Patterns of hospital attendance with epistaxis

The age and sex distribution of epistaxis admissions to hospital was examined. A retrospective analysis of 6,885 patients admitted to hospitals in the whole of Wales was performed, over a period of five years. The findings were compared with data from the 1991 National Population Census for the same region, thus providing a more representative estimate of the behaviour of this disease. A clear age relationship is demonstrated, with the incidence of epistaxis increasing rapidly after the age of 40 years. The female-to-male ratio is also age dependent. In the group aged between 20 to 49 years twice as many males as females were admitted, where no sex difference was expected from the population data. This difference was not present in the group aged 50 years and over where the ratio was similar to that in the underlying population. There was a 1.6 fold difference between the sex ratios of the two groups (95% confidence intervals of 1.9 to 1.4; p < 0.0001). It is possible that the female pre-menopausal state may provide a significant protection from this disease. The mechanism for this is unknown, but may be secondary to a direct effect of oestrogen on the nasal mucosa or vasculature, or the healing of vessels in this region. Alternatively, this observation may simply be a reflection of protection the pre-menopausal state provides against cardiovascular disease in general.

Spontaneous changes of unilateral nasal airflow in man. A re-examination of the 'nasal cycle'

It is now over 100 years since Kayser (Archiv für Laryngol Rhinol 1895; 3: 101-120) first reported in the scientific literature that the human nasal passages exhibit spontaneous changes in unilateral nasal airway resistance, yet our understanding of this unusual phenomenon is still very confused. Spontaneous, reciprocal changes in unilateral nasal resistance are often referred to as a "nasal cycle" and although this term is now commonly used to describe spontaneous changes in nasal resistance in man and animals, there is little evidence for any true periodicity. A major problem in increasing our knowledge and understanding of the so-called "nasal cycle" is that most studies have relied on simple descriptions of the changes in nasal resistance and have not developed any numerical parameters to quantify the changes in resistance over time. This lack of definition of what actually constitutes a nasal cycle has meant that the literature of the present day generally accepts the views put forward by Heetderks (Am J Med Sci 1927; 174; 231-244) and Stoksted (Acta Otolaryngol (Stockh) 1953; Suppl 109: 159-175) that around 80% of the healthy population exhibit a regular cycle. In order to define the characteristics of the spontaneous changes in nasal airway resistance we have used numerical measures of reciprocity and also developed a measurement of the division of airflow between the nasal passages over time. With these two parameters it is possible to describe the nature of the spontaneous changes in airflow in numerical terms and to define what exactly constitutes a nasal cycle. Fifty-two volunteers underwent hourly measurement of unilateral nasal airflow for 8 h. For each volunteer, two values were derived from the graph of unilateral nasal airflows against time; the correlation coefficient between unilateral airflows (r) and the airflow distribution ratio between the two nasal airways (ADR). The spread of different types of airflow pattern (nasal cycle) throughout the population was illustrated by plotting r against ADR for each subject. A nasal cycle was defined as having an r value between -0.6 and -1.0, and an ADR value between 0.7 and 1.0. Only 21% (11 of the 52 volunteers) exhibited airflow patterns that could be defined as a nasal cycle in these terms. This finding contradicts the generally accepted, but undefined, view that around 80% of the population exhibit a regular nasal cycle. The numerical definition of a nasal cycle in terms of both reciprocity and airflow distribution, as described in this paper may help to clarify our understanding of this interesting phenomenon and allow rhinologists to describe the spontaneous changes in nasal airflow in more exact terms than have been used previously in the literature.

Elder abuse in people with dementia in Northern Ireland: Prevalence and predictors in cases referred to a psychiatry of old age service

OBJECTIVE

To establish the prevalence of elder abuse in community-dwelling patients with dementia and to test the hypothesis that there is no difference in carer and patient characteristics between the abused and non-abused populations.

DESIGN

A cohort of consecutive referrals was formed and subdivided by the presence or absence of abuse and the two groups compared.

SETTING

A rural psychiatry of old age service in N. Ireland.

SUBJECTS

Each case had been newly referred, was 65 years old or over, lived at home, had an identifiable carer and met DSMIII-R criteria for a diagnosis of dementia. There were 49 such cases; 38 carers agreed to be interviewed.

MAIN OUTCOME MEASURES

The General Health Questionnaire 28, the Gilleard Pre-Morbid Relationship Rating Scale and Gilleard's Problem Checklist were administered to the carer and the information/orientation sub scale of the Clifton Assessment Procedure for the Elderly used to measure cognitive impairment in the patient.

