Clinical governance and palliative care: a question of synergy

The term clinical governance, coined in 1998 and referred to in the document A First Class Service: Quality in the New NHS (Department of Health (DoH), 1998), is now central to current healthcare policy (DoH, 1999). However, the concept of clinical governance predates 1998 in that the notion of continuous quality improvement is not new in healthcare delivery. This article addresses four key areas in relation to clinical governance: the meaning of cl inical governance; participants; the process; and the implications for palliative care.

Sex differences in renal transplantation in Canada

To determine if a patient's sex influences access to renal transplantation in Canada, transplant recipient data for first cadaveric unrelated renal transplants were obtained from the Canadian Organ Replacement Register (CORR) for the period 1985-1992. There were 4683 first unrelated cadaveric transplant recipients during this time. Differences in the proportion of men and women registered with CORR who received a renal transplant were analyzed. In Canada between 1985 and 1992, 25% of males 40 years and older on dialysis received renal transplants compared with 18% of females (p < 0.0001, RR 1.54, 95% CI 1.40-1.67). There was no difference in the rates of transplants in males and females who were under 40 years of age. Adjusting for panel-reactive antibody data did not change the significance of the difference in transplant rates between the sexes. In Canada from 1985 to 1992, male patients with end-stage renal disease received proportionately more transplants than females.

Reduced gastric mucosal vascularity in patients with chronic gastritis

OBJECTIVES/DESIGN

Chronic inflammation is increasingly being linked to ischaemia, but the mechanism is poorly understood, and little is known about its effect on local gastric endothelial microvessels. We aimed at studying the number and surface area of gastric mucosal endothelial microstructures in the presence or absence of chronic gastritis.

METHODS

Immunohistochemical assessments were carried out on gastric antral and body biopsies taken from patients with chronic gastritis and others with normal histology. The primary antibody (QB-END/10) was raised against CD34 antigen within the endothelial cell membranes. A computer attached to a microscope was used to count the number and measure the surface area of mucosal endothelial entities.

RESULTS

In patients with Helicobacter pylori gastritis (n = 19), the median number of endothelial microstructures per section was 43 in the antrum and 86 in the gastric body, compared with 205 (P = 0.00004) and 165 (P = 0.002), respectively, in subjects with normal gastric histology (n = 11). The median surface area of the endothelial microstructures was also reduced in patients with gastritis. The normal gastric antrum had more endothelial entities than the normal body (median of 205 vs 165; P = 0.007).

CONCLUSIONS

Within the normal stomach, the antrum is more richly vascularized than the gastric body. However, active chronic gastritis is associated with reduction in both the number and surface area of mucosal endothelial microstructures, with the reduction being more marked in the antrum. This is different from acute inflammation, and is relevant to our understanding of the natural history of mucosal defence, particularly the greater susceptibility of the gastric antrum to ulceration, compared with the gastric body.

Interleukins 4 and 13 upregulate expression of cd44 in human colonic epithelial cell lines

Interleukin 4 (IL-4) inhibits carcinoma cell growth and promotes expression of differentiation-associated products by normal and malignant epithelial cells. The effects of IL-4 and IL-13 on expression of the CD44 transmembrane adhesion receptor were examined in human epithelial cell lines of colonic (HT-29, CaCo-2, DLD-1, T84), breast (MCF-7, ZR75-1) and liver (Hep-G2, PLC/PRF/5) origins as well as mitogen-activated and resting peripheral blood lymphocytes (PBL) and T cell lines (Jurkat, HUT78). Liver and Jurkat cells were negative for CD44. Colonic, breast and HUT78 cells expressed CD44 constitutively and all except DLD-1 and HUT78 also expressed CD44 splice variant (CD44v) epitopes. All cell lines expressed IL-4 receptors, but IL-4 and IL-13 induced upregulation of CD44 only in the colonic cell lines. CD44v was also upregulated, but there was no de novo induction of CD44v in variant-negative cells and no de novo expression of CD44 in the CD44(-) lines. CD44 upregulation in mitogen-activated PBL was not increased by IL-4 and IL-13 and was not inhibited by neutralizing antibodies. Other cytokines tested [interferon gamma (IFN-gamma, tumour necrosis factor alpha (TNF-alpha), transforming growth factor beta1 (TGF-beta1) and IL-6] did not affect CD44 core epitope expression in the cell lines tested.

