The performance of Australian DRGs

This paper reports the results of an evaluation study of the Australian National Diagnosis Related Groups (AN-DRGs). The evaluation was based on statistical rather than clinical criteria with the principal goal being to provide information for the future development of the classification system. As well as comparing versions 1.0 to 3.0 of AN-DRGs, the project included a comparison of these systems with the most recent versions of the DRG systems from the United States. Taking all the evaluation criteria together, Version 3.0 of AN-DRGs performed best of all the systems except for the All Patient Refined (APR)-DRGs with its much larger number of groups. However, the differences between all the classifications were slight. Data of higher quality are needed if further refinements of the AN-DRGs are to produce substantial improvements in performance.

Reducing the incomplete excision of non melanotic skin cancers in Australian general practice

AIM

To develop a simple set of predictors of incomplete excision of non melanotic skin cancer and to test them prospectively.

METHOD

Possible predictors were identified by a literature review and modified by a retrospective analysis of histologically confirmed excisions by the author between 1992 and early 1998. The composite set was then tested prospectively on non melanotic skin cancer excisions from April 1998 to September 1999.

RESULTS

The set of predictors was used prospectively to identify lesions with which particular care should be taken to avoid incomplete excision. Using this method resulted in an overall reduction of incomplete excisions of about 50%.

CONCLUSIONS

The application of a set of predictors is an effective method of reducing incomplete excisions. A number of factors related to the age of the patient, the site of the lesion and its macroscopic appearance made up the set of predictors. Their application showed that particular care needs to be taken with lesions on the head and neck and lesions on patients who are under 50 years of age.

Matched unrelated bone marrow transplantation for combined immunodeficiency

Bone marrow transplantation (BMT) from siblings is the treatment of choice for severe combined immunodeficiency (SCID). The objective of this study was to evaluate the efficiency of BMT from matched unrelated donors (MUD) in congenital immunodeficiencies when a sibling donor is unavailable. Sixteen consecutive patients with SCID (n = 9) and CID (n= 7), were referred for an unrelated donor search. Acceptable donors were found for all patients. Fifteen patients received busulfan and cyclophosphamide pretransplant conditioning. One patient had an early loss of graft and was reconditioned using cyclophosphamide and total body irradiation. The graft-versus-host disease (GVHD) prophylaxis used was methylprednisolone, cyclosporin A with or without methotrexate. Neutrophil engraftment was rapid and was achieved in all patients within a mean of 15.4 days. Only 13 episodes of fever were recorded shortly after BMT. GVHD of grade II or more was apparent in 2/9 (22%) of SCID patients and in 4/7 (57%) of CID patients. Overall survival was 75% with a mean follow-up of 47.4 months (range 18-101). Six out of nine SCID patients (67%) and 6/7 (86%) of CID patients are alive and well. Eleven patients had normal humoral immunity, and cell-mediated immunity as measured by flow cytometry and mitogenic responses, was intact in all patients. Intradermal candida skin test was positive in 9/10 patients tested. We conclude that BMT from MUD results in rapid engraftment and is therefore associated with a low rate of infection contributing to the improved survival rate. The protocol used is especially favorable for patients with combined immunodeficiency.

Meeting the information needs of an evidence-based world

There are many new and exciting health information developments in Australia today. However, there are also many gaps and problems in the information available to support evidence-based decision-making. For example, computerisation in health lags behind other industries. However, these problems should not prevent us using the available data to manage individual care and the health care system more effectively. It is fruitless to wait for a technological solution to all our problems. Educational and staff changes are needed to prepare health professionals and patients to use information to make evidence-based decisions and bring health care into the information age.

Green fluorescent protein (GFP) as a reporter gene for the plant pathogenic oomycete Phytophthora palmivora

Transgenic Phytophthora palmivora strains that produce green fluorescent protein (GFP) or beta-glucuronidase (GUS) constitutively were obtained after stable DNA integration using a polyethylene-glycol and CaCl2-based transformation protocol. GFP and GUS production were monitored during several stages of the life cycle of P. palmivora to evaluate their use in molecular and physiological studies. 40% of the GFP transformants produced the GFP to a level detectable by a confocal laser scanning microscope, whereas 75% of the GUS transformants produced GUS. GFP could be visualised readily in swimming zoospores and other developmental stages of P. palmivora cells. For high magnification microscopic studies, GFP is better visualised and was superior to GUS. In contrast, for macroscopic examination, GUS was superior. Our findings indicate that both GFP and GUS can be used successfully as reporter genes in P. palmivora.

