An audit of patient acceptance of one-stop diagnosis for symptomatic breast disease

AIMS

The impetus for optimizing outpatient provision of breast-care services has come both from the patient and management in order to reduce anxiety and make full use of scarce resources. The one-stop diagnostic clinic for the investigation of symptomatic breast lesions is a relatively recent concept with well-known service benefits. However, acceptance to the patient has not been previously investigated.

RESULTS

The results of this prospective audit demonstrate a high level of patient satisfaction with the multi-disciplinary, one-stop breast clinic.

Criteria for the predictably restorable endodontically treated tooth

This paper outlines criteria which allow the clinician to identify endodontically treated teeth that can be restored with a high level of predictability. The intent of the article is not to preclude the restoration of teeth that do not meet these criteria; it is to provide a science-based approach for identifying those teeth with a high probability of long-term success upon restoration. For an endodontically treated tooth not requiring a post, the requirements are for biologic width + ferrule length, (i.e. 4.5 mm of supra-bony solid tooth--dentin a minimum of 1 mm thick after preparation). A tooth requiring a post needs, in addition, enough root length to allow a 4 mm apical seal and a post length--apical to the crown margin, equal to the length of the crown. It is essential to assess the functional loads to which the restored tooth would be subjected. Teeth that are endodontically treated, or are likely to be in future, should be avoided as abutments supporting precision attachment RPDs, distal extension RPDs or cantilever FPDs.

Prevalence of sensitization to aeroallergens in California patients with respiratory allergy. Allergy Skin Test Project Team

BACKGROUND

The number of allergy skin tests required to evaluate patients with respiratory allergy has recently been challenged by the managed care community.

OBJECTIVES

The purpose of this study was to determine which aeroallergens are prevalent in patients with respiratory allergy (allergic rhinitis and bronchial asthma) in California.

METHODS

Utilizing aeroallergens thought to be relevant from recent aerobiologic and botanic data, 141 allergic and 17 asymptomatic control subjects were tested for the prevalence of 103 allergens. A standardized prick puncture technique and standardized interpretation of wheal/flare responses were utilized using the same lot of allergen for 13 allergy practices distributed throughout California. Frequency curves based on prevalence were established to determine the number of tests required to give up to 90% of positive responses for tree, weed and grass pollen, mold spores, and miscellaneous allergens which included house dust mite, cat, dog, and cockroach allergens.

RESULTS

Positive responses in allergic subjects for grasses ranged from 46% to 54%, for weeds 19% to 37%, and for trees 10% to 42%. For molds the range was from 11% to 22%. The response rate for Dermatophagoides pteronyssinus was 53%, for Dermatophagoides farinae 42%, for cat pelt 39% and cat hair 37%, for cockroach 23% and dog dander 19%. Asymptomatic control subjects responded to only 4% of all allergens tested. Ninety percent of all positive tests required three miscellaneous allergens (house dust mite, cat, and cockroach), 9 molds, 2 grasses, 16 weeds, and 27 trees for a total of 57 allergens (56% of total tested). There was no clear relationship between locale and specific allergen response, probably related to the limited number of subjects tested and variability within the same geographic region. Several seldom tested tree and weed allergens showed a higher prevalence rate than several commonly tested for allergens.

CONCLUSIONS

This preliminary study suggests that approximately 57 aeroalleroens might be adequate to detect 90% of all positive responses in patients with respiratory allergy in California. This study was limited by subject number and variability between study sites. It is hoped a standardized model can be developed from this pilot study to definitively determine which aeroallergens are relevant in the United States.

Hemorrhagic necrotic schwannoma presenting as purulent meningitis

BACKGROUND

Intracranial schwannoma involving the XIIth cranial nerve is rare. We report an unusual clinical presentation and pathological verification of a schwannoma, which had become haemorrhagic and necrotic, simulating acute purulent meningitis.

METHODS

A literature review of intracranial tumors presenting as acute purulent meningitis, with emphasis on schwannomas, was undertaken.