Myxoid malignant fibrous histiocytoma mimicking papular mucinosis

Malignant fibrous histiocytoma is the most common type of soft tissue sarcoma in late adulthood. The myxoid variant of malignant fibrous histiocytoma, also known as myxofibrosarcoma, can develop in subcutaneous rather than deep soft tissue, and the true extent of these superficial tumors is often underestimated. Patients with these low-grade myxoid malignant fibrous histiocytomas have an excellent 5-year survival rate, and it is therefore important to recognize them. We present a case with a superficial cutaneous accumulation of mucin that was diagnosed clinically and histologically as papular mucinosis. In retrospect, a subcutaneous presentation of myxofibrosarcoma should have been considered.

Screening for diabetic retinopathy by general practitioners: ophthalmoscopy or retinal photography as 35 mm colour transparencies?

In order to assess the relative ability of general practitioners (GPs) to detect diabetic retinopathy (DR), especially sight-threatening diabetic retinopathy (STDR) by direct ophthalmoscopy or by examining, on a separate occasion, retinal images as 35 mm colour transparencies, a South and Mid Wales primary care-based study was performed in four general practices (six GPs). The participating GPs were provided with standardized training and equipment. Both methods were compared to the 'reference' grade of DR provided by the Diabetic Retinopathy Reading Centre (London), based on the same retinal images. Ophthalmoscopy and retinal photography (Canon CR4 45NM) with mydriasis were all practice based. The clinical assessments were based on a protocol developed for screening for DR in Europe. A total of 996 people with diabetes were identified, representing a prevalence of known diabetes of 2.1%. After exclusions on medical grounds, 897 patients were available for screening, of whom 605 (68%) were photographed. Based on the retinal images, the reference centre identified DR in 43% and STDR in 14.4%. In total, 597 valid comparisons between GPs and the reference centre were obtained; of these, 462 (77%) were high quality photographs which were used in subsequent analysis. The sensitivity for detecting any DR increased from 62.6% (95% CI 55.9-69.4) with ophthalmoscopy to 79.2% (95% CI 73.6-84.9) using retinal photographs, specificity remaining essentially unchanged at 75.0 (95% CI 69.5-80.5) and 73.5% (95% CI 68.0-79.1) with the positive predictive value (PPV) increasing from 67.2 (95% CI 60.4-74.0) to 71.0% (95% CI 65.0-77.0), respectively. The detection of STDR sensitivity increased from 65.7 (95% CI 54.4-77.1) with ophthalmoscopy alone to 87.3% (95% CI 79.4-95.2) based on retinal photographs with specificity falling from 93.8 (95% CI 91.4-96.3) to 84.8% (95% CI 81.2-88.5) and PPV from 65.7 (95% CI 54.4-77.1) to 51.2% (95% CI 42.1-60.3), respectively. We conclude that the use of standardized 35 mm colour transparency retinal photographs for screening by trained GPs in a primary care setting achieves an acceptable detection rate (>87%) for STDR, contrasting with ophthalmoscopy alone (66%), which was below the proposed UK standard of 80%.

Altered urinary interleukin-8/creatinine ratio in peptic ulcer disease: pathological and diagnostic implications

OBJECTIVES AND METHODS

To assess its clinicopathological and diagnostic significance, interleukin-8 (IL-8) was measured by radioimmunoassay in fasting urine specimens and in gastric mucosal incubates taken from 54 patients with dyspepsia. The presence of Helicobacter pylori, the activity of gastritis, and urine creatinine levels were also assessed.

RESULTS

The median urinary IL-8/creatinine ratio was 0.1 x 10(-6) in patients with current peptic ulcers (n = 13) and 0.2 x 10(-6) in patients with a history of ulcers (n = 8), compared with 0.4 x 10(-6) (p < 0.0001) in patients without ulcers who were infected with H. pylori (n = 20) or not infected (n = 13). The activity of gastritis had a positive correlation with gastric IL-8 (r = 0.5870, p < 0.01) and a negative correlation with urinary IL-8/creatinine ratio (r = -0.6447, p < 0.005). The improvement in the activity of gastritis in 20 patients given anti-H. pylori triple therapy was associated with a significant fall in gastric mucosal IL-8 and a rise in urinary IL-8/creatinine ratio.

