Effects of electrical stimulation on wound healing in patients with diabetic ulcers

OBJECTIVE

To evaluate the effects of two stimulation waveforms on healing rates in patients with diabetes and open ulcers. The hypothesis was that stimulus waveforms with minimal polar characteristics would provide significant healing for this patient sample.

RESEARCH DESIGN AND METHODS

This was a prospective study that enrolled 80 patients with open ulcers. Patients received stimulation with either an asymmetric biphasic (A) or symmetric biphasic (B) square-wave pulse. Amplitudes were set to activate intact peripheral nerves in the skin. Two other groups received either very low levels of stimulation current (MC), or no electrical stimulation (C). When combined these groups were referred to as the control group. Treatment was carried out daily until the wound healed, the patient withdrew from the study, or the physician changed the overall wound management program. Average healing rates were calculated from weekly measures of the wound perimeter and were used for statistical comparison through a one-way analysis of variance.

RESULTS

Stimulation with the A protocol significantly increased the healing rate, enhancing healing by nearly 60% over the control rate of healing. Stimulation with the B protocol did not increase the healing rate when compared with control subjects.

CONCLUSIONS

Electrical stimulation, given daily with a short pulsed, asymmetric biphasic waveform, was effective for enhancement of healing rates for patients with diabetes and open ulcers.

A pilot study of the introduction of audit into nursing homes

In 1993, all 37 private nursing homes in Mid-Staffordshire were invited to take part in this study, and 16 agreed. Over 1 year, a nurse audit facilitator visited these homes to teach staff, and stimulate and assist with audit projects. At the beginning and end of the 12-month period, the residents were assessed by administered questionnaires and by the short Geriatric Depression Scale. Thirteen of the 16 homes undertook at least one audit project during the study (ten of these had never previously carried out audit). Ten homes made at least one major procedural change during the study. Of the 570 residents of the 16 homes, 138 answered both questionnaires. The main reasons for non-inclusion were poor mental and physical conditions. Satisfaction levels improved significantly in six out of the 11 aspects of care studied. The mean Geriatric Depression Score in these 138 residents fell from 4.73 at the start, to 4.25 at the end of the study (p = 0.02). The fall in the mean score was significantly greater in the ten homes that had made at least one major change (from 4.40 to 3.81) than in the six homes that had made no major change (from 5.33 to 5.17). The introduction of audit into co-operative private nursing homes is associated with improvements in the standards of care, but it is uncertain whether this is a direct consequence of the audit carried out, or is due to the non-specific effects of an outside assessor visiting the homes. There is a need for methods of assessment that can be applied to higher proportions of nursing home residents.

Comparison of the amplified Mycobacterium tuberculosis (MTB) direct test, Amplicor MTB PCR, and IS6110-PCR for detection of MTB in respiratory specimens

Several nucleic acid amplification techniques (NAAT) have been developed for rapid and direct detection of Mycobacterium tuberculosis (MTB) from clinical specimens. This study compared the performances of the Gen-Probe Amplified MTB Direct Test (AMDT), Roche Amplicor MTB PCR test, and an IS6110-PCR assay with acid-fast smear and culture in the detection of MTB from 428 respiratory specimens from 259 patients. Patients' charts were reviewed for clinical correlation. Of 98 specimens that were clinically positive for MTB, acid-fast smear was positive in 50% of cases, culture in 93%, IS6110-PCR in 83%, AMDT in 84%, and Amplicor MTB PCR in 80%. Of 337 specimens that were negative for MTB, 117 (35%) were positive for nontuberculous mycobacteria. Specificities were as follows: smear, 89%; culture, 100%; IS6110-PCR, 99%; AMDT, 98%; and Amplicor MTB PCR, 96%. The accuracies of the tests were 80%, 98%, 96%, and 92%, respectively. MTB culture-positive specimens that were smear-negative were detected by AMDT and IS6110-PCR in 77% of cases and by Amplicor MTB PCR in 70%. NAAT was less sensitive than was culture for detection of MTB, but all these techniques had acceptable accuracy and were completed within hours. NAAT may be useful for rapid screening of respiratory specimens to distinguish MTB from nontuberculous mycobacteria infection in order to isolate patients.

Radical hysterectomy for stage IB1 vs IB2 carcinoma of the cervix: does the new staging system predict morbidity and survival?

