Clinical teaching in emergency medicine: the board round at Hope Hospital emergency department

This article discusses the educational value of the "board round", a clinical teaching forum introduced at Hope Hospital, Manchester, UK. At midday on weekdays all available consultants and middle grade doctors, and any other staff who can attend, meet to discuss a case selected from the patients currently in the department. As several experienced clinicians are available to discuss a clinical problem, the round allows a broad debate during which the merits of several management options are discussed. In addition, attending a board round addresses in part the concerns which senior clinicians may have about the balance of service delivery and protected teaching time. The paper describes several other advantages of this method of teaching, which has been adopted by other hospitals in the region.

The GRAIDS Trial: a cluster randomised controlled trial of computer decision support for the management of familial cancer risk in primary care

The objective was to evaluate the effect of an assessment strategy using the computer decision support system (the GRAIDS software), on the management of familial cancer risk in British general practice in comparison with best current practice. The design included cluster randomised controlled trial, and involved forty-five general practice teams in East Anglia, UK. Randomised to GRAIDS (Genetic Risk Assessment on the Internet with Decision Support) support (intervention n=23) or comparison (n=22). Training in the new assessment strategy and access to the GRAIDS software (GRAIDS arm) was conducted, compared with an educational session and guidelines about managing familial breast and colorectal cancer risk (comparison) were mailed. Outcomes were measured at practice, practitioner and patient levels. The primary outcome measure, at practice level, was the proportion of referrals made to the Regional Genetics Clinic for familial breast or colorectal cancer that were consistent with referral guidelines. Other measures included practitioner confidence in managing familial cancer (GRAIDS arm only) and, in patients: cancer worry, risk perception and knowledge about familial cancer. There were more referrals to the Regional Genetics Clinic from GRAIDS than comparison practices (mean 6.2 and 3.2 referrals per 10 000 registered patients per year; mean difference 3.0 referrals; 95% confidence interval (CI) 1.2–4.8; P=0.001); referrals from GRAIDS practices were more likely to be consistent with referral guidelines (odds ratio (OR)=5.2; 95% CI 1.7–15.8, P=0.006). Patients referred from GRAIDS practices had lower cancer worry scores at the point of referral (mean difference −1.44 95% CI −2.64 to −0.23, P=0.02). There were no differences in patient knowledge about familial cancer. The intervention increased GPs' confidence in managing familial cancer. Compared with education and mailed guidelines, assessment including computer decision support increased the number and quality of referrals to the Regional Genetics Clinic for familial cancer risk, improved practitioner confidence and had no adverse psychological effects in patients. Trials are registered under N0181144343 in the UK National Research Register.

Treatment monitoring and thermometry for therapeutic focused ultrasound

Therapeutic ultrasound is currently enjoying increasingly widespread clinical use especially for the treatment of cancer of the prostate, liver, kidney, breast, pancreas and bone, as well as for the treatment of uterine fibroids. The optimum method of treatment delivery varies between anatomical sites, but in all cases monitoring of the treatment is crucial if extensive clinical acceptance is to be achieved. Monitoring not only provides the operating clinician with information relating to the effectiveness of treatment, but can also provide an early alert to the onset of adverse effects in normal tissue. This paper reviews invasive and non-invasive monitoring methods that have been applied to assess the extent of treatment during the delivery of therapeutic ultrasound in the laboratory and clinic (follow-up after treatment is not reviewed in detail). The monitoring of temperature and, importantly, the way in which this measurement can be used to estimate the delivered thermal dose, is dealt with as a separate special case. Already therapeutic ultrasound has reached a stage of development where it is possible to attempt real-time feedback during exposure in order to optimize each and every delivery of ultrasound energy. To date, data from MR imaging have shown better agreement with the size of regions of damage than those from diagnostic ultrasound, but novel ultrasonic techniques may redress this balance. Whilst MR currently offers the best method for non-invasive temperature measurement, the ultrasound techniques under development, which could potentially offer more rapid visualisation of results, are discussed.

Physical activity, insulin-like growth factor 1, insulin-like growth factor binding protein 3, and survival from colorectal cancer

BACKGROUND

Recent reports have shown that physical activity improves the outcome of patients with colorectal cancer as well as breast and prostate cancer. However, the mechanisms whereby physical activity reduces cancer mortality are not well established.

METHODS

Incident cases of colorectal cancer were identified among participants of the Melbourne Collaborative Cohort Study, a prospective cohort study of 41,528 Australians recruited from 1990 to 1994. Information on tumour site and stage, treatments given, recurrences, and deaths were obtained from systematic review of the medical records. Baseline assessments of physical activity and body size were made, and cases with available plasma had pre-diagnosis insulin-like growth factor 1 (IGF-1) and insulin-like growth factor binding protein 3 (IGFBP-3) levels measured. We assessed associations between these hormones and colorectal cancer specific deaths with respect to physical activity.