CONCLUSIONS

An inverse relationship seems to exist between urinary IL-8 and the activity of gastritis and gastric IL-8. This may represent another concept in the pathogenesis of peptic ulcers and can assist in the noninvasive diagnosis of peptic ulcer disease.

Sending a copy of the letter to the general practitioner also to the parents in a child development centre: does it work?

Following concerns that a considerable extra workload would be involved in sending a copy of the GP outpatient letter to parents following a medical consultation, 100 consecutive letters from the CDC were analysed to see if they could be sent to parents. Changes would have been necessary in 11, of which 6 would need an extra letter to the GP conveying additional specific information. Letters were generally intelligible, but it was recommended that they could be written in a more simple way for parents. Following these recommendations, copies of letters to the GP were sent to parents and the practice reviewed 2 years later. GP letters from 100 consecutive patients who had just visited the Centre were analysed and found to have been sent in 94. Of the remaining six, five were not sent because they contained information specific to the GP. It was felt that this could be rectified fairly easily. An anonymous questionnaire, sent to those receiving a copy of the letter, indicated that it had been very well received. It was felt that this policy was most helpful to the parents and justified a small additional workload.

Insulin-like growth factor-I in Helicobacter pylori gastritis and response to eradication using bismuth based triple therapy

AIMS

To measure insulin-like growth factor-I (IGF-I) concentrations in the presence and absence of Helicobacter pylori infection and in response to eradication of the organism.

METHODS

An enzyme linked immunosorbent assay was used to measure gastric and fasting serum concentrations of IGF-I in 17 patients with and 11 without H pylori infection. Repeat assessments were performed in the infected patients six weeks after they received a two week course of bismuth chelate, metronidazole, and amoxycillin.

RESULTS

IGF-I was detected at very low concentrations in gastric juice and in mucosal incubates. The median serum IGF-I concentration was 88 micrograms/l in the patients infected with H pylori compared with 90 micrograms/l in the non-infected controls; IGF-I concentrations dropped to 77 micrograms/l following eradication therapy (p = 0.014).

CONCLUSION

The similarity in baseline IGF-I concentrations in the presence and absence of H pylori suggests that their subsequent drop after treatment is more likely to be due to the treatment.

Gastric mucosal hepatocyte growth factor in Helicobacter pylori gastritis and peptic ulcer disease

OBJECTIVES

Hepatocyte growth factor (HGF) is increasingly recognized for its role in a variety of hepatic and systemic diseases. Its relationship to gastritis has not been studied. We aimed at measuring gastric mucosal HGF levels in the presence or absence of Helicobacter pylori gastritis, in peptic ulcers, and in response to H. pylori eradication.

METHODS

Fifty one patients were studied. Patients were not entered if they had liver disease, malignancy, or any systemic illness. HGF was measured in gastric antral incubates using an enzyme-linked immunosorbent assay. Assessments were repeated 6 wk after a 2-wk course of anti-H. pylori triple therapy in 12 patients. Code numbers were used for blinding.

RESULTS

The median gastric mucosal HGF level was 36 ng/gm/tissue in patients with H. pylori gastritis (n = 33) compared with 19 ng/gm in 18 negative controls (p = 0.0024), 18 ng/gm after the eradication of H. pylori (p = 0.021), 23 ng/gm in all patients with ulcers (n = 10), and 26 ng/gm/tissue in H. pylori-positive ulcers (n = 7).

CONCLUSIONS

Gastric mucosal HGF levels were elevated in H. pylori gastritis and reduced by its eradication. These results are relevant to our understanding of the increased gastric cell proliferation in patients with H. pylori-related gastritis.

Breaking bad news to patients with cancer

For the patient with cancer, bad news can occur several times between diagnosis and death. Patients expect honesty from professionals. Patients may choose to face up to bad news or actively deny what is happening. Nurses need to be able to deal with the patient's emotional response to bad news.

Nocturnal enuresis and the use of desmopressin: is it helpful?

