Does HIPE data capture the complexity of stroke patients in an acute hospital setting?

The Hospital Inpatient Enquiry (HIPE) system is currently used as a principle source of national data on discharges from acute hospitals. The Casemix Programme is used to calculate funding for patient care (HIPE activity and Specialty Costs Returns). Th coding is usually undertaken by clerical personnel. We were concerned that the medical complexity of our stroke patients was not captured by the process. The aims of this study were to compare activity coded by HIPE coding staff and medical staff in consecutive stroke patients discharged from the hospital. One hundred consecutive discharged patients with stroke as primary diagnosis were coded by clerical staff [usual practice] and by medical staff. We compared the coding and any differences. We calculated the financial comparison of subsequent differences in Diagnostic Related Groups (DRGs) and Relative Values (RVs). Clinician coded DRGs resulted in a higher assigned RV in 45 cases. The total RV value for HIPE using clerical coding was 595,268.94 euros and using medical coding was 725,252.16 euros. We conclude that medical input is useful in detailing the complications arising in stroke patients. We suggest that physicians should assist in the HIPE coding process in order to capture clinical complexity, so that funding can be appropriately assigned to manage these complex patients.

The effect of coil phenotypes and genotypes on the fecundity and viability of Partula suturalis and Lymnaea stagnalis: implications for the evolution of sinistral snails

Why are sinistral snails so rare? Two main hypotheses are that selection acts against the establishment of new coiling morphs, because dextral and sinistral snails have trouble mating, or else a developmental constraint prevents the establishment of sinistrals. We therefore used an isolate of the snail Lymnaea stagnalis, in which sinistrals are rare, and populations of Partula suturalis, in which sinistrals are common, as well as a mathematical model, to understand the circumstances by which new morphs evolve. The main finding is that the sinistral genotype is associated with reduced egg viability in L. stagnalis, but in P. suturalis individuals of sinistral and dextral genotype appear equally fecund, implying a lack of a constraint. As positive frequency-dependent selection against the rare chiral morph in P. suturalis also operates over a narrow range (< 3%), the results suggest a model for chiral evolution in snails in which weak positive frequency-dependent selection may be overcome by a negative frequency-dependent selection, such as reproductive character displacement. In snails, there is not always a developmental constraint. As the direction of cleavage, and thus the directional asymmetry of the entire body, does not generally vary in other Spiralia (annelids, echiurans, vestimentiferans, sipunculids and nemerteans), it remains an open question as to whether this is because of a constraint and/or because most taxa do not have a conspicuous external asymmetry (like a shell) upon which selection can act.

Rheumatology education for undergraduate nursing, physiotherapy and occupational therapy students in the UK: standards, challenges and solutions

OBJECTIVES

Rheumatological conditions are common, thus nurses (Ns) occupational therapists (OTs) and physiotherapists (PTs) require at least basic rheumatology knowledge upon qualifying. The aim of this study was to develop a core set of teaching topics and potential ways of delivering them.

METHODS

A modified Delphi technique was used for clinicians to develop preliminary core sets of teaching topics for each profession. Telephone interviews with educationalists explored their views on these, and challenges and solutions for delivering them. Inter-professional workshops enabled clinicians and educationalists to finalize the core set together, and generate methods for delivery.

RESULTS

Thirty-nine rheumatology clinicians (12N, 14OT, 13PT) completed the Delphi consensus, proposing three preliminary core sets (N71 items, OT29, PT26). Nineteen educationalists (6N, 7OT, 6PT) participated in telephone interviews, raising concerns about disease-specific vs generic teaching and proposing many methods for delivery. Three inter-professional workshops involved 34 participants (clinicians: N12, OT9, PT5; educationalists: N2, OT3, PT2; Patient 1) who reached consensus on a single core set comprising six teaching units: Anatomy and Physiology; Assessment; Management and Intervention; Psychosocial Issues; Patient Education; and the Multi-disciplinary Team, recommending some topics within the units receive greater depth for some professions. An innovative range of delivery options was generated plus two brief interventions: a Rheumatology Chat Show and a Rheumatology Road Show.

CONCLUSIONS

Working together, clinicians and educationalists proposed a realistic core set of rheumatology topics for undergraduate health professionals. They proposed innovative delivery methods, with collaboration between educationalists, clinicians and patients strongly recommended. These potential interventions need testing.