RESULTS

Few cases of hypoglossal schwannoma have been reported; the association with purulent meningitis has not been previously documented.

CONCLUSION

In patients presenting with sterile purulent meningitis, a necrotic tumor should be considered as a possible etiology.

Effect of the nitric oxide donor, glyceryl trinitrate, on human gall bladder motility

BACKGROUND

Nitric oxide is a major neurotransmitter in non-adrenergic, non-cholinergic (NANC) pathways. NANC inhibitory innervation has been shown in human gall bladder muscle in vitro; the role of nitric oxide in human gall bladder emptying however is undefined.

AIMS

To study the effect of glyceryl trinitrate, a nitric oxide donor, on gall bladder emptying in healthy subjects using a randomised, double blind, cross-over, placebo controlled design.

METHODS

Ultrasonographic gall bladder volume was measured in the fasting state in eight healthy volunteers after randomised administration of either glyceryl trinitrate 1200 micrograms buccal spray or placebo spray. On two further occasions, after randomised administration of either glyceryl trinitrate 1200 micrograms buccal spray or placebo spray, gall bladder volumes were also measured after a liquid test meal.

RESULTS

Glyceryl trinitrate significantly increased fasting gall bladder volume to a mean of 114% (SEM 5%) of pretreatment volume (p = 0.039). Glyceryl trinitrate also significantly impaired gall bladder emptying between five and 40 minutes postprandially. Gall bladder ejection fraction was also reduced after glyceryl trinitrate compared with placebo (43 (6.9)% versus 68.4 (6.5)%, p = 0.016).

CONCLUSIONS

This study shows that glyceryl trinitrate produces gall bladder dilatation in the fasting state and reduces postprandial gall bladder emptying, suggesting that nitric oxide mechanisms may be operative in the human gall bladder in vivo.

Prognostic factors in intraoperative facial nerve monitoring for acoustic neuroma

OBJECTIVES

To determine the predictive value of intraoperative threshold stimulus for facial nerve outcome and the prevalence and prognostic value of persistent trains of activity and frequent spontaneous or mechanically induced contractions during acoustic neuroma surgery.

STUDY DESIGN

Prospective recording and subsequent review of facial nerve activity.

SETTING

Tertiary referral centre.

PATIENTS AND METHODS

Consecutive patients undergoing acoustic neuroma surgery. Intraoperative facial nerve activity was digitised and stored on a personal computer for future analysis. Operative events were flagged. Recordings were available in 27 patients.

MAIN OUTCOME MEASURES

Frequent mechanically induced contractions (< 20), prolonged trains of facial nerve activity (total time > 199 seconds), and facial nerve brainstem stimulus threshold were correlated with facial nerve outcome.

RESULTS

A brainstem stimulus threshold > 0.1 mA was significantly associated with intermediate or poor facial nerve function (House-Brackmann grade > 2) on the sixth postoperative day, at 1 month and 6 months. Patients with normal or near-normal facial function on the first day and a threshold of > 0.1 mA were significantly more likely to develop a delayed facial nerve palsy. Frequent contractions were noted in 74% of patients and persistent train activity in 59%. Neither was predictive of facial nerve outcome.

CONCLUSIONS

An elevated brainstem threshold is helpful in predicting delayed facial nerve palsy and suboptimal facial nerve outcome. Persistent train activity and frequent contractions, do not have major prognostic significance.