RESULTS

Abuse was elicited in 14 (37%) cases; four (10.5%) of physical and 13 (34%) of verbal abuse. No cases of abuse by neglect were detected. A poor premorbid relationship, verbal or physical abuse by the dependant, problem behaviours in the dependant, the carer's level of anxiety and a perception of not receiving help were significantly associated with abuse. Alcohol consumption of the carer, physical dependence, severity of cognitive impairment or financial or social circumstances were not associated with elder abuse.

CONCLUSIONS

Elder abuse is associated with aspects of the patient/carer relationship and should be regarded as a significant problem in patients with dementia referred to an old age service.

Getting with the program

Corporate compliance programs are rapidly becoming essential. The author, a corporate compliance officer from a six hospital system in Omaha, Nebraska, offers a concise guide to their design and implementation.

ISBT Code 128 and code changes as part of the implementation of a national IT system for the English National Blood Service

The implementation of PULSE within the NBS will bring considerable advantages to the Service and to hospitals. A system of dual labelling has been developed to overcome intrinsic constraints identified with the ABC Codabar system. This should not, however, impact directly on hospitals which will be able to continue to utilize the ABC Codabar system. The dual labelling system incorporates the use of the ISBT Code 128 barcode system for transfusion centre use. This must be clearly differentiated from the implementation of ISBT code 128 within the UK. This latter development would bring considerable benefit to transfusion practice, increasing the overall safety of blood transfusion. It is, however, recognized that extensive discussion with appropriate stakeholders will be necessary before any implementation date can be determined for this initiative, particularly so given the significant logistical and financial implications inherent in such a change.

Effect of beta blockers on the time to first syncope recurrence in patients after a positive isoproterenol tilt table test

Isoproterenol-headup tilt table testing provides a diagnosis of neuromediated syncope in many patients who faint. The involvement of beta-adrenoceptor stimulation in the provocation of syncope suggests that beta blockers might chronically prevent syncope. To assess this, a cohort of 153 syncope patients (age 39 +/- 20 years) underwent baseline assessment of demographic variables, symptomatic burden, and hemodynamic and clinical responses to tilt testing. Fifty-two patients then received beta blockers, and 101 did not receive drug therapy. The primary outcome was the time to the first recurrent syncopal spell. Actuarial survival analysis was used. Syncope recurred in 17 of 52 patients who received beta blockers and in 28 of 101 patients who were untreated. The actuarial probability of remaining free of syncope was similar in both groups. For example, the probability of remaining free of syncope 12 months following the tilt test was 0.72 in both populations. Thus, treatment with beta blockers may not have a significant effect in preventing syncope recurrence following a positive tilt test.

An unusual cause of facial pain

A case of chronic facial pain and headache is presented. This was found to be due to two pieces of windscreen-glass lodged in the superior meatus of the patient's nose since a road-traffic-accident 14 years earlier. Despite being reported as normal, review of previous X-rays of her sinuses showed that the glass was visible. The importance of carefully assessing the intranasal area on sinus-views is illustrated.

Tympanic thermometry and minor ear surgery

Infra-red tympanic thermometry is a relatively new technique for measuring body temperature which requires the minimum of co-operation and is quick and easy to use. It is therefore ideal for use in children. Its use is becoming more widespread and as it is theoretically possible that minor ear surgery may interfere with function its reliability in these patients may be in question. Twenty-two children (mean age 5.3 years) who underwent myringotomy +/- grommet insertion had the tympanic temperature of each ear measured immediately before, and 15 minutes after, surgery on the recovery ward. No difference was found between the pre- and post-operative temperatures (mean difference--0.1 degree C, p > 0.1, paired t-test, hypothesized difference of 0). This thermometer appears to be a reliable way of monitoring body temperature on a paediatric ENT recovery ward in patients who have undergone minor ear surgery.

Risk factors for syncope recurrence after a positive tilt-table test in patients with syncope

BACKGROUND

Recent work with head-up tilt-table testing has suggested that many patients with syncope may have recurrent neurally mediated episodes of bradycardia, hypotension, or both. The purpose of this study was to determine how to identify patients at high risk of a recurrence of neuromediated syncope after a positive isoproterenol/tilt-table test.

METHODS AND RESULTS

A cohort of 101 drug-free patients in a university hospital outpatient clinic with syncope and a positive isoproterenol/tilt-table test underwent baseline assessment of demographic variables, symptomatic burden, and hemodynamic and clinical responses to tilt testing. The primary outcome measure was the time to the first recurrent syncopal spell. The actuarial probabilities of remaining syncope free after 1 and 2 years were 72% and 60%, respectively. Multivariate proportional hazards analysis demonstrated that the most powerful predictor of a recurrence of syncope was the logarithm of the number of preceding syncopal spells (P<.001). Other predictive variables included the duration of syncopal symptoms, tilt test symptomatic outcome, and trough heart rate. The probability of a recurrence of syncope also varied with the logarithm of the frequency of preceding spells (P=.008). The median frequency of pretest spells was 0.3/month; after the tilt test, the median frequency dropped approximately 90% to 0.03 per month.

