Anatomy of the sural nerve and its relation to the Achilles tendon

Sural nerve injury is a complication of Achilles Tendon (TA) rupture. We dissected 30 cadaveric lower limbs to describe the course of the sural nerve in relation to the TA. At the level of insertion of the TA into the calcaneum, the sural nerve was a mean 18.8 mm from the lateral border of the TA. The proximal course of the nerve was towards the midline such that it crossed the lateral border of the TA at a mean distance of 9.8 cm from the calcaneum. The significant individual variation in the position of the sural nerve in relation to the achilles tendon should be borne in mind when placing sutures in the proximal part of the achilles tendon. Percutaneous sutures should not be placed in the lateral half of the TA.

A framework for perioperative advanced practice

The launch of the government's new nursing strategy Mating a Difference, DoH (1999), has highlighted the role that nursing will play in the future provision of healthcare in the NHS.

"Unnecessary suffering": the cornerstone of animal protection legislation considered

Causing "unnecessary suffering" has been widely adopted in legislation to define criminal liability in respect of the treatment of animals. This article examines the way in which the term has been interpreted and applied by the courts, and considers its effectiveness in affording animals protection from abuse.

Development of a meaningful learning environment in theatres

During the 1990s, geographical distancing of clinical areas and nurse education establishments led to breakdowns in communication. This article focuses on how Good Hope Hospital NHS Trust and the University of Central England in Birmingham created a meaningful learning environment for student nurses in the operating theatre using a revised version of Crofts and Taylor's (1996) perioperative placement model. The student evaluation has demonstrated that the quality of placement, teaching and supervision were of a high standard and students felt that their nursing skills had been enriched as a direct result of the placement. This article will also examine the background to student placements in the operating theatre.

Warfarin use following ischemic stroke among Medicare patients with atrial fibrillation

BACKGROUND

Elderly patients with ischemic stroke and atrial fibrillation are at especially increased risk for recurrent stroke. Warfarin sodium is highly effective in reducing this risk.

OBJECTIVE

To determine the use of warfarin among a population sample of elderly patients with atrial fibrillation hospitalized for ischemic stroke.

METHODS

The Connecticut Peer Review Organization conducted a chart review of Medicare patients, aged 65 years or older, hospitalized in 1994 with a diagnosis of atrial fibrillation. Patients with a principal diagnosis of acute myocardial infarction or another indication for anticoagulation were excluded.

RESULTS

Among 635 patients (402 women; 585 white; 218 > or =85 years old; 147 with a new diagnosis of atrial fibrillation), 334 had stroke as a principal diagnosis. Among those discharged alive after a stroke, only 147 (53%) of 278 were prescribed warfarin at discharge. Furthermore, among 130 (47%) of 278 patients not prescribed warfarin at discharge, 81 (62%) of 130 were also not prescribed aspirin. Increased potential benefit (additional vascular risk factors) was not associated with a higher rate of warfarin use. Low risk for anticoagulation (lack of risk factors for bleeding) was associated with a slightly higher rate of warfarin use. Among those with an increased risk of stroke and a low risk for bleeding (ideal candidates), 124 (62%) of 278 were discharged on a regimen of warfarin.

CONCLUSION

Anticoagulation of elderly stroke patients with atrial fibrillation, even among ideal candidates, is underused. The increased use of warfarin among these patients represents an excellent opportunity for reducing the risk of recurrent stroke in this high-risk population.

Warfarin use among patients with atrial fibrillation

BACKGROUND AND PURPOSE

Warfarin reduces the rate of stroke among patients with atrial fibrillation. We sought to determine warfarin use within a population sample of elderly patients with atrial fibrillation.

METHODS

The Connecticut Peer Review Organization conducted a chart review of Medicare patients aged > or = 65 years with a history of atrial fibrillation before a hospitalization during the first 6 months of 1994.