Yersinia enterocolitis mimicking Crohn's disease in a toddler

A 31/2-year-old girl presented with persistent abdominal pain, fever, vomiting, and diarrhea accompanied by rash, oral ulceration, anemia, and an elevated sedimentation rate. Initial evaluation revealed no pathogens and was extended to include abdominal ultrasound and computed tomography showing marked ileocecal edema and mesenteric adenopathy. Colonoscopy revealed focal ulceration from rectum to cecum with histology of severe active colitis with mild chronic changes. Enteroclysis demonstrated a nodular, edematous terminal ileum. Because of the patient's clinical deterioration despite antibiotics, these features were construed consistent with Crohn's disease, and glucocorticoid therapy was begun. By the ninth hospital day, admission cultures grew Yersinia enterocolitica, and trimethoprim/sulfamethoxazole was begun followed by prompt clinical improvement. The delay in diagnosis afforded an unusually comprehensive clinical description of the presentation and diagnosis of Yersinia enterocolitis in childhood.

Synaptic vesicle dynamics in rat fast and slow motor nerve terminals

We have investigated whether rat motor nerve terminals with different in vivo activity patterns also have different vesicle trafficking characteristics. To do this, we monitored, using combined optical and electrical techniques, the rate of exocytosis (during different frequencies and patterns of activity), the releasable pool size, and the recycle time of synaptic vesicles in terminals on soleus (slow-twitch) and extensor digitorum longus [(EDL); fast-twitch] muscle fibers. EDL terminals had a higher initial quantal content (QC) than soleus, but during tonic or phasic stimulation at 20-80 Hz, EDL QC ran down to a greater extent than soleus QC. By recording loss of fluorescence from exocytosing vesicles labeled with the dye FM1-43, EDL terminals were found to destain faster than those in soleus. Simultaneous intracellular recording of end plate potentials, to count the number of vesicles released, permitted estimation of the total vesicle pool (VP) size and the recycle time by combining the optical and electrophysiological data. Soleus vesicle pool was larger than EDL, but recycle time was not significantly different. These terminals, therefore, are adapted to their in vivo activity patterns by alterations in QC and VP size but not recycle time.

Long-term remission for disseminated Mycobacterium avium-intracellulare complex associated with antibody deficiency

Mycobacterium avium-intracellulare (MAI) is a ubiquitous organism with limited virulence in the immunocompetent host. Disseminated disease is associated with a high mortality rate. Except for localized cervical adenitis, MAI disease is rare in immunocompetent children. We report a child with antibody deficiency (dysgammaglobulinemia) and disseminated MAI infection, in whom complete, long-term remission was attained with multiple antimycobacterial therapy. The patient presented with progressive cervical lymphadenopathy and hepatomegaly at 7 years of age. A lymph node biopsy showed acid-fast bacilli and granulomas. Despite a transient response to conventional antituberculous therapy, including isoniazid and rifampin, his symptoms progressed. Cultures from blood, bone marrow, spleen, and cervical lymph node tissues revealed an MAI organism. Subsequent treatment using a combination of clarithromycin, amikacin, and ethambutol for 16 months resolved clinical symptoms, and subsequent blood culture results became negative. By the time of this report, the patient has been disease-free for 4 years. Multiple-drug therapy is promising for the treatment of MAI in children with antibody deficiency; however, the selection of antiinfective drugs should include a member of the newer macrolide family. acquired immunodeficiency syndrome, clarithromycin, dysgammaglobulinemia, Mycobacterium avium-intracellulare, treatment.

New methods for inactivation of lipid-enveloped and non-enveloped viruses

Two new methods are described for inactivating lipid-enveloped and non-enveloped viruses in plasma-derived products such as coagulation factors and intravenous immunoglobulin (IGIV). Iodine/Sephadex delivers iodine to IGIV solutions in a slow, controlled way and allows for inactivation of > or = 4 logs of porcine parvovirus (PPV), a hardy non-enveloped virus, under conditions which do not measurably damage the structural or functional properties of the IGIV, and with essentially no iodination of the protein. All detectable enveloped and non-enveloped viruses were inactivated by this treatment. Gamma irradiation has been successfully used to inactivate viruses at the final vial stage in freeze-dried plasma proteins. Four logs of PPV were inactivated by irradiation in the presence of fibrinogen, factor VIII and alpha 1-proteinase inhibitor (API) at doses of 23, 28 and 30 kiloGray (kGy) respectively, while retaining 93% of fibrinogen solubility, 67% of factor VIII activity and over 80% of API activity. Bovine viral diarrhea virus (BVDV), a lipid-enveloped model for hepatitis C virus, was completely inactivated by radiation doses of 20-30 kGy in these products. Gamma irradiation was less effective in inactivating viruses in freeze-dried IGIV.