RESULTS

A total of 526 cases of colorectal cancer were identified, of which 443 had IGF-1/IGFBP-3 levels measured. Median follow up among survivors was 5.6 years. For the physically active, increasing IGFBP-3 by 26.2 nmol/l was associated with a 48% reduction in colorectal cancer specific deaths (adjusted hazard ratio (HR) 0.52 (0.33-0.83); p = 0.006). No association was seen for IGF-1 (adjusted HR 0.90 (0.55-1.45); p = 0.65). For the physically inactive, neither IGF-1 nor IGFBP-3 was associated with disease specific survival.

CONCLUSIONS

This study supports the hypothesis that the beneficial effects of physical activity in reducing colorectal cancer mortality may occur through interactions with the insulin-like growth factor axis and in particular IGFBP-3.

Young onset limb spasticity with PSP-like brain and spinal cord NFT-tau pathology

A 30-year-old white man presented with a sporadic form of gradually progressive spastic gait and, later, supranuclear vertical and horizontal gaze palsy, mild cognitive impairment, loss of postural reflexes, and falls. DNA analysis revealed H1/H1 haplotype without tau gene (exons 9 to 13) mutation. Eight years later, postmortem revealed a tauopathy similar to progressive supranuclear palsy. Unusual aspects were early age at onset, neurofibrillary tangle, and tau involvement of the cord.

Metals, toxicity and oxidative stress

Metal-induced toxicity and carcinogenicity, with an emphasis on the generation and role of reactive oxygen and nitrogen species, is reviewed. Metal-mediated formation of free radicals causes various modifications to DNA bases, enhanced lipid peroxidation, and altered calcium and sulfhydryl homeostasis. Lipid peroxides, formed by the attack of radicals on polyunsaturated fatty acid residues of phospholipids, can further react with redox metals finally producing mutagenic and carcinogenic malondialdehyde, 4-hydroxynonenal and other exocyclic DNA adducts (etheno and/or propano adducts). Whilst iron (Fe), copper (Cu), chromium (Cr), vanadium (V) and cobalt (Co) undergo redox-cycling reactions, for a second group of metals, mercury (Hg), cadmium (Cd) and nickel (Ni), the primary route for their toxicity is depletion of glutathione and bonding to sulfhydryl groups of proteins. Arsenic (As) is thought to bind directly to critical thiols, however, other mechanisms, involving formation of hydrogen peroxide under physiological conditions, have been proposed. The unifying factor in determining toxicity and carcinogenicity for all these metals is the generation of reactive oxygen and nitrogen species. Common mechanisms involving the Fenton reaction, generation of the superoxide radical and the hydroxyl radical appear to be involved for iron, copper, chromium, vanadium and cobalt primarily associated with mitochondria, microsomes and peroxisomes. However, a recent discovery that the upper limit of "free pools" of copper is far less than a single atom per cell casts serious doubt on the in vivo role of copper in Fenton-like generation of free radicals. Nitric oxide (NO) seems to be involved in arsenite-induced DNA damage and pyrimidine excision inhibition. Various studies have confirmed that metals activate signalling pathways and the carcinogenic effect of metals has been related to activation of mainly redox-sensitive transcription factors, involving NF-kappaB, AP-1 and p53. Antioxidants (both enzymatic and non-enzymatic) provide protection against deleterious metal-mediated free radical attacks. Vitamin E and melatonin can prevent the majority of metal-mediated (iron, copper, cadmium) damage both in vitro systems and in metal-loaded animals. Toxicity studies involving chromium have shown that the protective effect of vitamin E against lipid peroxidation may be associated rather with the level of non-enzymatic antioxidants than the activity of enzymatic antioxidants. However, a very recent epidemiological study has shown that a daily intake of vitamin E of more than 400 IU increases the risk of death and should be avoided. While previous studies have proposed a deleterious pro-oxidant effect of vitamin C (ascorbate) in the presence of iron (or copper), recent results have shown that even in the presence of redox-active iron (or copper) and hydrogen peroxide, ascorbate acts as an antioxidant that prevents lipid peroxidation and does not promote protein oxidation in humans in vitro. Experimental results have also shown a link between vanadium and oxidative stress in the etiology of diabetes. The impact of zinc (Zn) on the immune system, the ability of zinc to act as an antioxidant in order to reduce oxidative stress and the neuroprotective and neurodegenerative role of zinc (and copper) in the etiology of Alzheimer's disease is also discussed. This review summarizes recent findings in the metal-induced formation of free radicals and the role of oxidative stress in the carcinogenicity and toxicity of metals.

Phonetic, phonological, and language skills of children with a cleft palate

OBJECTIVE

To evaluate the language, phonetic, and phonological skills at age 3 years of two groups of young children with a cleft palate, with different expressive language proficiency at 2 years of age.