HIV-1 dynamics after transient antiretroviral therapy: implications for pathogenesis and clinical management

Simple models of CD4 lymphocyte interactions with human immunodeficiency virus (HIV) lead to the hypothesis that progression of HIV infection involves an increase in viral replicative capacity, due either to changes in the virus or in the host environment, or both. In order to consider how changes in plasma virus load after transient, potent antiretroviral therapy can be used to test the above hypothesis--a simple mathematical model that encompasses the processes of (1) arrival of new CD4 lymphocytes, (2) death/removal of these cells by HIV-independent mechanisms, (3) infection of susceptible CD4 lymphocytes by HIV, and (4) death/removal of infected cells was investigated. This showed that the in vivo rate of increase in plasma virus load immediately after transient therapy provides a measure of the viral replicative capacity. Thus, the hypothesis that progression of HIV infection involves an increase in viral replicative capacity can be tested by measuring this viral growth rate in patients with high CD4 counts and in patients with low CD4 counts. Studies should thus investigate dynamics of changes in virus levels after stopping antiretroviral therapy and, in particular, measure rates of increase in virus in patients at high and low CD4 counts. In practice, such data may assist in therapeutic management of patients with HIV infection.

Comparative efficacy and potency of ipratropium via Turbuhaler and pressurized metered-dose inhaler in reversible airflow obstruction

Ipratropium bromide (IB), typically delivered by pressurized metered dose inhaler (pMDI), is used to treat patients with reversible airways obstruction. Use of the pMDI, unlike the Turbuhaler (TH), demands co-ordination of actuation with inspiration for efficient use. Two studies were carried out to compare the relative efficacy and potency of IB delivered by TH or pMDI. Both studies were of a randomized, double-blind and cross-over design. For the efficacy study, 15 patients received a cumulative dose of 160 microg IB via TH or pMDI as doses of 20, 20, 40 and 80 microg at 45 min intervals on two days. Forced expiratory volume in one second (FEV1) was measured prior to and 40 min after dosing. For the potency study, 33 patients received 10, 20 or 40 microg of IB via TH, 20 microg IB via pMDI, or placebo, on five days. FEV1 was recorded prior to and 15-360 min after dosing. For the efficacy study, there was no difference in FEV1 response to a cumulative dose of IB via pMDI and TH. More than 80% of the maximum effect was seen at the lowest dose (20 microg of IB). Regarding the potency study, the FEV1 response to 20 microg IB administered via pMDI was similar to that of 10 microg via TH; 20 microg via TH was significantly more effective than 20 microg via pMDI (p<0.05). In conclusion, the efficacy study showed that maximum FEV1 occurred at low doses of IB, negating any opportunity to identify differences between devices. The potency study indicated that the 10 microg dose via TH was of similar efficacy to the 20 microg dose via pMDI, confirming an efficacy ratio of 1.5-2.0:1 for the TH device.

Systemic corticosteriod rapidly reverses bronchodilator subsensitivity induced by formoterol in asthmatic patients

There is evidence that downregulation and desensitization of airway beta 2-adrenoceptors (beta 2-AR) develops after continuous exposure to long-acting beta 2-agonists such as formoterol and salmeterol. To investigate the facilitatory effects of acute administration of systemic corticosteroid on bronchodilator subsensitivity, as might occur in the setting of acute asthma, 12 subjects with moderately severe asthma, with a mean FEV1 of 66% predicted, of whom were all receiving inhaled corticosteriod, were randomized to receive either inhaled placebo (PL) or inhaled formoterol (FM) 24 micrograms twice daily for 4 wk in a double-blind crossover study. Subjects were also genotyped in terms of beta 2-Ar polymorphism at loci 16 and 27. A dose-response curve (DRC) and duration-time profile for FM (12 to 108 micrograms) was produced 1 h after administration of placebo tablets and after injection at 3 wk, and 1 h after administration of oral prednisolone, 50 mg, and intravenous hydrocortisone, 200 mg, at 4 wk. Comparisons between treatments were made with area-under-curve (AUC) measurements as the change from baseline. There was a significant rightward shift in the DRC after FM as opposed to placebo for delta FEV1 (as AUC, L.h): 2.51 versus 4.22 (95% CI: 0.54 to 2.89; p = 0.01) and delta FEF25-75 (as AUC, L x 10(3)): 11.30 versus 19.94 (95% CI: 2.12 to 15.12; p = 0.01). This was significantly reversed by steroid (S) for FEV1 (FM versus FM+5): 2.51 versus 3.57 (95% CI: 0.11 to 2.27; p = 0.03) and for FEF25-75: 11.30 versus 18.47 (95% CI: 2.52 to 11.70; p = 0.005). Lymphocyte beta 2-AR density (log Bmax; fmol/10(6) cells) showed significant upregulation 3 h after steroid (FM+5 versus FM): 0.34 versus 0.24 (95% CI: 0.02 to 0.18; p = 0.01). For heart-rate response (as AUC, beats), there was subsensitivity with FM versus PL: 2,700 versus 5,200 (95% CI: 40 to 5,000; p < 0.001), and this was reversed by steroid (FM+5 versus FM): 9,600 versus 2,700 (95% CI: 4,900 to 8,800; p < 0.001). This reversal by systemic corticosteroid appears to be generally independent of beta 2-AR polymorphism at loci 16 and 27. In conclusion, we have demonstrated that bronchodilator subsensitivity occurs after regular inhaled FM in asthmatic patients, and is rapidly reversed by systemic corticosteroid. Thus, in acute asthma, systemic corticosteroid should be administered a soon as possible, in order to restore normal airway beta 2-AR sensitivity, particularly in patients who are receiving regular long-acting beta 2-agonists.