The outcome of patients with hypogammaglobulinemia in infancy and early childhood

A 10-year prospective cohort study followed the evolution of antibodies in children less than 4 years of age with hypogammaglobulinemia. Three patterns were identified: in group 1, immunoglobulins and antibody production normalized;iin group 2, patients continued to have low IgG levels; and in group 3, IgG levels normalized but antibody levels were transient. Statistical analysis showed that invasive infection or low tetanus antibodies at presentation were associated with the development of significant humoral immunodeficiency.

Clinical utility of high-resolution pulmonary computed tomography in children with antibody deficiency disorders

OBJECTIVE

To assess the value of high-resolution computed tomography (HRCT) in determining the extent and significance of lung disease in children with antibody deficiency states.

MATERIALS AND METHODS

Seventy HRCT scans performed on 37 children with various antibody deficiency disorders over a 5-year period were retrospectively scored using a previously described demerit scoring system (0-25 with 0 = worst, 25 = best). Points are subtracted from 25 with increasing severity of disease. The potential correlations between CT scores and clinical factors, including age at diagnosis, age at CT, type of immunoglobulin deficiency, length of respiratory symptoms before diagnosis, number of pneumonias before diagnosis, type, length and success of therapy, patient compliance and pulmonary function tests (PFTs), were assessed.

RESULTS

Of the 37 children, a demonstrated 22 abnormal scans (CT score < or = 22). All nine demonstrated bronchiectasis with a lower lobe and right middle lobe predominance. Statistically significant correlations were seen between severity of lung disease (CT score) and length of respiratory symptoms before diagnosis (p = 0.01), success of therapy (P = 0.001) and PFTs (P = 0.0008). Of seven children who were followed with repeated scans, 4 of the 7 demonstrated CT scores which improved on high-dose intravenous immunoglobulin replacement therapy.

CONCLUSION

HRCT is a useful adjunct to demonstrate the extent and severity of lung disease at diagnosis and during therapy. Correlation with clinical factors suggests a higher risk group needing more aggressive management.

Tactic response of zoospores of the fungus Phytophthora palmivora to solutions of different pH in relation to plant infection

Zoospores of the plant pathogen Phytophthora palmivora use a number of tactic responses to target specific infectible regions of host roots. Although the dominant one is believed to be chemotaxis, it has been shown that zoospores of oomycetes may also use the exogenous proton/electrical currents generated by plant roots for guidance. Since these proton currents also generate significant pH gradients in the rhizosphere, the tactic response of zoospores to changes in pH was examined. Using ‘swim-in’ capillary tests, zoospores of P. palmivora were found to be repelled by solutions of high pH and attracted to solutions of low pH, relative to a control at neutrality. This in vitro tactic response was generally consistent with the measured pH at sites of zoospore accumulation around intact and wounded roots. However, the endogenous pH gradient around host roots could be abolished with buffers and this treatment did not affect the extent or pattern of zoospore accumulation. Therefore, detection of root-generated pH gradients is unlikely to have a major role in the homing response of zoospores towards plant roots.

Dehydroepiandrosterone-induced peroxisome proliferation in the rat: evaluation of sex differences

Dehydroepiandrosterone (DHEA) is a newly identified peroxisome proliferator that causes hepatomegaly, peroxisome proliferation, and induction of peroxisome-associated enzymes in rats and mice, and hepatocellular carcinomas in rats. In the present study, we have systematically analyzed sex differences and the effect of castration on DHEA-induced peroxisome proliferation in male and female rats, since no information is available on this subject. DHEA was fed in diet at a concentration of 0.45% for 2 weeks and livers were analyzed for hepatomegaly, peroxisome volume density, peroxisome proliferator associated Mr 80,000 polypeptide (PPA-80), and enoyl-CoA hydratase/3-hydroxyacyl-CoA dehydrogenase (PBE) mRNA. Both intact and castrated rats showed similar response to DHEA characterized by increased peroxisome volume density, PBE mRNA, and PPA-80. Significant difference was observed in the liver weights between castrated and intact animals in both the sexes. Castrated rats that received DHEA had 20%-30% more liver weight than DHEA-administered intact rats. These results clearly indicate that peroxisome proliferative effect of DHEA is not influenced by sex hormones and it is equally potent in both males and females.

Localised pulmonary resection for bronchiectasis in hypogammaglobulinaemic patients

BACKGROUND

Bronchiectasis and pulmonary infections are common in patients with hypogammaglobulinaemia. Despite intravenous gammaglobulin treatment and appropriate antibiotics, a subgroup of patients remains with persistent localised pulmonary infection in segments where bronchiectasis had developed before appropriate treatment. As such localised pulmonary suppuration (segmental or lobar) may serve as a focus for progression of bronchiectasis, surgical resection of the involved segments may be considered. The outcome of pulmonary resection in four such patients is reported.