DESIGN

Two groups of children with a cleft palate with differing abilities in early expressive language skills were identified at age 2 years. Comparisons across groups were made over a range of speech and language measures at age 3 years.

PARTICIPANTS

Twenty children with cleft palate were allocated to two groups dependent on expressive language abilities at age 2 years. One group had normal language development, and the second group had been identified as having significantly delayed (8 to 12 months' delay) expressive language development.

MAIN OUTCOME MEASURES

The children were assessed at 3 years of age using standardized assessments and spontaneous speech samples. Comparisons between the two groups were made on a range of language measures including comprehension, expressive language, and speech.

RESULTS

Group differences were found on both language and speech abilities at age 3 years. Significant group differences were found in expressive language, percentage of consonants correct, phonetic inventory, and phonological process usage. The group with delayed early expressive language abilities at 2 years continued to have expressive language difficulties at 3 years of age and had more disordered speech development, compared with the nondelayed group.

CONCLUSIONS

A subgroup of children with a cleft palate was identified who exhibited delays in early expressive language and continued to have delayed language and disordered phonological patterns at a later age. Support for three possible etiologies including a structural/anatomical deficit, cognitive/linguistic delay, or language/phonological disorder are discussed.

A little nightclub medicine: the healthcare implications of clubbing

OBJECTIVE

To describe the scale and range of acute medical problems among patients who present to an inner city accident and emergency (A&E) department after attending nightclubs in Liverpool.

METHODS

From April 1997 to April 1998, all patients identified as having attended a nightclub before their arrival at the department were included in the study. Information regarding their attendance was gathered retrospectively using a standard proforma.

SETTING

A large, city centre, teaching hospital A&E department with an annual new patient attendance rate of over 95,000.

RESULT

777 such patients were enrolled in the study (0.81% of all new attendances during the same period). This was probably an underestimate, as some eligible patients were not identified during the study. Predictably, most presentations were at the weekend between midnight and 08.00. Surprisingly, the commonest mode of transport to the hospital was an ambulance (38%, 298 of the total). Assault accounted for most presentations (57%, 443 of the total) and lacerations were the commonest injury (the face being most frequently affected). Alcohol was the commonest intoxicant overtly associated with the A&E department attendance.

CONCLUSIONS

Injury after assault is the commonest precipitant of hospital care among clubbers in Liverpool. Alcohol is the most important contributory factor, although illegal drug misuse is a considerable challenge in the clubs themselves. A number of measures such as (a) the introduction of unbreakable glass or plastic containers; (b) the elimination of glass from outside clubs; (c) the provision of high quality immediate medical care at larger venues; (d) the curbing of over crowding and cheap drinks promotions; (e) registration of doormen, and (f) targeted policing of the areas around nightclubs are urgently required to reduce the healthcare (and civic) burden of clubbing. The cost for these should be borne by the highly profitable clubbing and brewing industries. A national code of practice for clubs-already in existence voluntarily-should be made mandatory.

Neuropathologic variation in frontotemporal dementia due to the intronic tau 10(+16) mutation

BACKGROUND

An increasing number of recently described tau mutations show considerable clinical heterogeneity. The assessment of this phenotypic variation is of vital importance in the differential diagnosis of neurodegenerative diseases.

OBJECTIVE

To assess the neuropathologic heterogeneity in a comprehensive study of 12 brains with a tau mutation at exon 10(+16) (C-to-T) splice site from 9 families.

METHODS

A comprehensive neuropathologic examination has been carried out, using a wide range of tau antibodies.

RESULTS

All brains showed frontotemporal atrophy of varying severity and pallor of the pigmented nuclei of the brainstem. The histologic changes were more extensive to include other cortical areas, the deep gray matter, and the white matter. The hallmark histologic lesions were the tau-positive neuronal and glial inclusions. In neurons, these ranged from typical neurofibrillary tangles through well-circumscribed inclusions to diffuse cytoplasmic staining. This tau pathology was complemented by the presence of large, abnormal achromatic neurons, neuronal loss, astrocytosis, and superficial status spongiosus.

CONCLUSION

The distribution, type, and severity of these histologic abnormalities varied not only from case to case but also within the same brain. These brains with a common tau mutation raise important differential diagnostic problems: cases in the past might have been misdiagnosed as corticobasal degeneration or even atypical Pick disease, disorders with similar, if not identical, phenotypic manifestations.