RESULTS

Among 488 patients (308 women; 457 white; 173 aged > or = 85 years), 38% (184/488) had a relative contraindication to anticoagulation (history of bleeding, dementia, alcohol use, falls, cancer, or the need for nonsteroidal anti-inflammatory drugs). Among the remaining patients (with known atrial fibrillation, but without a contraindication), only 38% (117/304) had been prescribed warfarin. Of those not prescribed warfarin, 63% (117/187) were also not taking aspirin. There were 272 patients with at least one additional vascular risk factor and no contraindication to anticoagulation. Among these patients at moderate to high risk for stroke, anticoagulation had been prescribed in 40% (109/272). Overal, among those not prescribed warfarin, 58% (95/163) were not taking aspirin. Patients admitted with a stroke were more likely to be significantly underanticoagulated (with international normalized ratio < 1.5) (43.5% versus 20.9% for those without stroke; P < .005). Anticoagulation was most effective for those with an international normalized ratio > or = 2.0.

CONCLUSIONS

Warfarin anticoagulation with atrial fibrillation, even among "ideal" candidates, appears dramatically underutilized. In addition, among those prescribed warfarin, patients are often undertreated. Increased warfarin use among patients with atrial fibrillation represents an excellent opportunity for stroke prevention in the elderly.

Does histology influence outcome in childhood Hodgkin's disease? Results from the United Kingdom Children's Cancer Study Group

PURPOSE

Histology has been identified as an important prognostic factor in Hodgkin's disease (HD) in adults. Information regarding the impact of histology on outcome in childhood HD is scarce. This study determines the effect of histology on the overall survival (OS) or progression-free survival (PFS) in a national series of children treated in a standardized manner.

PATIENTS AND METHODS

The results of treatment of 331 assessable patients, treated between January 1, 1982 and June 30, 1992, in the United Kingdom Children's Cancer Study Group (UKCCSG) Hodgkin's study I were reviewed to evaluate OS, PFS, and deaths according to stage and histology. Treatment was either involved-field radiation alone (stage IA) or chlorambucil, vinblastine, procarbazine, and prednisolone (ChlVPP) chemotherapy with or without mediastinal radiation. All were clinically staged at diagnosis.

RESULTS

Nodular sclerosing (NS) HD was the most common histologic subtype (155 of 331 patients [47%]) and was uniformly distributed through all stages. Lymphocyte-depletion (LD) HD was extremely uncommon (< 1%). Mixed-cellularity (MC) HD had the highest relapse rate, but this was only significant (P < .05) in stage I patients who received local irradiation alone. There was no other statistically significant difference in OS and PFS between the various histologic subtypes. Multivariate analysis for PFS and OS confirmed that stage was the most important prognostic factor and that histology did not have an effect after stratification by stage.

CONCLUSION

This study demonstrates that with effective multiagent chemotherapy, histologic subtype does not influence outcome. The high relapse rates in stage I MC subtype indicates that MC HD is biologically aggressive and systemic treatment with or without local irradiation may be indicated. The high relapse rate in stage IV patients appeared to be independent of histology.

Gonadal function following chemotherapy for childhood Hodgkin's disease

Gonadal function was assessed in 101 postpubertal subjects after chemotherapy for childhood Hodgkin's disease. All had received ChlVPP (chlorambucil, vinblastine, procarbazine, and prednisolone) chemotherapy alone, with no radiotherapy below the diaphragm. Gonadotropin levels were available in 46 (79.3%) male and 32 (74.4%) female subjects. The mean age at diagnosis in the male cohort was 12.2 years (range 8.2-15.3) and in the females 13.0 years (9.0-15.2). The males and the females were studied at a median of 6 years (range 2.5-11.1) and 4.3 years (range 1.9-11.5) from diagnosis, respectively. Forty-one (89.1%) male subjects had elevated follicle-stimulating hormone (FSH) levels, confirming severe germinal epithelial damage. Germinal epithelial damage was seen in subjects up to 10 years out of therapy. Subtle Leydig cell dysfunction was identified in 24.4% with raised luteinzing hormone (LH) levels. All subjects, however, progressed spontaneously through puberty. Seventeen (53%) women had raised gonadotropin levels, with variable estradiol levels. Of these, 10 subjects presented with symptomatic ovarian failure and 6 received hormone replacement therapy (HRT). Nine women had 11 successful pregnancies, two of whom had previously had symptoms of ovarian failure with one requiring HRT. A much higher prevalence of ovarian failure has been observed, than has previously been considered in the prepubertal and pubertal female following combination chemotherapy. These conclusions have important implications for future counseling, management, and research in this population.