Two hundred twenty-nine patients with Stage IB cervical cancer treated with radical hysterectomy were assigned to the new FIGO substages IB1 (n = 181) and IB2 (n = 48) based on clinical tumor diameter. Our purpose was to determine the impact of the new staging system for IB1 and IB2 cervical cancer on nodal status and survival. Additionally, we analyzed the morbidity of radical hysterectomy in light of the new staging system. The complications were similar between the two groups. Para-aortic lymphadenectomy was the only independent predictor of complications (P = 0.00026). Stage IB2 patients did have a significantly worse 5-year survival (72.8%) when compared with IB1 (90.0%) (P = 0.0265). Multivariate stepwise logistical regression analysis indicated that the new staging system did not have an independent impact on survival. Stage acts through nodal status in its impact on survival. Positive lymph nodes, tumor diameter, and Ponderal Index are all independent predictors of survival (P = 0.0001). Patients with Stage IB2 carcinoma of the cervix undergoing radical hysterectomy showed no significant increase in morbidity when compared with patients with Stage IB1 disease treated with the same procedure.

The geriatric obstacle course: a training session designed to help prehospital personnel recognize geriatric stereotypes and misconceptions

A significant proportion of ambulance transports to the Emergency Department involve elderly patients, and this use of EMS services by the elderly is expected to increase. Emergency medical technicians (EMTs) may have preconceived notions about the behavior they observe in this group of patients, who tend to be difficult to assess. To provide EMTs with the perspective from which their elderly patients view the situations in which they find themselves, we developed and implemented training scenarios in which the EMTs were required to play the role of the geriatric patient. The EMTs' evaluations of the sessions were enthusiastically positive and indicated that the course did enable them to reevaluate their attitudes toward elderly patients. It is our conviction that this type of sensitivity training is an easily implemented and highly valuable method of augmenting the facts and algorithms taught to these prehospital care providers.

Stresses, coping mechanisms and job satisfaction in general practitioner registrars

BACKGROUND

There is concern about the morale of general practitioner registrars. There may be stress-provoking factors that could be avoided or minimized.

AIMS

The aims of the study were to assess the sources of stress and job satisfaction of general practitioner registrars, to compare registrars' job satisfaction with that of established principals using a recently published survey and to identify registrars' usual responses to stress.

METHOD

A postal questionnaire survey was sent to all 143 general practitioner registrars in the West Midlands Region. The main measures were: self-rating scales of stresses associated with work and training; the Warr, Cook and Wall job satisfaction scale; and self-reported responses to stress.

RESULTS

A total of 118 (83%) general practitioner registrars responded. The most potent sources of stress were family-job conflict, working for the Membership of the Royal College of General Practitioners, patients' unrealistic expectations and disruption of social life. Registrars practised good coping responses to stress. Registrars in this study had significantly greater job satisfaction than general practitioner principals in a 1993 survey for three out of 10 items measured (responsibility given, hours of work and the job as a whole) and significantly worse scores for three items (recognition for good work, rate of pay and variety of work).

CONCLUSIONS

Registrars have additional stresses to those of established principals because they need to study for examinations, learn new tasks in general practice and carry out their service commitments at a stage in life when many are newly married or have a young family. Training in stress management for general practitioner registrars is recommended.

Gender differences in general practitioners at work

BACKGROUND

The proportion of female general practitioners is steadily increasing.

AIM

To compare male and female general practitioners with respect to their job satisfaction and professional commitments within and outside their practices.

METHOD

A questionnaire was sent to all 896 general practitioner principals with patients in Staffordshire in 1994. The main elements were: job satisfaction (on a five-point scale) from eight possible sources; whether personal responsibility was taken for 12 different practice tasks; and professional commitments outside the practice.

RESULTS

A total of 620 (69%) general practitioners responded. Female doctors derived more satisfaction than male doctors from relationships with patients (P = 0.002). Female doctors were more likely to be working in training practices, and were likely to be on-call less and to work fewer sessions. Male general practitioners were more likely to take lead responsibility for practice computers, minor surgery, meeting external visitors and finance, whereas female practitioners were more likely to be responsible for looking after women patients' health.

CONCLUSION

Considerable differences were found between male and female general practitioners. These differences are likely to have an increasing impact as the percentage of female general practitioners continues to rise.

Anxiety and depression in general practitioners: associations with type of practice, fundholding, gender and other personal characteristics

BACKGROUND

There is evidence both that a doctor's own well-being is closely associated with efficiency and positive attitude to patients, and that levels of stress, anxiety and depression in doctors are rising.

OBJECTIVES

This postal survey aimed to measure anxiety and depression levels in general practitioners in 1994 and identify any associations with personal and practice characteristics.

METHODS

All general practitioners with patients in Staffordshire were invited to complete the Hospital Anxiety and Depression (HAD) scale.