We assessed the outcome of the use of an enuretic alarm and desmopressin according to conventional guidelines and investigated the reasons for resistance to desmopressin. Children were given a 4 month course using an enuretic alarm if they had not previously used one; 12 out of 21 were dry (57%) after 4 months and one relapsed 1 month later. Those who had previously failed with an alarm or were considered poorly motivated to use it, were given a 4 month course of intranasal desmopressin. Of these 26 children, 10 (38%) were dry at the end of 4 months but only two (7%) remained dry after this was withdrawn. After the initial treatment with alarm or desmopressin, 27 children were still enuretic and attending the clinic. They were shown how to use the alarm and eight also used the dry bed training technique: 15 had become dry after a further 6 months. Of the 12 children who made no response to intranasal desmopressin, nine were given this medication under supervision in hospital; seven of these children still wet the bed despite producing small amounts of concentrated urine overnight. They also had small measured diurnal bladder capacities. We conclude that if a 4 month course with an enuretic alarm is unsuccessful, rather than using desmopressin, the alarm should be continued with relearning and consideration given to additional use of the dry bed training technique. The major factor causing nocturnal enuresis in children is likely to be a small nocturnal bladder capacity.

Low dose famotidine in the prevention of sleep disturbance caused by heartburn after an evening meal

AIM

To determine whether, in a susceptible population, dosing with 10 mg famotidine 1 h before an evening meal could decrease the interference with sleep caused by heartburn.

METHODS

Patients with a history of frequent heartburn (n = 309) were randomized to receive 10 mg famotidine or placebo 1 h before an evening meal likely to induce symptoms. Patients assessed the efficacy of the treatment in preventing heartburn after the meal, at bedtime and during the night. The number of awakenings due to heartburn and the consumption of antacid tablets taken to alleviate symptoms were also recorded.

RESULTS

Treatment groups were well matched and data from 302 patients were available for analysis. Compared to placebo, famotidine treated patients had: less heartburn after the meal (P < 0.0001 mean global scores), less interference with getting to sleep (P = 0.0156 mean global scores), fewer awakenings (P = 0.0001 difference in mean number) and better control of heartburn during the night (P < 0.0001 mean global scores). They were also almost three times less likely to need antacid treatment than the placebo group during the night (relative odds for no antacid 2.78 (95% CI: 1.29-5.96). Only four patients in each group suffered adverse events.

CONCLUSION

Taking a 10 mg dose of famotidine 1 h before an evening meal appears to be a successful and well tolerated strategy for preventing post-prandial heartburn and avoiding the associated interference with sleep.

Dispersal of the Old World screw-worm fly Chrysomya bezziana

Dispersal of the Old World screw-worm fly, Chrysomya bezziana Villeneuve, was studied in Papua New Guinea by releasing radio-isotope labelled, laboratory-reared flies and collecting their labelled egg masses from sentinel cattle. A log-linear model was developed to describe recapture rate. Distance was found to dominate the model and was represented by a bilinear ('broken-stick') term as log-distance. Further terms in the model such as attractiveness of the site (estimated from the number of non-labelled egg masses), the season of the year and a time trend were statistically significant but of minor importance. From the model, the median distance females dispersed before depositing an egg mass was 10.8 km. The maximum distance from the release site that egg masses were recovered was 100 km. The dispersal ability of C. bezziana is discussed in terms of its impact on the prospects of eradicating this species using SIRM if an outbreak occurred in Australia.

Sire Transmission of Acquired-Resistance to Myxomatosis

Male rabbits that had recovered from myxomatosis transmitted to their offspring some factor that increased by 22% the offspring's probability of survival to myxoma virus challenge. The degree of protection transmitted differed between sires challenged with different myxoma strains and between sires challenged with myxoma virus and those challenged with Shope's fibroma virus (SFV). We suggest that future tests of the resistance of wild rabbits should be designed to minimise or eliminate the sire effect.

Differences in the treatment of male and female patients with end-stage renal disease

OBJECTIVE

To determine whether there is a difference in the allocation of types of dialysis to male and female patients with end-stage renal disease (ESRD).

DESIGN

Descriptive study.

SETTING

Canada.