Effect of amiodarone on clinical status and left ventricular function in patients with congestive heart failure. CHF-STAT Investigators

BACKGROUND

Although trials of amiodarone therapy in patients with congestive heart failure have produced discordant results with regard to effects on survival, most studies have reported a significant rise in left ventricular ejection fraction during long-term therapy. In the present study, we determined whether this increase in ejection fraction is associated with an improvement in the symptoms and/or physical findings of heart failure or a reduction in the number of hospitalizations for heart failure.

METHODS AND RESULTS

In the Department of Veterans Affairs cooperative study of amiodarone in congestive heart failure, 674 patients with New York Heart Association class II through IV symptoms and ejection fractions of < or = 40% were treated with amiodarone or placebo for a median of 45 months in a randomized, double-blind, placebo-controlled protocol. Clinical assessments and radionuclide ejection fraction were performed at baseline and after 6, 12, and 24 months. Compared with the placebo group, ejection fraction increased more in the amiodarone group at each time point (8.1 +/- 10.2% [mean +/- SD] versus 2.6 +/- 7.9% at 6 months, 8.0 +/- 10.9% versus 2.7 +/- 8.0% at 12 months, and 8.8 +/- 10.1% versus 1.9 +/- 9.4% after 24 months, all P < .001). However, this difference was not associated with greater clinical improvement, lesser diuretic requirements, or fewer hospitalizations for heart failure (11.1% for amiodarone and 13.6% for placebo group; overall relative risk in the amiodarone group, 0.81 [95% CI, 0.56 to 1.10], P = .18). Of note is the trend toward a reduction in the combined end point of hospitalizations and cardiac deaths (relative risk, 0.82 [CI, 0.65 to 1.03], P = .08), which was significant in patients with nonischemic etiology (relative risk, 0.56 [CI, 0.36 to 0.87], P = .01) and absent in the ischemic group (relative risk, 0.95).

CONCLUSIONS

Although amiodarone therapy resulted in a substantial increase in left ventricular ejection fraction in patients with congestive heart failure, this was not associated with clinical benefit in the population as a whole. The substantial reduction in the combined end point of cardiac death plus hospitalizations for heart failure in the nonischemic group suggests possible benefit in these patients.

Assessment of the continued supervision and asthma management knowledge of patients possessing home nebulizers

This paper describes the results of a questionnaire survey on some aspects of nebulizer use, nebulizer instruction, and features relating to the recognition and management of deteriorating asthma. The study population consisted of 90 children with home nebulizers attending a paediatric asthma clinic, and 200 asthmatic children and 200 asthmatic adults whose nebulizers had been purchased directly from a manufacturer in the U.K. The results suggest that follow-up supervision of the patients who bought their own nebulizers occurred in only approximately 25% of cases. Written information focusing on the management of symptoms was also lacking. Peak flow meters were being under-used. Although the majority (77-100%) of patients were aware of the '4 h rule' for repeat use of bronchodilator therapy at home, there was still some confusion about the acceptable time interval and action to be taken should the dose be required more frequently. Very few (32%) in the nationwide adult group had a crisis action plan should the nebulizer fail to produce relief. This paper recommends that a simple treatment and crisis plan should be included with the purchased nebulizer, highlighting the key areas to be discussed by the patients with the doctor or other medical professionals. Such a package may prevent the occasional disaster that can occur with unsupervised nebulized bronchodilator usage.

Frequent use of medical services. Patient reports of intentions to seek care

OBJECTIVE

To examine differences between frequent and infrequent users in decisions to seek medical care based on symptom type and duration of experience of the symptom.

DESIGN

Retrospective study.

SETTING

University family practice clinic.

PATIENTS

Fifty-eight of 130 patients returned the completed instruments, a response rate of 45%.