Computed tomography in chronic inflammatory bowel disease

In children with complicated inflammatory bowel disease, conventional ultrasound imaging may not define the extent of extraluminal disease and the involvement of other viscera. Three children with chronic inflammatory bowel disease are presented, where computed tomography was well tolerated and provided valuable information on extraluminal disease, involvement of other organs, and the state of the bowel wall and mesentery. In children in whom ultrasound examination is inconclusive or limited by gas or tenderness, computed tomography can provide important information that may determine clinical management.

Correlation of peak systolic velocity and angiographic measurement of carotid stenosis revisited

BACKGROUND AND PURPOSE

Recent observations from the North American Symptomatic Carotid Endarterectomy Trial (NASCET) questioned the reliability of peak systolic velocity (PSV) criteria for grading carotid stenosis. We compared PSV and angiographic measurements at our center together with known physiological relationships to investigate the accuracy of ultrasound.

METHODS

Consecutive patients who underwent both color-coded duplex ultrasound and intra-arterial digital subtraction angiography were studied. PSV was determined with angle correction at the site of the tightest internal carotid artery narrowing. Carotid stenosis was measured on angiograms with the North American (N) and common carotid (C) methods. Variables for the stepwise multiple linear regression analysis were selected from an axisymmetrical flow model.

RESULTS

Eighty bifurcations were imaged in 40 patients. PSV did not exceed 140 cm/s in normal vessels. In diseased arteries, PSV increased proportionally with increasing stenosis and decreased to 0 cm/s at occlusion. In stepwise selection of polynomial terms, the linear, quadratic, and cubic correlations of .38, .17, and .22 for N and .45, .24, and .03 for C were found to be significant (P < .02). When only stenosed vessels were evaluated, PSV increase was found with greater scatter for the N measurement: r2 = .73 for N and r2 = .85 for C (n = 50; P = .03 for the difference between two correlated correlation coefficients).

CONCLUSIONS

At our laboratory PSV consistently correlates well with N and C angiographic measurements, as determined with a simple flow model. The complex nature of these correlations and greater variability of the N measurement should be taken into account when data from different centers are compared.

Comparative psychophysical evaluation in cochlear implantation: electrical and magnetic stimulation