Effect of exogenous cholecystokinin (CCK)-8 on food intake and plasma CCK, leptin, and insulin concentrations in older and young adults: evidence for increased CCK activity as a cause of the anorexia of aging

Healthy aging is associated with reductions in appetite and food intake--the so-called anorexia of aging, which may predispose to protein-energy malnutrition. One possible cause of the anorexia of aging is an increased satiating effect of cholecystokinin (CCK). To investigate the impact of aging on the satiating effects of CCK, 12 young and 12 older healthy subjects received 25-min iv infusions of saline (control) and CCK-8, 1 ng/kg per min or 3 ng/k per min, on 3 separate days before a test meal. Older subjects ate less than young subjects, and food intake was suppressed 21.6% by CCK-8, compared with the control day (P < 0.05). The suppression of energy intake by CCK-8 in older subjects was twice that in young subjects (32 +/- 6% vs. 16 +/- 6% SEM, P < 0.05) and was related to plasma CCK-8 concentrations, which were higher at baseline (P < 0.05) and increased more during CCK-8 infusions in older than young subjects (P < 0.01). The extent of suppression of food intake per given rise in plasma CCK-8 concentrations did not differ between the two age groups (P = 0.35). Endogenous CCK concentrations were higher at baseline in older subjects (P < 0.001) and decreased during the CCK-8 but not control infusions (P < 0.01), suggesting that CCK suppresses its own release. Plasma leptin concentrations were not affected by CCK infusion, whereas postprandial insulin concentrations were lowered and the peak postprandial glucose concentration was delayed but not affected by CCK-8 infusion. Because older people retain their sensitivity to the satiating effects of exogenous CCK and plasma endogenous CCK concentrations are higher in older people, increased CCK activity may contribute to the anorexia of aging.

Assessment of Fallopian tube patency by HyCoSy: comparison of a positive contrast agent with saline solution

OBJECTIVE

To compare the efficiency of air-filled albumin microspheres (Infoson) with saline solution in determining Fallopian tube patency during hysterosalpingo contrast sonography (HyCoSy).

METHODS

This was a prospective randomized multicenter study with a sequential design. Over a 10-month period, 23 patients (mean age, 33 years) referred for infertility were examined by HyCoSy (saline or Infoson) before conventional hysterosalpingography (Iopamiron 370), performed during the same session. Contrast agents were administered through a 5-F Ackrad balloon catheter inserted transcervically into the uterine cavity. HyCoSy was performed with a 7-MHz transvaginal probe using both B-mode and color Doppler, and tubal patency was demonstrated by the appearance of contrast agent in the peritoneal cavity near the ovaries. Data were registered for each patient during the examination and the results were monitored by sequential analysis.

RESULTS

Mean volumes of contrast injections were 35.3 mL of saline, 14.4 mL of Infoson, and 13.8 mL of Iopamiron 370. Infoson-enhanced HyCoSy provided a significantly larger (P = 0.006) number of correct diagnoses (20/22 Fallopian tubes) than did saline HyCoSy (12/24 Fallopian tubes), and the same number as that achieved by hysterosalpingography.

CONCLUSION

A positive ultrasound contrast agent appears to be more efficient than saline solution at determining Fallopian tube patency in infertile women by means of HyCoSy, and as efficient as an iodinated contrast agent in the same population explored by HSG. HyCoSy could be used to screen infertile women, thereby avoiding the use of iodinated contrast medium and exposure to ionizing radiation during conventional HSG in patients with patent Fallopian tubes.

Oxygen free radical generating mechanisms in the colon: do the semiquinones of vitamin K play a role in the aetiology of colon cancer?

It is proposed that bile acids (deoxycholic acid), the K vitamins, iron(II) complexes and oxygen interact to induce an oncogenic effect in the colon by the generation of free radicals. In the relatively low oxidising/reducing conditions of the colonic lumen the K vitamins exist in the reduced form; however, if absorbed into the mucosa they have the capacity to be chemically oxidised and to enter into a redox cycle yielding oxygen radicals. The semiquinone radical of K(1) (phylloquinone) has been stabilised in bile acid mixed micelles and investigated by electron paramagnetic resonance spectroscopy and quantum chemical calculations. The estimated half-life of the radical was about 30 min which confirms a remarkably high stability in aqueous micellar solution. A model is presented in which the reduced K vitamins may initiate superoxide radical, O2(-*) generation leading to Fe(II) mediated Fenton reactions in the stem colon cells.

No pathogenic mutations in the synphilin-1 gene in Parkinson's disease

alpha-Synuclein is mutated in rare autosomal dominant forms of Parkinson's disease and is a major component of Lewy bodies and neurites. Synphilin-1, a novel protein interacts in vivo and co-localises with alpha-synuclein in Lewy bodies. We analysed the synphilin-1 gene in familial Parkinson's disease by single-strand conformation polymorphism (SSCP) and automated sequencing but found no coding mutations. However, we identified two novel intronic polymorphisms; an A/T polymorphism in intron 2, resulting in the introduction of an Alu1 site and a second G/T polymorphism in intron 4. We analysed the intron 2 polymorphism for allelic association as it was conducive to rapid screening but observed no changes in frequency between Parkinson's disease cases and controls.