MAIN OUTCOME MEASURES

The following two instruments were used: the Intentions to Seek Care questionnaire, which measures intention to see a physician, self-treat, or use medications for 11 different symptoms after three time periods--1 day, 3 days, and 1 week of symptom duration--and the SF-36 Health Survey measure.

RESULTS

Initial analyses suggested that patients perceive three clusters of symptoms, which we have labeled as serious, mild, and psychological. Scale scores for these groups of symptoms yielded significant reliability and were used in subsequent analyses. Multivariate analysis of variance comparing source of care, symptom duration, and frequent vs infrequent user groups indicated that both user groups are more likely to seek care from physicians for symptoms that are serious. Analysis of mild and psychological symptoms yielded significant three-way interactions, with frequent users more likely than infrequent users to seek care from physicians at a 1-day duration. Such differences disappear by 7 days. Significantly lower scores were obtained on five of the eight SF-36 Health Survey dimensions for the infrequent users.

CONCLUSIONS

Frequent users are more likely than infrequent users to report that they would seek care for minor symptoms. Infrequent users tend to self-treat for 3 to 7 days, after which time physician advice is sought. Efforts to teach patients optimal timing of use for different symptoms may be an effective intervention.

Current lifestyle of young adults treated for cancer in childhood

The aim of this study was to look at the current lifestyle of young adult survivors of childhood cancer between the ages of 16 and 30 years to document their achievements and expose any psychosocial problems. Sixty six young adult survivors were contacted and asked if they and their siblings (16-30 years) would take part in a lifestyle study; 48 patients and 38 sibling controls were interviewed. This took the form of a structured lifestyle questionnaire, a self esteem questionnaire (Oxford Psychologists Press), and an unstructured interview. Fifty five per cent of patients achieved five or more A-C grades at 'O' level/GCSE compared with 62% of siblings and a national average of 30%. Despite that these patients were significantly less likely to go on to higher education than their siblings. The two groups were equally employable and earning similar salaries. There were three cases of known employer prejudice. A slightly higher percentage of patients than siblings had their driving licence. Seventeen patients felt their appearance had changed and eight felt that they had a residual physical mobility problem. Both groups were socially active and equally likely to partake in competitive sports. There was no overall difference in the self esteem of the two groups. In general the survivors of childhood cancer were coping well in their young adult life and achieving the same lifestyle goals as their siblings. However, significant problems have been identified.

Do mutations at the glycophorin A locus in patients treated for childhood Hodgkin's disease predict secondary leukaemia?

Childhood Hodgkin's disease has a high cure rate but second cancers are common, related to treatment and perhaps genetic predisposition. The glycophorin A (GPA) mutation assay measures the frequency of NO and NN mutant erythrocytes of MN blood-group heterozygous individuals. Mutant frequencies in Hodgkin's disease patients were compared with controls. No significant difference from controls was found pretreatment or in patients treated with radiotherapy only. Patients who received chemotherapy had a significantly increased frequency (total mutation frequency per 10(6) cells: 31 vs 11, p < 0.001), which may be relevant to their known increased risk of secondary leukaemia.

Synovial sarcoma of the larynx in a child: case report and histological appearances

Synovial sarcoma of the larynx is extremely rare having been reported only six times previously in the literature. We add another case report, which to our knowledge is the first recorded case in a child. We discuss the alternative approach of combination chemotherapy and radiotherapy which in this case led to a remission lasting about 3 years. The immunohistological and ultrastructural characteristics of the tumour are also presented.

An open study to assess the long-term safety of fluticasone propionate in asthmatic children. International Study Group