Transtympanic electrical stimulation, either in the form of round window or promontory placement of electrode prior to cochlear implantation is an accepted and commonly used psychophysical tool. Certain response parameters have been identified as predictors of outcome. This study compared the subjective auditory responses generated by promontory electrical stimulation (PES) with those from two noninvasive modalities, namely peritympanic electrical stimulation (PTES) and transcranial magnetic stimulation (TMS). Ten postlingually deafened adult cochlear implant candidates were studied. Standard psychophysical parameters were obtained from patients undergoing PES and PTES. A more subjective form of evaluation was conducted for TMS. Subsequently, nine patients received the multichannel Nucleus (Cochlear Corp., Denver, CO, U.S.A.) implant and one patient a Clarion (Advanced Bionics, Sylmar, CA, U.S.A.) implant. Compared with PES. PTES elicited increased threshold responses with similar dynamic ranges between 50 and 400 Hz of stimulation. The differences were, by and large, insignificant. PTES appeared to be a useful alternative in selected individuals owing to its noninvasiveness. TMS, on the other hand, was incapable of clearly inducing auditory percepts. It also produced concomitant facial and trigeminal stimulation, limiting its potential use as a prognostic tool.

A locus for bipolar affective disorder on chromosome 4p

The main clinical feature of bipolar affective disorder is a change of mood to depression or elation. Unipolar disorder, also termed major depressive disorder, describes the occurrence of depression alone without episodes of elevated mood. Little is understood about the underlying causes of these common and severe illnesses which have estimated lifetime prevalences in the region of 0.8% for bipolar and 6% for unipolar disorder. Strong support for a genetic aetiology is found in the familial nature of the condition, the increased concordance of monozygotic over dizygotic twins and adoption studies showing increased rates of illness in children of affected parents. However, linkage studies have met with mixed success. An initial report of linkage on the short arm of chromosome 11 (ref. 4) was revised and remains unreplicated. Reports proposing cosegregation of genes found on the X chromosome with bipolar illness have not been supported by others. More recently bipolar disorder has been reported to be linked with markers on chromosomes 18, 21, 16 and a region on the X chromosome different from those previously suggested. We have carried out a linkage study in twelve bipolar families. In a single family a genome search employing 193 markers indicated linkage on chromosome 4p where the marker D4S394 generated a two-point lod score of 4.1 under a dominant model of inheritance. Three point analyses with neighbouring markers gave a maximum lod score of 4.8. Eleven other bipolar families were typed using D4S394 and in all families combined there was evidence of linkage with heterogeneity with a maximum two-point lod score of 4.1 (theta = 0, alpha = 0.35).

Peak inspiratory flow through Turbuhaler in acute asthma

Efficient use of dry powder inhalers, such as Turbuhaler, is dependent on the generation of adequate inspiratory flow. It is not clear whether patients with acute asthma are able to generate adequate flow. Peak inspiratory flow (PIF) was measured through an empty Turbuhaler, and without this device, in 99 adults presenting to hospital with acute exacerbations of asthma. Where possible, patients were studied prior to nebulized bronchodilator therapy. Mean (SD) forced expiratory volume in one second (FEV1) was 1.2 (0.7) L, forced vital capacity (FVC) 2.1(1.0) L and peak expiratory flow (PEF) 199 (92) L.min-1. PIF without Turbuhaler was 152 (77) L.min-1 and correlated with PEF (r = 0.69). PIF through Turbuhaler was 60 (20) L.min-1 and weakly correlated with PEF (r = 0.35), and with PIF without Turbuhaler (r = 0.43). Two patients failed to generate the minimum inspiratory flow (30 L.min) required for efficient use of Turbuhaler; both recorded 26 L.min-1. Acute asthma is associated with considerable inspiratory, as well as expiratory airflow limitation. The relationship between inspiratory and expiratory airflow is not strong enough to predict whether patients with severe acute asthma will have difficulty using dry powder inhalers efficiently. Despite this, 98% of patients in this study generated inspiratory flow through Turbuhaler which would allow a therapeutically active amount of bronchodilator drug to be delivered to the airways.