RESULTS

Six hundred and twenty of 896 general practitioners replied (response rate 69%). No gender differences were found in rates of anxiety and depression; overall, 19% of respondents were 'cases' of anxiety and 22% others had borderline anxiety scores; 10% were 'cases' of depression and 16% others had borderline depression scores. Anxiety 'caseness' was associated with living alone, amount of on-call duties undertaken, and being fourth/fifth wave fundholders. Depression 'caseness' was associated with having little free time from practice work, amount of on-call, being single handed, and working in a non-training practice.

CONCLUSIONS

The authors concluded that the level of mental ill-health in general practitioners is a matter of concern and is associated with workload.

Investigation into the attitudes of general practitioners in Staffordshire to medical audit

OBJECTIVES

To investigate the attitudes of general practitioners to medical audit, and any associations between their attitudes and their personal characteristics.

DESIGN

Postal questionnaire survey. SETTING --Staffordshire, United Kingdom.

SUBJECTS

870 Staffordshire general practitioners.

MAIN MEASURES

Agreement or disagreement and associations between the attitudes to 16 statements about audit and the doctors' personal or practice characteristics--namely, sex, number of years since qualification, practice list size, number of partners, and the practices' experience of audit.

RESULTS

601 Staffordshire general practitioners (69%) responded. There was most agreement with the statements that audit is time consuming (86%), that ongoing training and education is needed (71%), that there is a compulsion applied on doctors to audit (68%), and that extra resources for audit should be provided by the medical audit advisory group (65%). There was considerable disagreement (53% of general practitioners) with the statement that ¿government policy to expect general practitioners to do audit will enhance the population's health.¿ The median response by the 601 general practitioners was four positive responses out of 14 statements about audit (two of the 16 statements could not be graded positive or negative to audit). Women doctors generally had more positive attitudes towards audit, and so had those working with smaller mean list sizes, those in larger partnerships, and those in practices that had carried out audit for a longer time.

CONCLUSIONS

There was a generally negative attitude to medical audit, but it was encouraging that those doctors with the most experience of audit obtained the most job satisfaction from it.

IMPLICATIONS

More effort is needed to convince general practitioners of the value of audit. Without this, attempts to involve other members of the primary care team in multidisciplinary clinical audit are unlikely to be effective. Successful audits that are shown to be cost effective as well as leading to improvements in patient care should be publicised and replicated. A higher proportion of resources should be devoted to audit.

Predictive model to assess risk for cardiac allograft vasculopathy: an intravascular ultrasound study

OBJECTIVES

This study was performed to assess the influence and interdependence of immunologic and nonimmunologic risk factors in the development of cardiac allograft vasculopathy. Another primary objective was to establish a clinically useful model for risk assessment of cardiac allograft vasculopathy that would facilitate identifying those heart transplant recipients likely to have severe intimal proliferation and thereby at greater risk for adverse clinical events.

BACKGROUND

To our knowledge, no comprehensive intravascular ultrasound study has assessed the relative influences of both nonimmunologic and immunologic factors in the development of cardiac allograft vasculopathy, currently the major limitation to long-term cardiac allograft survival.

METHODS

Using a computer-assisted model of stepwise logistic regression, immunologic and nonimmunologic risk factors were evaluated to help identify the development of severe intimal thickening in 101 subjects who underwent intravascular ultrasound. Prospective validation of the findings was performed in a separate consecutive cohort of 37 heart transplant recipients, and the accuracy of this model to predict a relative risk > 1 for the development of severe intimal hyperplasia was assessed.

RESULTS

Significant independent predictors of severe intimal hyperplasia in this model included a donor age > 35 years, a first-year mean biopsy score > 1 (a measure not only of severity of rejection, but also of frequency of insidious rejection) and hypertriglyceridemia at two incremental levels of risk (150 to 250 mg/dl [1.70 to 2.83 mmol/liter] and > 250 mg/dl [2.83 mmol/liter]). Based on the absence (0) or presence (1) of these factors, 12 individual categories of risk were ascertained with increasing relative risks and predicted probabilities for severe intimal hyperplasia. Prospective validation of this model revealed a sensitivity and specificity of 70% and 90%, respectively, and the positive and negative predictive values were 85% and 80%, respectively. Additionally, subjects with severe intimal thickening had a four-fold higher cardiac event rate than those without severe intimal proliferation on intravascular ultrasound.

CONCLUSIONS

This study establishes a clinically useful predictive model that can be applied to individual heart transplant recipients to assess their risk for developing significant cardiac allograft vasculopathy and, thus, aids in the identification of patients at risk for cardiac events in whom closer surveillance and risk factor modification may be warranted.