Effect of nitinol wire surface properties on albumin adsorption

The superelastic, shape memory alloy nitinol ( approximately 50% nickel and approximately 50% titanium) is an important medical device material used for stent applications. However, the role specific surfaces properties have in protein adsorption remain controversial. In this study the effects of nitinol wire surface roughness, hydrophobicity and elemental composition upon albumin adsorption are investigated. In particular, we demonstrate that the technique of matrix-assisted laser desorption/ionization time-of-flight mass spectrometry in the so-called surface mode can be used for the direct detection of albumin on the wire surfaces. In addition, albumin adsorbing to the wires was determined by using (125)I-labelled albumin. Albumin was detected on all wire samples. Surface roughness and hydrophobicity appeared to have no effect on albumin adsorption. There was however a clear correlation between the surface nickel and oxygen concentration and the amount of albumin adsorbed. Samples with higher levels of nickel and less oxygen in the surface oxide layer of the wires showed increased albumin adsorption, which could lead to improved biocompatibility. However, nickel is a toxic substance and can cause many adverse effects on humans, and thus nitinol with a slightly enriched surface nickel concentration that does not exhibit nickel release may have potential as a medical device material.

Is undergraduate otorhinolaryngology teaching relevant to junior doctors working in accident and emergency departments?

Undergraduate ENT teaching provides junior doctors with skills and knowledge useful for the practice of medicine. However, ENT has been removed from the curriculum of nine of the 29 medical schools in the United Kingdom, as it was not deemed relevant to general medical practice. A telephone survey was performed of 20 senior house officers working in accident and emergency (A&E) departments across the United Kingdom. The results showed that 90 per cent felt their undergraduate ENT teaching was directly beneficial to working in A&E, 75 per cent felt they had not received enough undergraduate ENT teaching and 45 per cent currently received no postgraduate teaching whilst working in A&E. These results illustrate the importance of ENT teaching in the undergraduate curriculum and its value to practising doctors. They highlight the fact that prospective studies are required to examine the effect on junior doctors of changing the curriculum.

Current provision of rheumatology education for undergraduate nursing, occupational therapy and physiotherapy students in the UK

OBJECTIVES

Rheumatological conditions are common and all health professionals (HPs) therefore need sufficient knowledge and skills to manage patients safely and effectively. The aim of this study was to examine current undergraduate education in rheumatology for HPs in the UK.

METHODS

A questionnaire was sent to curriculum organizers and clinical placement officers for all undergraduate courses in adult nursing, occupational therapy (OT) and physiotherapy (PT) in the UK to ascertain the nature and amount of rheumatology theory and clinical exposure provided.

RESULTS

Of the 47 adult nursing, 26 OT and 30 PT undergraduate courses surveyed, 85-90% responded. Overall, rheumatology teaching is 5-10 h over 3 yr. Nursing students receive moderate/in-depth teaching on rheumatoid arthritis (RA) in only 52% of courses (OT 91%, PT 96%) and on osteoarthritis (OA) in 63% (OT 91%, PT 92%). Clinical experience of RA is probably/definitely available in only 56% of nursing courses (OT 72%, PT 88%), with similar results in OA. Overall, nursing students receive the least rheumatology exposure, particularly in psychosocial issues and symptom management, while PT students receive the most. OT students have limited opportunities for clinical exposure to psychosocial and joint protection issues. Use of local rheumatology clinical HP experts is variable (18-93%) and cross-disciplinary exposure is limited (0-36%). Many educators consider their rheumatology training to be insufficient (nursing 50%, PT 42%, OT 24%).

CONCLUSIONS

Rheumatology training for undergraduate HPs is limited in key areas and often fails to take advantage of local clinical expertise, with nursing students particularly restricted. Clinical HP experts should consider novel methods of addressing these shortfalls within the limited curriculum time available.

Potentially toxic element release by fenton oxidation of sewage sludge

The presence, in sewage sludge, of excess levels of the potentially toxic elements (PTE) copper, zinc, chromium, cadmium, nickel, lead and mercury, could impact on our ability to recycle these residues in the future. Far stricter limits on the levels of PTEs are likely in proposed legislation. A method involving the dosing of Fenton's reagent, a mixture of ferrous iron and hydrogen peroxide, under acidic conditions was evaluated for its potential to reduce metal levels. The [Fe]:[H2O2] (w/w) ratio was found to give a good indication of the percentage copper and zinc elution obtainable. Sites with no iron dosing as part of wastewater treatment required extra iron to be added in order to initiate the Fenton's reaction. A significant reduction, in excess of 70%, of the copper and zinc was eluted from both raw primary and activated sludge solid fractions. Cadmium and nickel could be reduced to below detection limits but elution of mercury, lead and chromium was less than 40%. The iron catalyst concentration was found to be a crucial parameter. This process has the potential to reduce the heavy metal content of the sludge and allow the recycling of sludge to continue in a sustainable manner.

