Managing asthma in accident and emergency departments: an assessment in non teaching hospitals

Background: The management and follow-up of asthma patients presenting at Accident and Emergency (A&E) departments have mostly been studied in children's hospitals or specialised teaching hospitals. Aims: To study the adequacy of assessment, treatment and follow-up of patients presenting at A&E departments in non-teaching hospitals. Methods: A twenty-five per cent sample of presentations to A&E departments in all public hospitals in the Illawarra for one year was selected for a case note audit. Information on demographics, assessment, management and referral was extracted from the A&E case notes and medical records of cases with documentation of a final diagnosis of asthma. Chi square and Fischer's Exact tests were used for comparisons among hospitals. Results: Of 359 presentations with a final diagnosis of asthma, 88% were self referred and only 5% were first presentations. Objective measures of airways obstruction was not documented in 34% of admissions and 48% of nonadmissions. There was no documented follow-up in 28% of cases. The assessment and management of asthma in A&E was significantly poorer in smaller hospitals. Conclusion: Evidence of high use of A&E as a primary care facility by asthma patients was found in the study. There is a need to implement protocols to optimise assessment and treatment of asthma in smaller hospitals. (Aust NZ J Med 1993; 23: 672–677.).     

DAY-ONLY ADMISSION FOR VARICOSE VEIN SURGERY

Day-only admissions for surgery are strongly encouraged, in an effort to keep costs down. Varicose vein surgery has been considered too major for day-only management despite the fact that there have been studies from overseas showing that it can be done with a morbidity comparable to inpatient surgery. The morbidity of day-only surgery for varicose veins (both long and short saphenous procedures) was assessed and compared with the results of inpatient surgery. Patients were also asked whether they were satisfied with the surgery being done this way. There were 165 consecutive patients available for study, 64 day-only and 101 inpatient. All patients attending Shellharbour Hospital, Shellharbour, had surgery done as day-only (as it was a morning list and allowed adequate time for recovery). Patients attending Bulli Hospital, Bulli, had surgery done as an inpatient (afternoon list). All surgery was performed by one surgeon. There was no difference (Chi-squared) in the age distribution (mean 48 years for day-only, 51 years for inpatient) or sex proportion in either group (Chi-squared test of proportions with continuity correction). Assessment of the results was done by review of the surgeon's notes, as well as telephone interviews for day-only subjects. The complication rate in both groups was similar. Wound problems represented the main complication with an incidence of 10.5% in each group. There was one deep venous thrombosis (DVT) in each group (diagnosed by duplex scan). Response to the telephone interview suggested that most patients were happy to have the surgery done as a day-only procedure. Sixty-nine per cent responded that they would have it done this way again and 76% were satisfied with the result of the surgery. This study confirms the results of overseas studies, in that varicose vein surgery can be performed as day-only procedures with a complication rate similar to inpatient procedures and with a high degree of patient satisfaction. It is suggested that this should be used as the method of choice for the majority of patients requiring varicose vein surgery.     

Temporomandibular joint: morphology and signal intensity characteristics of the disk at MR imaging

Magnetic resonance (MR) imaging has been used in the temporomandibular joint (TMJ) primarily to define the disk position. This report examines altered morphology and signal intensity characteristics of the TMJ disk as they relate to the severity of internal derangement. Two hundred sixteen joints in 133 patients with a history of such derangement. were imaged with MR. Disk position, signal intensity, morphology, and the presence of osteoarthritis were determined for each joint. The normal disk was not anteriorly displaced and had a normal "bow-tie" shape. A grade 1 disk was anteriorly displaced and had a normal shape; a grade 2 disk was anteriorly displaced and had an abnormal shape. Forty (19%) joints were considered normal; none of these exhibited osteoarthritis. One hundred thirty-nine (64%) joints were grade 1; osteoarthritis was found in 17%. Thirty-seven (17%) were grade 2; osteoarthritis was found in 95%. All forty normal joints had high or intermediate signal intensity in the disk. Osteoarthritic joints had a higher percentage of disks with diminished intensity (P less than .0001). Severe or untreated osteoarthritis is known to be a complication of TMJ internal derangements; hence this grading system seems to correlate with the severity of internal derangement.     