CONCLUSIONS

The risk of a recurrence of syncope after a positive tilt-table test can be predicted with simple pretest and intratest variables.

Evaluation of a combined HIV-1/2 and HTLV-I/II assay for screening blood donors

A combined immunoassay for the simultaneous detection of antibodies to HIV-1/2 and HTLV-I/II (Bioelisa, Launch Diagnostics) has been evaluated to determine its suitability for routine use in blood screening. 84,222 donations were tested from 76,452 donors. One HIV- and 1 HTLV-1-positive donor were identified. The specificity was 99.7%, and the sensitivity for anti-HIV-1, anti-HIV-2, and anti-HTLV-1 on 173 positive sera was 100%; 2 of 25 anti-HTLV-II-positive sera were non-reactive. Although the specificity of the assay is not as high as that of HIV-1/2 kits currently in UK transfusion use, the information gained about donor HTLV antibody status makes the test an attractive alternative to them.

Predicting maltreatment of children of teenage mothers

OBJECTIVE

To determine the degree to which knowing certain characteristics about young high-risk families can help distinguish those families most likely to maltreat their children from those families at lower risk of maltreating their children.

DESIGN

Observational cohort from which the following predictor variables were gathered when infants were 2 months old: maternal age, depressive symptoms, childrearing attitudes, social support, and living situation (with or apart from related adults). Families were followed up for 24 months to identify the occurrence of maltreatment.

SETTING

An urban, socioeconomically disadvantaged cohort of teenage mothers and their infants attending a hospital-based special primary care clinic for teen mothers and their infants.

PARTICIPANTS

All full-term infants and mothers enrolled into the clinic in 1990 participated in the study. This included 47 mother-infant pairs enrolled when infants were 2 months of age. Forty-five of these pairs were available for follow-up when infants were 24 months of age.

MAIN OUTCOME MEASURES

Maltreatment defined as any incident that prompted investigation by the state child protective agency and was found to be a substantiated case of maltreatment by that agency.

RESULTS

Maltreatment occurred in 15 of 45 families before the child's second birthday. Discriminate function analysis produced a model that correctly classified 13 of 15 maltreating mothers and misclassified one of 30 non-maltreating mothers. Stepwise analysis revealed that living situation was by far the strongest predictive variable (R2 = 7).

CONCLUSION

Maltreatment was a predictable outcome within this extremely high-risk cohort. Living apart from related adults was the strongest risk factor associated with maltreatment. This easily obtainable piece of information may be an important risk marker for practitioners, social service personnel, and others working with this very-high-risk population. It may allow early supportive interventions that might prevent maltreatment.

Possible association between fluoxetine hydrochloride and colic in an infant

This is a case study of a 6-week-old infant referred for colic whose mother was using fluoxetine hydrochloride and breast feeding the infant. The mother switched to a commercial formula and reported a dramatic decrease in the infant's crying. We asked the mother to feed the infant breast milk from a bottle and she agreed. Throughout the study the mother kept a daily diary of her infant's crying, sleeping, stooling patterns, and feeding problems. Analysis of the mother's breast milk showed concentrations of 69 ng/mL for fluoxetine and 90 ng/mL for norfluoxetine. Infant blood serum/plasma level was analyzed for fluoxetine hydrochloride following return to breast milk. The concentrations were 340 ng/mL for fluoxetine and 208 ng/mL for norfluoxetine. The diary records showed increased crying, decreased sleep, increased vomiting, and watery stools when fluoxetine hydrochloride was transmitted through breast feeding or breast milk in bottle. These symptoms were reduced when the infant was formula fed. We suggest a possible relationship between colic and associated symptoms and fluoxetine hydrochloride in maternal breast milk.

Use of anti-GOR testing in the screening of blood donors for hepatitis C virus infection

Sera from 12/1,155 (1%) anti-HCV-negative (Elisa) UK blood donors were found to be anti-GOR positive. None out of 12 of those sera were positive for HCV RNA by the reverse transcriptase/polymerase chain reaction (RT/PCR). In a cohort of 316 anti-HCV Elisa-positive sera, 27/57 RIBA-positive, and 1/188 RIBA-negative sera were anti-GOR positive, resulting in a sensitivity of 47% and a specificity of 99.5% for anti-GOR as a marker for RIBA-confirmed HCV infection. Four out of 71 (6%) of RIBA-indeterminate sera were anti-GOR positive. Donors with anti-GOR reactivity were more likely to have antibodies against each of the individual HCV antigens represented in the RIBA, and those antibodies were of greater intensity, when compared to the anti-GOR negative cohort. Twenty out of 36 (55.6%) of RT/PCR-positive sera were anti-GOR positive, compared to 1/7 (14.3%) of RT/PCR-negative sera (p = 0.09). The usefulness of anti-GOR testing of UK blood donors is discussed in the light of these results.