This study was conducted to assess the long-term safety of fluticasone propionate 50 micrograms twice daily (100 micrograms/day) or 100 micrograms twice daily (200 micrograms/day) administered via a dry powder inhaler in children aged 4-17 years with moderately severe asthma. A total of 257 patients received open treatment for 12 months. Of these, 110 had not received treatment with fluticasone propionate in any prior study. The remaining 147 patients had completed one of two previous short-term inhaled fluticasone propionate studies. In all, 132 patients (51%) reported 273 adverse events, the pattern of which was as expected in an atopic population with asthma; only 26 (10%) of these reports were considered either certainly, probably or possibly related to study treatment. The events most commonly reported either as a single or multiple diagnosis were: asthma and related events (25%), upper respiratory tract infection (13%), and rhinitis (6%). For most patients who reported a worsening of asthma, additional therapy was all that was required to control symptoms, and they continued in the study. There was a low incidence (2%) of pharmacologically predictable adverse events. Eight patients (3%) withdrew from the study because of an adverse event, five of which events (one each of hypertension, hoarseness and asthma and two of oral candidiasis) were recorded as being possibly or probably drug-related. Sixteen adverse events reported by 15 patients (6%) were classified as serious but none was considered to be related to the study drug. Of these reports 10 ( patients; 4%) were exacerbations of asthma requiring hospital admission; the other six adverse events were unrelated to asthma.(ABSTRACT TRUNCATED AT 250 WORDS)

Overnight urine growth hormone, cortisol and adenosine 3' 5' cyclic monophosphate excretion in children with chronic asthma treated with inhaled beclomethasone dipropionate

Overnight urine samples were obtained from 34 asthmatic children, 24 of whom were receiving inhaled beclomethasone dipropionate (BDP), and 30 controls. The urine volume of the children receiving inhaled steroids was significantly greater than that of the other asthmatic children and of the controls (P < 0.05). Urine growth hormone was within the normal range for all of the subjects and there was no demonstrable relationship between urine growth hormone and height or height standard deviation score. Urine steroid output was significantly reduced in the BDP receiving group when the results were expressed in U l-1 but there was no difference between the groups when the results were expressed per specimen. Urine adenosine 3' 5' cyclic monophosphate (cAMP) results were similar for all groups. We conclude that use of BDP increases overnight urine volume but, in our study, does not appear to influence the output of urine cortisol. Urine free cortisol measurements may not be a very sensitive tool for the detection of small changes in endogenous steroid production. The use of BDP does not adversely affect the output of urine growth hormone.

Comparison of the efficacy and safety of inhaled fluticasone propionate 200 micrograms/day with inhaled beclomethasone dipropionate 400 micrograms/day in mild and moderate asthma

This study was designed to compare the efficacy and safety of a new inhaled corticosteroid, fluticasone propionate at a total daily dose of 200 micrograms, with beclomethasone dipropionate 400 micrograms/day in childhood asthma. A total of 398 asthmatic children (aged 4-19 years) were randomised to receive either fluticasone propionate 200 micrograms daily or beclomethasone dipropionate 400 micrograms daily for six weeks inhaled via a spacer device from a metered dose inhaler. During the study the patients recorded morning and evening peak expiratory flow rate (PEFR), symptom scores, and use of beta 2 agonist rescue medication. In addition, clinic visit PEFR and forced expiratory volume in one second were measured. Safety was assessed by recording all adverse events and by performing routine biochemistry and haematology screens including plasma cortisol concentration before and after treatment. For the purposes of analysis the diary card data were grouped into three periods: week 3 (days 15-21), week 6 (days 36-42), and weeks 1-6 (days 1-42). The results showed no significant difference between treatments on most efficacy parameters. However, there were significant differences in changes from baseline in favour of fluticasone propionate for % predicted morning PEFR both at week 3 (fluticasone propionate 6.1%, beclomethasone dipropionate 3.9%) and at week 6 (fluticasone propionate 8.3%, beclomethasone dipropionate 5. 9%) and % predicted evening PEFR at week 6 (fluticasone propionate 7.3%, beclomethasone dipropionate 4.9% and over weeks 1-6 (fluticasone propionate 5.5%, beclomethasone dipropionate 3.6%. Comparison between groups showed that the group receiving fluticasone propionate had a lower % of days with symptom-free exercise at week 6 (fluticasone propionate 87%, beclomethasone dipropionate 81%) and % days without rescue medication at week 6 (fluticasone propionate 87%, beclomethasone dipropionate 80%) and over weeks 1-6 (fluticasone propionate 80%, beclomethasone dipropionate 73%). Except for a higher incidence of sore throat in the fluticasone propionate group, the two treatments did not differ with regard to safety. There was no evidence of adrenal suppression with either treatment. In conclusion, fluticasone propionate 200 microgram daily ws at least as effective and as well tolerated as beclomethasone dipropionate 400 microgram daily in childhood asthma.