The evolution of the clinician-scientist model of neurological rehabilitation

Over the past three or four decades two treatment technologies have been evolving in parallel, recently to some extent merging. The first of these technologies is behaviour analysis, with its emphasis on identification and manipulation of variables external to the individual as controlling agents. The second is neurological rehabilitation, with a characteristic focus of resources on recovery of function following neurological damage. The histories of both of these technologies are similar in that they emerged from basic laboratory research with non-human subjects, followed by extension of findings to research with humans, culminating in widespread formal application of results. The past 5 years have seen a convergence of behaviour analytic and neurological rehabilitation techniques resulting in major shifts in treatment service delivery systems. We briefly chronicle the emergence of these two technologies from their basic underpinnings through world-wide use. Further, discussion is provided describing our and others' experience with the combining of behaviour and neurological rehabilitation. Finally, we give an account of an innovative neurological rehabilitation service delivery system designed to deliver effective cost-efficient treatment in the patient's natural environment. Implicit in the design and implementation of this real-world model of rehabilitation is the combination of behavioural technology and neurological rehabilitation towards the achievement of functional outcomes which endure. Our purpose in the above is to provide an introduction to present use and future potential of behaviour analytic methodologies and technologies in rehabilitation.

Clinical audit of a specialist symptomatic breast clinic

The efficient delivery of health care requires vigilant quality assurance. We describe the audit of our symptomatic breast clinic, which includes the option of a one-stop diagnostic service. A total of 134 new and 386 follow-up patients attended over four consecutive clinics. The majority of new referrals (68%) were seen by a consultant surgeon. Urgent referrals were seen significantly sooner than routine referrals (P < 0.001, chi 2-test), and the mean wait from designated appointment to seeing the surgeon was 37.6 (range-68 to 171) min. One-stop investigations were offered to 50 patients; of these, 36 women (72%) had a total wait of less than 2 h. For those not investigated at the same clinic, the mean time until investigations was 6.1 (range 0-36) days and mean recall was 2.7 (range 1-8) weeks. Patients undergoing definitive surgery for cancer (n = 5) were operated on average 14.2 (range 7-27) days after the decision was made in outpatients, while the mean waiting time for non-cancer operations was 49.7 (range 15-98) days. Objective audit on outpatient services is possible and can lead to improvement of services.

Tuberculous pancreatitis: a diagnostic problem. Case report and review of literature

A 22-year-old Pakistani man presented with a 1-year history of recurrent attacks of pancreatitis of unknown etiology that had required hospitalization and extensive investigation in Pakistan. He was admitted with abdominal pain, fever, and weight loss. An ultrasound and computed tomographic scan of the abdomen revealed abdominal lymphadenopathy, bulky and inhomogeneous pancreas, and a large fluid collection anterior to the right lobe of the liver. The collection was aspirated but Gram-stain, Ziehl-Neelsen stain for acid-fast bacilli, and DNA analysis by a highly specific polymerase chain reaction-based assay were negative. Because of a strong clinical suspicion of tuberculosis, the patient was started on antituberculous chemotherapy; 4 weeks later the aspirate grew Mycobacterium tuberculosis (hominis). The patient improved rapidly and has remained well after 18 months follow-up. A high index of clinical suspicion and appropriate microbiological investigation is required for the diagnosis of this rare, but potentially curable cause of pancreatitis.

Empowerment and the psychiatric consumer/ex-patient movement in the United States: contradictions, crisis and change

A political movement in the United States by consumers and ex-patients of psychiatry has challenged the assumptions and negative consequences of traditional mental health practice and its control by professionals. In recent years, the movement has succeeded in gaining support to produce alternative programs based on a philosophy of 'consumer empowerment' and run entirely by consumers and ex-patients. In this article, I present results from an ethnographic study of one such alternative and I attempt to explain the discrepancy between the center's philosophy of empowerment and its actual practices. Utilizing this data, the consumer literature, and interviews with consumer leaders nationwide, I explain this situation in terms of conceptual problems with the terms 'empowerment' and 'consumer empowerment', local structural conditions under which the center operated, and the larger situation of the psychiatric consumer/ex-patient movement in the United States today. The case study represents a crisis in the consumer movement today, in which rapid growth of alternatives has been accompanied by a social amnesia of the emancipatory vision that originally spawned the movement.