Influence of Nitinol wire surface treatment on oxide thickness and composition and its subsequent effect on corrosion resistance and nickel ion release

Medical implants and devices are now used successfully in surgical procedures on a daily basis. Alloys of nickel and titanium, and in particular Nitinol are of special interest in the medical device industry, because of their shape memory and superelastic properties. The corrosion behavior of nitinol in the body is also of critical importance because of the known toxicological effects of nickel. The stability of a NiTi alloy in the physiological environment is dependant primarily on the properties of the mostly TiO(2) oxide layer that is present on the surface. For the present study, a range of nitinol wires have been prepared using different drawing processes and a range of surface preparation procedures. It is clear from the results obtained that the wire samples with very thick oxides also contain a high nickel content in the oxide layer. The untreated samples with the thicker oxides show the lowest pitting potential values and greater nickel release in both long and short-term experiments. It was also found that after long-term immersion tests breakdown potentials increased for samples that exhibited lower values initially. From these results it would appear that surface treatment is essential for the optimum bioperformance of nitinol.

Biometry of the pubovisceral muscle and levator hiatus by three-dimensional pelvic floor ultrasound

OBJECTIVE

Until recently, magnetic resonance was the only imaging method capable of assessing the levator ani in vivo. Three-dimensional (3D) ultrasound has recently been shown to be able to demonstrate the pubovisceral muscle. The aim of this study was to define the anatomy of the levator hiatus in young nulliparous women with the help of 3D ultrasound.

METHODS

In a prospective observational study, 52 nulligravid female Caucasian volunteers (aged 18-24 years) were assessed by two-dimensional (2D) and 3D translabial ultrasound after voiding whilst supine. Pelvic organ descent was assessed on Valsalva maneuver. Volumes were acquired at rest and on Valsalva maneuver, and biometric indices of the pubovisceral muscle and levator hiatus were determined in the axial and coronal planes.

RESULTS

In the axial plane, average diameters of the pubovisceral muscle were 0.4-1.1 cm (mean 0.73 cm). Average area measurements were 7.59 (range, 3.96-11.9) cm2. The levator hiatus at rest varied from 3.26 to 5.84 (mean 4.5) cm in the sagittal direction, and from 2.76 to 4.8 (mean 3.75) cm in the coronal plane. The hiatus area at rest ranged from 6.34 to 18.06 (mean 11.25) cm2 increasing to 14.05 (6.67-35.01) cm(2) on Valsalva maneuver (P = 0.009). There were significant correlations between pelvic organ mobility and hiatus area at rest (P = 0.018 to P < 0.001) and on Valsalva maneuver (all P < 0.001).

CONCLUSIONS

Biometric indices of the pubovisceral muscle and levator hiatus can be determined by 3D ultrasound. Significant correlations exist between hiatal area and pelvic organ descent. These data provide support for the hypothesis that levator ani anatomy plays an independent role in determining pelvic organ support.

Bladder neck mobility is a heritable trait

OBJECTIVE

Congenital connective tissue dysfunction may partly be responsible for female pelvic organ prolapse and urinary incontinence. We undertook a heritability study to determine whether mobility of the bladder neck, one of the main determinants of stress urinary incontinence, is genetically influenced.

DESIGN

Heritability study using a twin model and structural equation modelling.

SETTING

Queensland Institute of Medical Research, Brisbane, Australia.

POPULATION

One hundred and seventy-eight nulliparous Caucasian female twins and their sisters (46 monozygotic pairs, 24 dizygotic pairs and 38 sisters) aged 18-24 years.

METHODS

We performed translabial ultrasound, supine and after bladder emptying, for pelvic organ mobility. Urethral rotation and bladder neck descent were calculated using the best of three effective Valsalva manoeuvres.

MAIN OUTCOME MEASURES

Bladder and urethral mobility on Valsalva assessed by urethral rotation, vertical and oblique bladder neck descent.

RESULTS

Genetic modelling indicated that additive genes accounted for up to 59% of the variance for bladder neck descent. All remaining variance appeared due to environmental influences unique to the individual, including measurement error.

CONCLUSION

A significant genetic contribution to the phenotype of bladder neck mobility appears likely.