Comparison of biphasic and monophasic shocks for defibrillation using a nonthoracotomy system

A comparison of defibrillation thresholds was made using biphasic and monophasic shocks delivered by a nonthoracotomy lead system in 2 clinically distinct groups of patients. The first group were patients receiving an implantable cardioverter-defibrillator who were studied before surgery with their chests closed. The second group were patients undergoing coronary artery bypass grafting (CABG) who were studied before surgery with their chests open but reapproximated. Biphasic defibrillation thresholds (stored energy) were significantly (p < 0.001) less than monophasic ones in subjects with the implantable cardioverter-defibrillator (12.3 +/- 5.3 vs 21.1 +/- 9.3 J) or CABG (14.6 +/- 7.1 vs 24.2 +/- 12.6 J). These values are less than were previously reported with a similar nonthoracotomy lead configuration. There were no significant differences between the 2 groups in all measurements derived from corresponding shock waveforms, although impedance tended to be greater in patients with CABG. However, subjects with CABG had greater left ventricular ejection fractions and did not have history of potentially lethal ventricular arrhythmias. Despite these differences, the conclusion that biphasic shocks are more effective would have been made in a study of either group alone. It is concluded that patients with CABG who have not had preceding potentially lethal ventricular arrhythmias may be a potential source of surrogate subjects for defibrillation research such as epicardial mapping, which requires that the chest be open.

Effects of intraventricular hemorrhage and socioeconomic status on perceptual, cognitive, and neurologic status of low birth weight infants at 5 years of age

A prospective longitudinal study assessed the effects of intraventricular hemorrhage (IVH) and socioeconomic status on the perceptual, cognitive, and neurologic status of preterm infants at 5 years of age. The preterm group consisted of infants with no IVH, grade I to II IVH, and grade III to IV IVH; a control group of normal term infants was also studied. Outcome was evaluated at 3, 4, and 5 years of age. Twenty-four percent of infants with grade III to IV IVH had abnormal neurologic diagnoses at 5 years of age. Correlations of predictor variables including IVH status, latency of visual evoked response, days of hospitalization, and socioeconomic status with 5-year neurologic outcome indicated that IVH status and visual evoked response at 1, 2, and 3 years continued to have an effect on neurologic outcome, but socioeconomic status and days of hospitalization did not; socioeconomic status did have a significant effect on the McCarthy cognitive scores but not on the perceptual scores at 5 years. Multiple regression analyses revealed that duration of hospitalization (reflecting neonatal morbidity), visual evoked response, and socioeconomic status all have independent effects on the cognitive index, whereas only duration of hospitalization has an independent effect on the perceptual index. These data support the concept that a complex interaction of biologic and environmental risk factors determines the degree of recovery from IVH by high-risk preterm infants.

Lymphokine-activated effector cells: modulation of activity by cytokines

Interleukin 2 (IL-2) has been demonstrated to generate lymphokine-activated killer (LAK) cells from normal human peripheral blood lymphocytes (PBL). Such LAK cells have demonstrated lytic activities on certain tumor cell targets including melanoma, renal carcinoma, and other tumor targets. B lymphoblastoid cell lines such as Raji cells are routinely employed to assess functional LAK cell activity. In our studies we have assessed the effect of various cytokines that affect lymphocyte cell growth and differentiation, including rIL-2, interleukin 4 (rIL-4), interleukin 6 (rIL-6), interferon alpha and gamma (rIFN-alpha and -gamma) and tumor necrosis factors alpha and beta (rTNF-alpha, rTNF-beta), for their ability to generate functional LAK cell activity. Our data confirm that rIFN-alpha and -gamma singularly are capable of inducing LAK cell activity (55 +/- 21 and 40 +/- 10, respectively, in comparison to rIL-2 at 1000 units/ml) whereas rIL-4, rIL-6, BCGF, rTNF-alpha, or rTNF-beta failed to generate the functional LAK cell activity from human PBL. Interferon alpha, itself capable of generating LAK cell activity, was augmentative in its effect with rIL-2 for the generation of functional LAK cell activity. Conversely, rIL-4 inhibited LAK cell activity induced by either rIL-2 alone or the combination of rIL-2 and rIFN-alpha. Furthermore, the increased effects of rIFN-alpha with rIL-2 on LAK cell activity are partly abrogated by as much as 30 or 52% by delaying the addition of either rIL-2 or rIFN-alpha, respectively, for more than 24 h. These results suggest a regulatory role for certain cytokines on LAK cell functions.