Good medical practice: guidance for occupational physicians

Following a catalogue of serious, highly publicized medical misdemeanours, the General Medical Council (GMC) has introduced plans for a new system of medical licensing in the UK called 'revalidation'. Under this, the onus will fall on individual doctors, including occupational physicians, to demonstrate their continuing fitness to practice. Doctors will need to show that they meet basic minimum standards in terms of the care they provide, their own continuing professional development, and other aspects of professional life like probity and ethical behaviour. As part of the process, the Faculty of Occupational Medicine, Royal College of Physicians, has produced its own guidance on good medical practice for occupational physicians, following an extensive consultation exercise. This paper summarizes the background to the initiative, the development process and the standards that have been recommended to aid professional accountability.

Vaccination against influenza: UK health care workers not on-message

Vaccination of health care workers against influenza is considered to be important as a means of protecting patients from nosocomial infection. Vaccine uptake rates have been reported to be no more than 40% and often between 20 and 30%. An evaluation of the performance of UK National Health Service trusts, following a governmental directive to implement vaccination during the winter of 2000-2001, has shown a poor uptake of vaccine. Reasons for accepting or declining vaccine are discussed. There is a need for global leadership on this issue to promote the value of vaccination and to change the behaviour of health care workers.

A randomised comparison of a foot pump and low-molecular-weight heparin in the prevention of deep-vein thrombosis after total knee replacement

Patients who undergo total knee replacement (TKR)are at high risk of venous thromboembolism. Low-molecular-weight heparins (LMWH) are the most suitable chemical prophylactic agents but there are some uncertainties about their safety and effectiveness. The foot pump offers an alternative.

We randomised 229 patients undergoing primary, unilateral TKR to receive either the A-V Impulse foot pump or enoxaparin, a LMWH. Ascending venography was undertaken between the sixth and eighth postoperative day in 188 patients without knowledge of the randomisation category. The prevalence of venographic deep-vein thrombosis was 58% (57/99) in the foot-pump group and 54% (48/89) in the LMWH group which was not statistically significant. There were four cases of proximal thrombi and two of fatal pulmonary emboli in the foot-pump group and none in the LMWH group. There were fewer haemorrhagic complications and soft-tissue effects in the foot-pump group.

We conclude that the neither method provides superior prophylaxis.

A randomised comparison of a foot pump and low-molecular-weight heparin in the prevention of deep-vein thrombosis after total knee replacement

Patients who undergo total knee replacement (TKR) are at high risk of venous thromboembolism. Low-molecular-weight heparins (LMWH) are the most suitable chemical prophylactic agents but there are some uncertainties about their safety and effectiveness. The foot pump offers an alternative. We randomised 229 patients undergoing primary, unilateral TKR to receive either the A-V Impulse foot pump or enoxaparin, a LMWH. Ascending venography was undertaken between the sixth and eighth postoperative day in 188 patients without knowledge of the randomisation category. The prevalence of venographic deep-vein thrombosis was 58% (57/99) in the foot-pump group and 54% (48/89) in the LMWH group which was not statistically significant. There were four cases of proximal thrombi and two of fatal pulmonary emboli in the foot-pump group and none in the LMWH group. There were fewer haemorrhagic complications and soft-tissue effects in the foot-pump group. We conclude that the neither method provides superior prophylaxis.

Falls: a comparison of trends in community, hospital and mortality data in older Australians

BACKGROUND AND AIMS

Falls are major contributors to disability, morbidity and death for older people. Frequently, falls-related data for each of these areas is viewed in isolation. The aim of this study was to establish trends in incidence of falls-related events including: community reporting of falls and falls-related injuries, hospitalizations as a result of accidental falls, and mortality related to accidental falls for older people in two states of Australia (Victoria and South Australia).

METHODS

We analysed data sets for falls hospitalizations and mortality rates for the period 1988 to 1997, and from two longitudinal population-based proportional samples during the same time period.

RESULTS

Age-standardised falls mortality rates have steadily declined in Victoria, and remained unchanged between 1988 and 1997 in South Australia. In both states, age-standardised falls hospitalization rates have increased significantly (in Victoria, RR=1.32, 95% CI: 1.30-1.34; and South Australia, RR=1.05, 95% CI: 1.03-1.06). In both states, there was a clear age-related effect, with those in the 85-year and older age group having a falls-related mortality rate approximately 40 times that of those aged 65-69 years, and a hospitalization rate 9 times that of those in the 65-69 age group. The community studies indicated that falls rates remain high among older Australians, and that injurious falls occurred in 10% in the first wave of data collection in each of these studies.

CONCLUSIONS

The results highlight that various indicators related to falls trends taken in isolation may yield differing conclusions. For a true reflection of the effectiveness of falls prevention programs, falls-related mortality, hospitalization and community data need to be integrated. Increased focus on falls prevention activity in Australia during the 1990's has not reduced the magnitude of this major public health problem.