Pelvic organ descent in young nulligravid women

OBJECTIVE

There is little information available on what constitutes "normal" pelvic organ mobility. This study presents normal values for urethral, bladder, cervical, and rectal descent on Valsalva.

STUDY DESIGN

One hundred eighteen nulligravid white women aged 18 to 24 years were recruited for a prospective observational study. Translabial ultrasound was undertaken supine and after voiding, with the most effective of at least 3 Valsalva maneuvers used for evaluation.

RESULTS

Urethral rotation on Valsalva varied from 0 to +90 degrees (mean 32 degrees), bladder neck descent from 1.2 to 40.2 mm (mean 17.4 mm). The cervix descended to between 59 and 0 mm above the symphysis pubis (mean 30.8 mm); the rectal ampulla descended to between 54 mm above and 22 mm below the symphyseal margin (mean 7.8 mm). In a test-retest series, intraclass correlations were between 0.64 and 0.89, implying good-to-excellent repeatability of the ultrasound assessment.

CONCLUSION

A wide range of values was obtained for all parameters. A significant congenital contribution to the phenotype of female pelvic organ prolapse appears likely.

A multi-centre randomised controlled trial of minimally invasive direct coronary bypass grafting versus percutaneous transluminal coronary angioplasty with stenting for proximal stenosis of the left anterior descending coronary artery

OBJECTIVES

To compare the clinical- and cost-effectiveness of minimally invasive direct coronary artery bypass grafting (MIDCAB) and percutaneous transluminal coronary angioplasty (PTCA) with or without stenting in patients with single-vessel disease of the left anterior descending coronary artery (LAD).

DESIGN

Multi-centre randomised trial without blinding. The computer-generated sequence of randomised assignments was stratified by centre, allocated participants in blocks and was concealed using a centralised telephone facility.

SETTING

Four tertiary cardiothoracic surgery centres in England.

PARTICIPANTS

Patients with ischaemic heart disease with at least 50% proximal stenosis of the LAD, suitable for either PTCA or MIDCAB, and with no significant disease in another vessel.

INTERVENTIONS

Patients randomised to PTCA had local anaesthetic and underwent PTCA according to the method preferred by the operator carrying out the procedure. Patients randomised to MIDCAB had general anaesthetic. The chest was opened through an 8-10-cm left anterior thoracotomy. The ribs were retracted and the left internal thoracic artery (LITA) harvested. The pericardium was opened in the line of the LAD to confirm the feasibility of operation. The distal LITA was anastomosed end-to-side to an arteriotomy in the LAD. All operators were experienced in carrying out MIDCAB.

MAIN OUTCOME MEASURES

The primary outcome measure was survival free from cardiac-related events. Relevant events were death, myocardial infarction, repeat coronary revascularisation and recurrence of symptomatic angina or clinical signs of ischaemia during an exercise tolerance test at annual follow-up. Secondary outcome measures were complications, functional outcome, disease-specific and generic quality of life, health and social services resource use and their costs.

RESULTS

A total of 12,828 consecutive patients undergoing an angiogram were logged at participating centres from November 1999 to December 2001. Of the 1091 patients with proximal stenosis of the LAD, 127 were eligible and consented to take part; 100 were randomised and the remaining 27 consented to follow-up. All randomised participants were included in an intention-to-treat analysis of survival free from cardiac-related events, which found a non-significant benefit from MIDCAB. Cumulative hazard rates at 12 months were estimated to be 7.1 and 9.2% for MIDCAB and PTCA, respectively. There were no important differences between MIDCAB and PTCA with respect to angina symptoms or disease-specific or generic quality of life. The total NHS procedure costs were 1648 British pounds and 946 British pounds for MIDCAB and PTCA, respectively. The costs of resources used during 1 year of follow-up were 1033 British pounds and 843 British pounds, respectively.

CONCLUSIONS

The study found no evidence that MIDCAB was more effective than PTCA. The procedure costs of MIDCAB were observed to be considerably higher than those of PTCA. Given these findings, it is unlikely that MIDCAB represents a cost-effective use of resources in the reference population. Recent advances in cardiac surgery mean that surgeons now tend to carry out off-pump bypass grafting via a sternotomy instead of MIDCAB. At the same time, cardiologists are treating more patients with multi-vessel disease by PTCA. Future primary research should focus on this comparison. Other small trials of PTCA versus MIDCAB have now finished and a more conclusive answer to the original objective could be provided by a systematic review.