Audit activity and quality of completed audit projects in primary care in Staffordshire

OBJECTIVES

To survey audit activity in primary care and determine which practice factors are associated with completed audit; to survey the quality of completed audit projects.

DESIGN

From April 1992 to June 1993 a team from the medical audit advisory group visited all general practices; a research assistant visited each practice to study the best audit project. Data were collected in structured interviews.

SETTING

Staffordshire, United Kingdom.

SUBJECTS

All 189 general practices.

MAIN MEASURES

Audit activity using Oxford classification system. Quality of best audit project by assessing choice of topic; participation of practice staff; setting of standards; methods of data collection and presentation of results; whether a plan to make changes resulted from the audit; and whether changes led to the set standards being achieved.

RESULTS

Audit information was available from 169 practices (89%). 44(26%) practices had carried out at least one full audit; 40(24%) had not started audit. Mean scores with the Oxford classification system were significantly higher with the presence of a practice manager (2.7(95% confidence interval 2.4 to 2.9) v 1.2(0.7 to 1.8), p < 0.0001) and with computerisation (2.8(2.5 to 3.1) v 1.4 (0.9 to 2.0), p < 0.0001), organised notes (2.6(2.1 to 3.0) v 1.7(7.2 to 2.2), p = 0.03), being a training practice (3.5(3.2 to 3.8) v 2.1(1.8 to 2.4), p < 0.0001), and being a partnership (2.8(2.6 to 3.0) v 1.5(1.1 to 2.0), p < 0.0001). Standards had been set in 62 of the 71 projects reviewed. Data were collected prospectively in 36 projects and retrospectively in 35. 16 projects entailed taking samples from a study population and 55 from the whole population. 50 projects had a written summary. Performance was less than the standards set or expected in 56 projects. 62 practices made changes as a result of the audit. 35 of the 53 that had reviewed the changes found that the original standards had been reached.

CONCLUSIONS

Evaluation of audit in primary care should include evaluation of the methods used, whether deficiencies were identified, and whether changes were implemented to resolve any problems found.

Recruiting for success--the potential for using occupational personality questionnaires for the assessment of doctors

OBJECTIVES

to evaluate the Saville and Holdsworth Occupational Personality Questionnaire (OPQ) to assess its potential and validity as a tool in the recruitment of doctors. To determine the range of personality characteristics in a group of general practitioners.

DESIGN

an administered commercially available questionnaire.

SETTING

general practitioners in North and Mid. Stafftordshire.

SUBJECTS

133 general practitioners or trainees.

RESULTS

44% of general practitioners agreed to participate. The majority found it useful and recognised its potential to increase self-awareness, highlight weaknesses that might be improved and for future recruitment of others to their teams. Doctors' personality traits were similar to those of managerial/professional norms. The validity of the OPQ was supported by (a) significant associations with subjects' previously reported mental health problems and (b) 83% of respondents confirming that their reports correctly described their personalities at work.

CONCLUSIONS

OPQs have a place in the recruitment of doctors by identifying appropriate people to strengthen the team.

Comparison of genetically engineered herpes simplex viruses for the treatment of brain tumors in a scid mouse model of human malignant glioma

Genetically engineered viruses and viral genes inserted into retroviral vectors are increasingly being considered for experimental therapy of brain tumors. A primary target of these viruses and vectors is human gliomas, the most frequently occurring primary human brain tumor. To investigate the potential of genetically engineered herpes simplex viruses (HSVs) in the therapy of these tumors, we compared the attributes of two viruses, a recombinant from which the gamma 1(34.5) gene had been deleted (R3616) and a recombinant in which the gamma 1(34.5) gene had been interrupted by a stop codon (R4009). Previous studies have shown that these recombinants were completely devoid of the ability to multiply in the central nervous system of rodents. To pursue these studies, we developed a scid mouse glioma model. Tumor cell response (survival) for 10(3), 10(4), and 10(5) implanted MT539MG glioma cells was 38, 23, and 15 days, respectively. The results were as follows: (i) both R3616 and R4009 replicate and cause cytolysis in diverse glioma cell lines of murine and human origin in vitro, and (ii) Winn-type assays 10(5) MT539MG cells coinoculated with R3616 or R4009 as compared to saline significantly prolonged survival in a dose-dependent fashion. Mice that received only tumor cells or the wild-type parent strain of the recombinants, HSV-1(F), died within 15 days. Survival was greatest with R4009. These experiments define both a model for screening oncolytic viruses and a genetically engineered virus of significant potential use as an oncolytic agent.