Correlating sonography, mammography, and pathology in the assessment of breast cancer size

BACKGROUND

With the increasing use of neoadjuvant and minimally invasive therapy, the accuracy of preoperative determination of breast tumor size becomes important. Therefore, we undertook this study to compare mammography and ultrasonography (US).

METHODS

A total of 180 invasive breast cancer patients were prospectively examined by mammography and US; 146 eligible patients had tumors visualized by both modalities.

RESULTS

In 69% of cases, US was better than or equivalent to mammography in determining tumor size. Both underestimated tumor size; mean (median) underestimation was 3.8 +/- 0.7 mm (1.7 mm) by US and 3.5 +/- 0.9 mm (2 mm) by mammogram. Maximal tumor dimension was accurate within 5 mm in 65% of cases by mammography and 75% of cases by US. For mammographically determined size (versus pathologic size) correlation, r, was 0.4 and for US it was 0.63 and improved for only T1 and T2 tumors.

CONCLUSIONS

These data suggest that US is more accurate than mammography in assessing breast cancer size.

Observation of feeding in the diagnosis of posttraumatic feeding disorder of infancy

OBJECTIVES

To delineate diagnostic criteria for posttraumatic feeding disorder (PTFD) of infancy and to differentiate PTFD from infantile anorexia (IA) via observation of feeding interactions.

METHOD

Three groups of infants (aged 6-32 months) participated: PTFD (n = 30), IA (n = 30), and healthy eater controls (n = 30). The three groups were matched with regard to age, gender, ethnicity, and socioeconomic status. Child psychiatrists used infants' medical and feeding histories and observed 20-minute mother-infant feeding interactions to determine diagnoses and group placement. Feeding interactions were also videotaped, and two raters assessed infants' resistance to feeding situations and to swallowing, as well as specific qualities of mother-infant feeding interactions.

RESULTS

Overall, the clinical groups (PTFD and IA) demonstrated more problematic feeding interactions than did the control group. However, the PTFD group exhibited more resistance during feeding interactions than did the other two groups. In particular, the PTFD group displayed the most resistance to swallowing food.

CONCLUSIONS

Infants' medical and feeding histories, as well as observations of feeding, are important to making the diagnosis of PTFD and differentiating it from other feeding disorders. Implications for treatment of PTFD are discussed.

A novel, resorbable suture anchor: pullout strength from the human cadaver greater tuberosity

The pullout strength of a collagen bone anchor that creates interference fixation as the result of radial swelling on hydration was compared with a Mitek rotator cuff anchor after insertion into the greater tuberosity of human cadaver humeri. Bones were fully hydrated at 37 degrees C. Stiffness, peak load, and the mode of failure were recorded. Real and apparent bone densities were measured. Peak load for the collagen anchor at 15 minutes (121.0N +/- 81.3N) was greater than at 2 minutes (60.5N +/- 38.5N) after insertion (P <.05). At between 5 and 60 minutes after insertion, peak loads for the Mitek and the collagen anchors did not differ. After 30 minutes from insertion, the mode of failure of the collagen anchor changed from pullout with minor body damage to pullout with major body damage. Peak load at pullout correlated with bone density for the Mitek (P <.05, r = 0.516) but for the collagen bone anchor appeared unaffected by bone density.

Cloning and in vitro characterization of alpha 1(I)-collagen 11 beta-hydroxysteroid dehydrogenase type 2 transgenes as models for osteoblast-selective inactivation of natural glucocorticoids

The NAD-dependent enzyme, 11beta-hydroxysteroid dehydrogenase type II (11 beta HSD2), catalyzes the unidirectional conversion of biologically active glucocorticoids to inactive metabolites. In vivo, 11 beta HSD2 protects the mineralocorticoid receptor from activation by glucocorticoids in mineralocorticoid target tissues such as kidney. The goal of the present study was to use targeted overexpression of 11 beta HSD2 as a novel means of disrupting glucocorticoid signaling in osteoblastic cells. Rat 11 beta HSD2 complementary DNA was cloned downstream of a 2.3- and 3.6-kb alpha 1(I)-collagen (Col1a1) promoter fragment to produce the expression plasmids Col2.3-HSD2 and Col3.6-HSD2, respectively, which were transiently and/or stably transfected in osteoblastic ROS 17/2.8 and MC3T3-E1 cells. Transgene messenger RNA and protein were detected in transfected cells by Northern blot analysis and immunostaining, respectively. Transfection of 11 beta HSD2 led to higher rates of conversion of [(3)H]corticosterone to [(3)H]dehydrocorticosterone and reduced glucocorticoid-dependent regulation of a mouse mammary tumor virus promoter-reporter construct, cell growth, and messenger RNA markers compared with transfection of a control vector. Expression of 11 beta HSD2 under the control of Col1a1 promoter fragments may provide a novel model to study the role of glucocorticoid signaling in osteoblastic cells.

