived as such in a quarter of these patients. A change in patient management occurred significantly more frequently in patients with complaints of cough (67%), those who exhibited abnormalities during physical examination (69%), or those with a suspected diagnosis of pneumonia (68%). CONCLUSION: Patient management by the GP changed in 60% of patients following CXR. CXR substantially reduced the number of referrals and initiation or change in therapy, and more patients were reassured by their GP. Thus, CXR is an important diagnostic tool for GPs and seems a cost-effective diagnostic test.     

Completeness of reporting on prognostic factors for breast cancer: a regional survey.

BACKGROUND: Effective management of breast cancer is dependent on adequate pathological reporting of the surgical specimen. OBJECTIVE: To describe the frequency with which histopathological features of known prognostic importance are routinely recorded. STUDY POPULATION: 885 cases of invasive breast cancer diagnosed in NHS laboratories in Lancashire and Greater Manchester. METHODS: Pathology reports were reviewed for details for tumour histological type, size, and grade, the presence or absence of tumour in blood or lymphatic vascular channels, and a comment on the proximity of tumour to the lines of surgical excision. Laboratories were categorised according to their throughput of cases of breast cancer, involvement in the breast screening programme, and whether they were attached to a teaching hospital. RESULTS: Histological type, tumour size, presence or absence of tumour in vascular channels, and adequacy of excision were recorded for 843 (95%), 803 (91%), 436 (49%), and 761 (86%) cases, respectively. Non-screening and low throughput laboratories were significantly less likely to record certain histopathological features. No significant differences were observed between teaching and non-teaching hospitals. CONCLUSIONS: The substantial interlaboratory variation in the histopathological reporting of breast cancers can, in part, be related to throughput of cases and involvement in the breast screening programme.