Predicting mental health problems in general practitioners

A total of 704 general practitioners completed questionnaires enquiring about mental health problems (response rate = 82.0%). Excessive anxiety was reported by 31.1%, troublesome depression by 13.4%, exhaustion or stress (on three or more weekdays) by 60.7%, and sleep difficulties by 47.6%. General practitioners aged 40-49 years old were most likely to report anxiety, exhaustion or stress, sexual and sleep difficulties. Retired doctors reported mental health problems markedly less often. Predictive factors for anxiety were depression, one or more nights on-call per week, and exhaustion or stress; predictive factors for depression were anxiety, and exhaustion or stress; predictive factors for exhaustion or stress were anxiety, depression, no hobbies, paperwork on three or more evenings per week, and sleep difficulties. Gender, country of origin, being single-handed, excessive alcohol consumption, and having no coping methods were not predictive factors for mental health problems.

Work patterns of general practitioners before and after the introduction of the 1990 contract

A questionnaire survey was undertaken to examine the work patterns of general practitioners before and after the introduction of the 1990 contract. A total of 408 and 697 general practitioners responded to the questionnaire in 1989 and 1991, respectively (response rates of 47% and 82%). In 1991 general practitioners reported spending significantly more evenings on paperwork than in 1989 and significantly more reported being exhausted or stressed at the end of five or more working days. General practitioners were significantly less likely to work four or more sessions per week outside the practice in 1991 than in 1989. There was no difference between 1989 and 1991 in the number of surgeries carried out per week or the number of nights spent on call in a month. In 1991 there was no correlation between the Jarman index allocated to a practice principal and the numbers of surgeries per week, sessions worked outside the practice per week, nights on call per month, weekdays exhausted or stressed, or evenings each week spent on paperwork. Older doctors in 1991 were significantly more likely to work 12 or more nights on call per month, to spend more time doing paperwork in the evenings and more likely to report exhaustion than younger doctors. Women doctors in 1991 were significantly more likely to report doing 10 or more surgeries per week than their men colleagues. It has become more common for general practitioners to complete paperwork at home and report exhaustion or stress since the introduction of the 1990 contract.

Comparison of the health and lifestyle of general practitioners and teachers

A total of 704 general practitioners and 588 teachers responded to a questionnaire about their health and lifestyle in 1991 (response rates 82% and 87%, respectively). The results for lifestyle measures were compared with those of a similar questionnaire completed by about half of each group two years before--there were no changes in the answers of either occupational group in the intervening two years. In 1991, 9% of general practitioners and 15% of teachers drank 22 units of alcohol per week or more; 13% of general practitioners and 23% of teachers reported troublesome depression and 31% of doctors and 37% of teachers excessive anxiety in the preceding 12 months. Teachers had more sickness absence, and significantly more experienced a need for daily alcohol and binge eating, and reported sleep difficulties, depression and anxiety than general practitioners. Self-medication among general practitioners was common and overall accounted for 83% of the medication taken by doctors. A follow-up survey of non-respondents found that only 11% of general practitioners and 11% of teachers indicated they had a health problem they wished to conceal or that they felt the questions were too intimate. General practitioners' lifestyle habits are better than those of teachers and published figures for the general population. The frequency of reported mental health problems in both professions gives cause for concern.

Irrigation of the abdominal cavity in the treatment of experimentally induced microbial peritonitis: efficacy of ozonated saline

Ozone is an oxidizing agent possessing potent in vitro microbicidal capacity. This study was designed to address the extent to which irrigation of the contaminated abdominal cavity using a saline solution primed with ozone is effective in reducing morbidity and mortality. Gelatin capsules containing different quantities of a premixed slurry of filtered human fecal material were implanted in the peritoneal cavities of a preliminary series of rats. Three inocula concentrations were selected for later experiments, based upon their ability to produce morbid consequences: (1) high (100% 1-day mortality), (2) medium (70% 3-day mortality, 100% abscess rate in survivors), and (3) low (100% 10-day survival, 100% abscess rate). Fecal and abscess bacteriology were similar in all rats. The peritoneal cavities of 240 rats then underwent fecal-capsule implantation (three groups of 80 rats/inoculum concentration). At celiotomy 4 hours later, equal numbers of rats from each group were randomly assigned to one of four protocols: (1) no irrigation, (2) normal saline irrigation, (3) saline-cephalothin irrigation, and (4) ozonated saline irrigation. Each treatment lasted 5 minutes, using 100 ml of irrigation fluid. Mortality was significantly reduced when, in lieu of no irrigation, any of the irrigation solutions were used. Additionally, ozonated saline statistically proved the most effective irrigating solution for reducing abscess formation in survivors.