Selectively impaired reaction time in Parkinson's disease: persistent absence of simple reaction advantage in a patient with frontal complications

The search for specific patterns of impaired reaction time in Parkinson's disease has yielded conflicting results. We propose subtypes that exhibit different patterns of impairment and report the case of a patient, Jobe, whose simple and binary choice reaction times were tested repeatedly in a variety of stimulus-response paradigms over a period of 4 years. Jobe consistently failed to exhibit the normal simple reaction advantage even though his choice reaction times fell well within the normal range. While his general intellectual status was above average, he had great difficulty with some neuropsychological tests. He was seldom able to acquire a new category in the Wisconsin Card Sort Test and also had difficulty with the Tower of London Test. We ascribe Jobe's selective impairment of simple reactions to an inability to engage in the off-line preparatory processing that confers an advantage on simple reactions.

SFE1, a constituent of the fertilization envelope in the sea urchin is made by oocytes and contains low-density lipoprotein-receptor-like repeats

At fertilization in most animals, cortical granules of the egg or oocyte secrete their contents, whose function it is to modify the extracellular matrix. This modified matrix then participates in the block to polyspermy and protection for early embryonic development. In the sea urchin, contents of the cortical granules are secreted within 30 sec of insemination. Several of these content proteins then bind to the nascent vitelline layer of the egg and lift off the cell surface to form a stable, impervious, fertilization envelope. At least six major proteins are present in the envelope, and recently we have identified cDNA clones of two, ovoperoxidase, and SFE9. Here we report on the identification and characterization of SFE1, a constituent of the fertilization envelope of the sea urchin Strongylocentrotus purpuratus, that has revealing characteristics of how the envelope might form and what protein interaction domains might predominate. We present the largest cDNA sequence we were able to identify representing approximately two thirds of the predicted protein coding region. The C-terminal half of the cognate SFE1 protein contains two different amino acid repeat motifs: a cysteine-rich (15%) motif of 40 amino acids that is tandemly repeated 22 times and is followed by a serine/threonine-rich (38%) repeat of 63 amino acids that is tandemly repeated 3.5 times. Surprisingly, just N-terminal to the cysteine-rich repeat region is a sequence of five repeats with similarity to repeats in another cortical granule protein, SFE9, and to the motif originally identified in the receptor of low-density lipoproteins, the LDLr motif. The amino acid composition deduced from the partial SFE1 cDNA is similar also to the composition of proteoliaisin, a protein thought to tether the ovoperoxidase to the vitelline layer of the egg and thereby sequester the crosslinking activity of the ovoperoxidase to a limited population of proteins in the fertilization envelope. However, by use of monoclonal and polyclonal antibodies to SFE1 and proteoliaisin, we show here that they are distinct gene products. We also show that SFE1 is packed selectively into the cortical granules and then is crosslinked into the fertilization envelope following fertilization. In situ RNA hybridization analysis shows that the mRNA of SFE1 (9 kilobases) is present in oocytes selectively and is turned over rapidly in the oocyte following germinal vesicle breakdown. Our findings suggest that the gene encoding this major product of the egg is activated concomitantly with the other cortical granule-specific products already identified, and that a common LDLr-like motif of the fertilization envelope may reveal a structural mechanism for protein interactions in its construction.

Internet access: the impact on nurses and PAMs

An outline of a research project into the use of the internet on hospital wards and its impact on nurses and professionals allied to medicine.

Helicobacter pylori and the learning disabled

Those with a learning disability previously cared for in institutions have now been discharged into smaller community homes. This has meant that an increased burden has been placed on general practitioners (GPs) to evaluate and treat those who have symptoms that may be difficult to interpret. This report presents the prevalence of Helicobacter pylori in those still awaiting discharge and discusses the possible symptoms that GPs may encounter.

Wasp sting mortality in Australia

Wasp sting fatalities have rarely been reported in Australia. We used data from the Australian Bureau of Statistics and State coronial authorities to investigate deaths from wasp stings in Australia from 1979 through 1998. Seven cases were identified, all involving men in rural settings. Five of the seven victims had prior histories of wasp or bee venom allergy, or both, but none carried injectable adrenalin. All patients with a history of systemic Hymenoptera sting allergy should undergo assessment for immunotherapy and carry adrenalin.

Improving quality of life for carers

There are 5.7 million carers across the UK, providing care and support to family members, relatives or friends who are ill, disabled or elderly and frail (Office of Populations, Censuses and Surveys, 1995). It is estimated that informal carers save the country £34 billion annually (Nuttall et al, 1993). If carers decided to stop providing informal care, health and social services would be overwhelmed by the increase in workload, many people would suffer and taxes would increase dramatically.