RESULTS

Surgery was well tolerated except for one postoperative empyema. Information on follow up is available from 3.5 to 5 years. All patients experienced considerable reduction of symptoms including cough, sputum production, antibiotic use, and hospital admissions.

CONCLUSIONS

Surgical resection of localised bronchiectatic segments should be considered in patients with hypogammaglobulinaemia with persistent localised suppuration and symptoms refractory to medical treatment.

Release of vasoactive intestinal peptide and neuropeptide Y from canine heart

The effects of right cervical vagal and left sympathetic stimulation on release of immunoreactive vasoactive intestinal peptide (VIP) and neuropeptide Y (NPY) into cardiac venous and lymphatic effluent was tested in 11 anesthetized adult mongrel dogs. After stimulation of the right cervical vagus (1 ms, 20 Hz, 5 V) for 3 min, VIP output in lymphatic effluent was significantly increased at 1.90 +/- 0.56 pg/min compared with control of 0.90 +/- 0.42 pg/min. NPY output in lymphatic effluent and VIP and NPY release into coronary venous effluent, as measured by the arterial-coronary sinus concentration difference, were not changed. After stimulation of the ansae of the left sympathetic ganglion (1 ms, 10 Hz, 5 V) for 3 min, NPY output in lymphatic effluent was significantly increased at 4.72 +/- 1.58 pg/min compared with a control of 0.73 +/- 0.66 pg/min. VIP output in lymphatic effluent was not changed. VIP arterial-coronary sinus concentration difference decreased slightly but significantly, and NPY arterial-coronary sinus concentration difference decreased markedly after left sympathetic stimulation. In three additional dogs in which coronary sinus blood flow was measured, NPY overflow during left sympathetic stimulation increased from 28.2 +/- 23.5 to 129.6 +/- 212.7 pg/min. Thus VIP and NPY release from the canine heart can be evoked by right cervical vagal and left sympathetic stimulation, respectively. VIP and NPY may play a role as cardiac noncholinergic-nonadrenergic neurotransmitters.

'But we're doing it already!' Exploring a response to the concept of reflective practice in order to improve its facilitation

The paper uses the stimulus of a personal reflection to explore how the concept of reflective practice can be facilitated. The thoughts on facilitation combine the use of recognised knowledge, experience and reflection to offer a way of reducing the risk of rejection of reflective practice. In setting the context for such an exploration, reflective practice is defined and its potential contribution to nursing considered.

VIP and NPY in canine hearts. Distribution and effect of total and selective parasympathetic denervation

The hypotheses that vasoactive intestinal peptide (VIP) is evenly distributed throughout atrial and ventricular myocardium and is present in postganglionic parasympathetic neurons in the regions of the sinoatrial and atrioventricular nodes were tested in three groups of dogs. Neuropeptide Y (NPY) tissue concentrations were determined in each group. In six sham dogs VIP and NPY concentrations were evenly distributed and were higher in atria compared with ventricles. In nine parasympathectomized dogs, VIP concentrations in sample sites from regions of the sinoatrial and atrioventricular nodes were comparable to those in sham-operated controls. In nine denervated dogs VIP concentrations were significantly decreased in three adjacent sample sites along the atrioventricular groove. In these dogs NPY concentrations were not detectable or were significantly decreased at all sample sites of both atria and ventricles. These data suggest that VIP neurons are evenly distributed in atrial and ventricular myocardium but do not originate in parasympathetic ganglia supplying the sinoatrial and atrioventricular nodes. The data also demonstrate the possible presence of extrinsic VIP neurons in the canine right ventricle and indicate that NPY may be a useful marker of myocardial adrenergic innervation.

Implementing managed care and case management: the neuroscience experience

The case management model for patient care in the neuroscience area was recently implemented in the neurosciences area at a tertiary care hospital. Understanding of the concepts of case management and managed care were essential to the implementation process. Clustering of case types and appointment of group leaders made the development of individual care maps a manageable task. Case management of 2 case types, Parkinson's disease and Guillain Barré syndrome are described, including the rationale for selection, care map development and education. The process of continuing education focused on operational issues regarding utilization of the map and professional issues such as health teaching responsibilities.

Diabetic gastroparesis due to postprandial antral hypomotility in childhood

Nausea, vomiting, chronic abdominal pain, and constipation developed in three children with insulin-dependent diabetes mellitus beginning 1 to 7 years after the onset of diabetes. All three had considerable difficulty in achieving satisfactory glycemic control. All had delayed gastric emptying of solids and postprandial antral hypomotility. Diabetic autonomic neuropathy must be considered in the differential diagnosis of gastrointestinal symptoms even in the young diabetic patient.