Characterization of human monoclonal antibodies selected with a hypervariable loop-deleted recombinant HIV-1(IIIB) gp120

Recombinant gp120 of the HIV-1(IIIB) isolate (BH10 clone) has been mutated to form the PR12 protein with the first 74 C-terminal amino acids and the V1, V2 and V3 hypervariable loops deleted. A variety of studies have shown that the CD4 binding domain (CD4bd) is very well exposed in PR12 in contrast to rgp120(LAI). Using PR12 for selection of human monoclonal antibodies (MAbs) from HIV-infected individuals, five MAbs were generated with specificities to the epitopes overlapping the CD4bd (1570A,1570C,1570D,1595 and 1599). The three MAbs, 1570A, C and D, generated from one HIV-infected individual, represent one MAb as determined by sequence analysis of the V(H)3 region. Since the epitopes overlapping the CD4bd exhibit variability among HIV-1 clades, the specificity of anti-CD4bd MAbs were distinguished by differing patterns of binding to recombinant envelope proteins derived from clade A, B, C, D and E viruses. The PR12-selected MAbs were also compared with a panel of gp120-selected anti-CD4bd MAbs and showed a different range of specificities. MAb 1599 is clade B specific, MAb 1595 reacts with the A, B and D clades, while MAb 1570 recognises the most conserved epitope, as it binds to all proteins. The results show that the exposure of different epitopes in the CD4bd of the PR12 protein allows this protein to serve as an immunogen and to induce anti-CD4bd antibodies.     

Partial characterization and kinetics of expression of Sm15, aSchistosoma mansoni tegumental antigen

Differential antibody screening of an adultSchistosoma mansoni cDNA expression library constructed in lambda gt11 identified a partial cDNA clone, A70. This cDNA encodes a fusion protein recognized by antibodies raised against highly irradiated schistosomula and adult worm tegumental membranes but not by anti-egg antibodies. Anti-tegumental membrane antisera affinity-purified on the A70 cDNA fusion protein were used for Western blotting analysis and indirect immunofluorescence, resulting in the identification of a 15-kDa protein (Sm15) in the tegument of adult worms. This is one of the principal tegumental antigens recognized by antibodies from mice protectively vaccinated with adult worm tegumental membranes. Sm15 is much smaller than the protein encoded by its gene, suggesting that it results from a highly processed precursor. It was found that Sm15 behaves as an integral membrane protein upon partitioning in Triton X-114 and that it is present in worms of 2 weeks or older but not in schistosomula or miracidia. The affinity-purified antibodies also revealed the presence of a 23-kDa antigen in whole-worm homogenates that is apparently coexpressed with Sm15. The 23-kDa antigen was not found associated with membranes and is probably a soluble protein. A further series of Western blots were undertaken using antibodies affinity-purified from serum raised against schistosomula. In this case, the 23- and 15-kDa products were not recognized, but rather soluble proteins ranging from 45- to 150-kDa were detected in almost all larval stages investigated. The results suggest that the precursor is differentially processed during maturation.     

Urethral prolapse in children: insights into etiology and management

The pathophysiology of urethral prolapse has never been clearly elucidated. Following en bloc removal of the urethra, bladder, vagina, uterus and pelvic floor tissues from a 4-year-old burn victim with urethral prolapse at the time of death and from a female newborn cadaver, careful step-sectioning of the specimens at 5 mm. intervals for histological examination was performed. The anatomical defects of urethral prolapse noted were marked eversion of the urethral mucosa, vascular congestion of the "corpus spongiosum urethrae muliebris", and a cleavage plane between the inner longitudinal and outer circular-oblique smooth muscle layers of the urethra. We propose that urethral prolapse results from poor attachments between the smooth muscle layers of the urethra in association with episodic increases in intra-abdominal pressure. A clinical review of 12 cases revealed that at least 8 (67 per cent) had antecedent episodes of marked increases in intra-abdominal pressure. Obliteration of the cleavage plane between the smooth muscle layers is important for successful treatment of this lesion.     

Clinical audit of the process of referral to genitourinary medicine of patients found to be chlamydia positive in a family planning service

This paper describes a collaborative audit between a large family planning and genitourinary medicine (GUM) service undertaken to ensure that all women presenting for termination of pregnancy (TOP) or IUD fitting were offered screening for chlamydia, were informed of a positive result, and were subsequently referred to GUM for full sexual health screening and contact tracing. Over a six month period in 1996 1072 patients were seen for either TOP (763) or W1) fitting (309) and of these 999 were offered a test which was performed in 988. Overall 38 positive tests were reported (3.8 per cent) but only two of 259 patients tested prior to lUD fitting were found to have chlamydia (<0.8 per cent). Only 27 of these 38 women (74 per cent) had information recorded in their notes that they had been given their result and 24 patients (63 per cent) were seen in GUM. The audit uncovered problems with documentation and cross-referencing of information which largely accounted for the failure to reach some of the standards set. An action plan has been formulated in an attempt to improve this aspect of the screening service. If more widespread screening for chlamydia is to be effectively implemented as recommended by the 31st RCOG Study Group on the Prevention of Pelvic Infection, then it is of importance that workable local protocols are in place including arrangements for partner notification and treatment. This will involve close collaboration between a range of specialities working in the sexual health field.