Cutaneous squamous cell carcinoma following treatment for acute lymphoblastic leukaemia

The importance of second malignant neoplasms following successful treatment of childhood malignancy is of concern to all professionals involved with the care of these patients. We present an 18 year old patient with a squamous cell carcinoma of his lower lip following prolonged treatment for acute lymphoblastic leukaemia in childhood. The rarity of this tumor in this age group and the aetiological factors involved in developing the second malignancy are discussed.

Increased resting energy expenditure in childhood asthma: does this contribute towards growth failure?

In order to determine whether or not there was a relationship between disorders of growth in children suffering from asthma and either increased resting energy expenditure or inadequate energy intake, a group of 34 children suffering from perennial symptoms were studied. A control group matched with the asthmatic children for sex and fat free mass were similarly studied. The children kept seven day records of weighed food intake. Basal metabolic rate was measured on one occasion in the fasted state by means of indirect calorimetry using the ventilated hood technique. The asthmatic children kept a 28 day record of peak expiratory flow rates, asthma symptoms, and medication usage. The asthmatic children expended significantly more energy at rest than their matched controls in absolute terms (14%). There was no correlation between height or height SD score and any parameter of energy balance. The causes of these finding are as yet speculative.

'VEEP' in children with Hodgkin's disease--a regimen to decrease late sequelae

In an attempt to decrease the risk of second malignancies and future infertility in children with Hodgkin's disease (HD) while retaining acceptable remission rates, an anthracycline based regimen containing no alkylating agent has been devised. VEEP contains vincristine, epirubicin, etoposide and prednisolone given at 3 weekly intervals. Forty-four patients, aged 2-15 years, have been treated: ten relapsed patients and 34 previously untreated with chemotherapy (including three relapsed stage I treated initially with radiotherapy). The median follow up for all patients is 25 months (range 6-52 months). The response rate in previously treated patients was 80% (95% CI 44-97%) and five remain alive in remission. The response rate in untreated patients was 88% (95% CI 72-97%) with 62% CR + CR(u) (uncertain/unconfirmed) (95% CI 44-77%). Of four patients who had a final response of CR(u) three have relapsed at 9, 16 and 38 months. Two of the children in CR have relapsed at 6 and 16 months. The relapse free rate at 3 years is 67% (95% CI 17-82%). In this pilot study the event free survival appears somewhat poorer than conventional combinations and further follow up is required to confirm the salvagability of relapsed patients.

Characterization and molecular analysis of nondisjunction in 18 cases of trisomy 21 and leukemia

We recently began a cytogenetic and molecular study of nondisjunction in leukemic Down syndrome individuals to determine whether the mechanism by which the extra chromosome 21 originates predisposes the individual to leukemia. In the present report, we summarize our observations on 18 patients with trisomy 21 and acute or transient leukemia, including 11 patients with acute lymphocytic leukemia, three with acute myeloid leukemia, one with B-cell lymphoma, one with acute megakaryoblastic leukemia, and two with transient leukemia. Results of DNA marker studies of the parental origin of the extra chromosome 21 indicated that 16 of the 18 cases (89%) were maternally derived, a percentage similar to that seen among nonleukemic Down syndrome patients. We noted that most leukemic Down syndrome patients had one locus or more in which parental heterozygosity was maintained in the trisomic individual, indicating a meiotic rather than a mitotic origin for the trisomy.

Comparative study of affective disorders in three Asian countries. II. Differences in prevalence rates and symptom presentation

This study used standardized diagnostic criteria and method to investigate both prevalence rates and nature of symptoms of depressive disorders in three Asian centres--Nagasaki, Shanghai and Seoul. Of the patients who visited a psychiatric clinic in each of the 3 centres for the first time, over 20% suffered from depression. Unlike previous reported prevalence rates for Asian countries, these results suggest that rates in Asia may not be much lower than those reported in Western countries. Although prevalence rates of depression were similar in all 3 centres, differences in symptoms were noted.