PATIENTS

All patients registered with the Canadian Organ Replacement Register (CORR) whose treatment began between 1981 and 1991. Data were obtained for 19,732 patients, of whom 18,010 had sufficiently complete data and were being treated with either peritoneal dialysis or hemodialysis 3 months after the diagnosis of ESRD.

OUTCOME MEASURES

Proportions of patients receiving peritoneal dialysis and hemodialysis according to sex.

RESULTS

Significantly more male (58.1%) than female (50.8%) patients were receiving hemodialysis 3 months after diagnosis (p < 0.00001). Multivariate analysis to control for the possible confounding effects of age, province of treatment, diagnosis, concurrent illness and year of diagnosis did not explain the difference.

CONCLUSIONS

In Canada from 1981 to 1991 male patients were more likely than female patients to receive hemodialysis for the treatment of ESRD. Additional research is needed to explain this finding.

Virulence of Strains of Myxoma Virus and the Resistance of Wild Rabbits, Oryctolagus-Cuniculus (L), From Different Locations in Australasia

Wild rabbits, Oryctolagus cuniculus (L.), caught at six locations in Australia and one in New Zealand in 1976-80, were bred in Canberra and their offspring (n=1392) challenged with seven strains of myxoma virus. Innate resistance varied between locations and was higher in rabbits from inland Australia. The virulence (lethality) of the myxoma strains in the rabbits from the different localities was not correlated with mean survival times. As the correlation between survival time and virulence has previously been the basis for the allocation of virulence grades by survival times, it is suggested that the virulence of field strains may be different from, and higher than, published results. On the basis of survival rates of unselected New Zealand wild rabbits the field strains collected in 1973-78 were allocated virulence grades of I and II.

Medical accelerator safety considerations: report of AAPM Radiation Therapy Committee Task Group No. 35

Ensuring safe operation for a medical accelerator is a difficult task. Users must assume more responsibility in using contemporary equipment. Additionally, users must work closely with manufacturers in promoting the safe and effective use of such complex equipment. Complex treatment techniques and treatment modality changeover procedures merit detailed, unambiguous written procedural instruction at the control console. A thorough "hands on" training period after receiving instructions, and before assuming treatment responsibilities, is essential for all technologists. Unambiguous written instructions must also be provided to guide technologists in safe response when equipment malfunctions or exhibits unexpected behavior or after any component has been changed or readjusted. Technologists should be given a written list of the appropriate individuals to consult when unexpected machine behavior occurs. They should be assisted in identifying aberrant behavior of equipment. Many centers already provide this instruction, but others may not. Practiced response and discussion with technologists should be a part of an ongoing quality assurance program. An important aspect of a safety program is the need for continuous vigilance. Table III gives a summary of a comprehensive safety program for medical accelerators. Table IV gives a list of summary recommendations as an example of how one might mitigate the consequences of an equipment failure and improve procedures and operator response in the context of the environment described. Most of these recommendations can be implemented almost immediately at any individual treatment center.

Sarcoidosis: association with small bowel disease and folate deficiency

A 30 year old woman with recurrent anaemia due to folate deficiency had evidence of sarcoid granuloma on small bowel biopsy but was presumed to have Crohn's disease. The diagnosis of small bowel sarcoidosis was not seriously considered until she developed systemic manifestations of sarcoidosis (cutaneous and pulmonary lesions) over the following 20 years. Sarcoidosis of the gastrointestinal tract, particularly the small bowel, is rare and this case is unusual because bowel pathology preceded more generalised lesions. As far as is known it is also the first case to be described presenting with malabsorption of folic acid.

The image database: pictures and computers

Information technology offers important new ways of using pictures for teaching in medicine. Methods for storing and delivering high quality images for computer-based learning systems are discussed.

General anaesthesia in the accident and emergency department

This paper describes the results of a survey in 1990 which examined the practice of general anaesthesia in Accident and Emergency Departments. Data were obtained concerning the anaesthetics induced during the previous year, specifically the number of procedures undertaken, the equipment, the facilities and the personnel involved, including any complications. These findings are discussed in relation to recommendations for minimum standards in anaesthetic practice.

Plasma porphyrins in chronic renal failure

Using a quantitative sensitive HPLC fluorometric assay for the measurement of plasma and urine porphyrins, we have calculated the renal clearance of uro- and coproporphyrin in normal volunteers and in patients with congenital erythropoietic porphyria and hereditary coproporphyria (HCP). In patients with porphyria cutanea tarda (PCT), only uroporphyrin clearance was calculated. Plasma porphyrin concentrations were measured in patients with chronic renal failure (CRF). All our CRF patients on haemodialysis (10) had raised plasma uroporphyrin, 4 had raised plasma heptacarboxyporphyrins and 2 had raised plasma coproporphyrin, unchanged by haemodialysis. CRF patients with raised uroporphyrins and 7-carboxyporphyrins could be distinguished from PCT in patients with normal renal function, by their higher uro/7-carboxyporphyrin ratio (8.0 vs. 1.7). Renal clearance of coproporphyrin was much greater in HCP than in any of the other groups studied. Since coproporphyrin clearance was less than creatinine clearance in most normal subjects, and because 2 patients with CRF had raised plasma coproporphyrin concentrations, we argue that the kidney is probably not a major source of coproporphyrin, as previously reported. Furthermore, the variability and degree of abnormality in plasma porphyrins in CRF would suggest caution in diagnosing chronic porphyria in patients with renal impairment.

The incidence of flystrike in sheep in relation to weather conditions, sheep husbandry, and the abundance of the Australian sheep blowfly, Lucilia cuprina (Wiedemann) (Diptera: Calliphoridae)

The incidence of cutaneous myiases (flystrike) in sheep in the Southern Tablelands of New South Wales is examined in relation to the abundance of the Australian sheep blowfly, Lucilia cuprina (Wiedemann), and various management and environmental variables known to affect sheep susceptibility. Regression analysis showed that the incidence of flystrike increased with increases in the density and activity of gravid L. cuprina. Body strike was more predictable than crutch strike, and was positively correlated with monthly rainfall, cloud cover and the rate of pasture growth. Rainfall intensity was also important, with frequent, small falls of rain being more conducive to flystrike than occasional heavy showers. The combination of weather, pasture and fly effects accounted for 76% of the observed variance in body strike and 58% of that for crutch strike. Crutch strike appeared to replace body strike under dry conditions and also when fly densities were low (less than 0.5 gravid females h-1 trap-1), irrespective of weather conditions. The analysis of total strike suggested that rainfall determined overall levels of strike, whereas pasture conditions and cloud cover regulated type of strike.

Factors determining maintenance of sinus rhythm after chronic atrial fibrillation with left atrial dilatation

Successful therapy of atrial fibrillation (AF) has been reportedly influenced by a variety of factors including patient age, type of underlying heart disease, duration of arrhythmia, left ventricular function and left atrial (LA) size. To determine which of these factors are associated with maintenance of sinus rhythm after conversion, 43 patients with symptomatic chronic AF in the setting of a dilated left atrium (greater than or equal to 45 mm, range 45 to 78) were followed for at least 6 months after the return of sinus rhythm. Class IA drugs, IC drugs or amiodarone were used for therapy. Life table analysis showed sinus rhythm to be maintained in 81% for 6 months, 79% for 12 months and 60% for 24 months. Factors positively associated with success were conversion with drug therapy alone, duration of chronic AF less than or equal to 1 year, absence of mitral valve disease and LA dimension less than or equal to 60 mm (all p less than 0.05). Patient age, left ventricular function and presence of coronary disease were not associated with outcome. Thus, patients with moderate LA dilatation (45 to 60 mm) and a short duration of chronic AF can often be maintained in sinus rhythm, especially if they convert with pharmacologic intervention alone.

Fundamentals of stereophotography in medicine

Depth perception is given by binocular vision and it can be reproduced photographically by taking left and right pictures. However, the optimum separation between the views may not always correspond to the distance between our eyes, particularly in close-up work. Important applications of stereophotography in medicine are examined in this article as well as some of the fundamental principles and techniques for taking 3-D pictures and viewing the results.

Lymphomatoid granulomatosis presenting with polyarthritis

Polyarthritis in lymphomatoid granulomatosis is rare. In the present report we describe a patient with lymphomatoid granulomatosis who presented with an acute inflammatory polyarthritis three years before the typical skin and pulmonary manifestations of the disease became evident.