General practitioners' knowledge and experience of the abuse of older people in the community: report of an exploratory research study in the inner-London borough of Tower Hamlets

A pioneering study aimed to quantify general practitioners' (GPs') knowledge of cases of elder abuse in the community. The research found that elder abuse is a problem encountered by GPs, and that a large majority of responders would welcome training in the identification and management of the problem.

Internal quality assurance activities of a surgical pathology department in an Australian teaching hospital

AIM

To assess the role of a quality assurance programme in improving the service provided by a surgical pathology department.

METHODS

A continuous internal quality assurance study of the activities of an anatomical pathology department in an Australian teaching hospital was undertaken over a five year period. This addressed all steps involved in the production of a surgical pathology report. These were addressed in an open forum which included technical, scientific, clerical, and medical staff. Minor errors not needing immediate action were discussed and incorporated into laboratory practice. For major discrepancies with potential implications for patient management supplementary reports were issued and the relevant clinician informed of the outcome.

RESULTS

Comprehensive peer review of 8.9% of the total workload of the department (3530 cases) and all the frozen sections (916 cases) over a period of five years, beginning in 1991, led to comments on some aspects of the original report by the reviewer in 19.6% of the cases. The great majority of the comments were minor, concerning issues related to the microscopic findings (4%), macroscopic description (3.1%), clerical aspects (3%), typographical errors (3%), coding errors (2.7%), technical errors including poor sections and incorrect labelling (1.7%), inadequate clinical history (1.2%), and incomplete or incomprehensible diagrams (0.9%). In two cases (0.05%) the original report did not state proximity of the tumour to surgical margins and in three of the frozen sections (0.3%) the original diagnosis was incorrect. However, in these cases the frozen section assessment did not alter the overall management of the cases.

CONCLUSIONS

This study highlights the importance of a review system in detecting errors in surgical pathology reporting. Recognition of the fact that surgical pathology is not infallible has improved the end product. It has also minimised interobserver variability in the department, resulting in a uniform approach among the pathologists to macroscopic description, specimen sampling, special stains, and histological reporting.

Nerve growth factor induced hyperalgesia in the rat hind paw is dependent on circulating neutrophils

The mechanisms by which nerve growth factor (NGF) induces thermal hyperalgesia and neutrophil accumulation have been investigated in the rat. Thermal nociceptive thresholds in rat hind paw were measured as the time taken for paw withdrawal from a heat source and neutrophil accumulation was measured in hind paw and dorsal skin samples using a myeloperoxidase assay. NGF (23-80 pmol intraplantar (i.pl.) injection) induced a significant (P < 0.05, n = 6-16) thermal hyperalgesia at 5 h after injection and significant neutrophil accumulation (P < 0.05, n = 6) was observed with NGF (40 pmol). In dorsal skin, where multiple samples can be assessed, intradermal (i.d.) NGF was 10-30 times less potent than interleukin-1beta in inducing neutrophil accumulation. The 5-lipoxygenase inhibitor ZM230487 (10 nmol co-injected with NGF) significantly attenuated neutrophil accumulation and hyperalgesia induced by NGF; unlike the histamine and 5-hydroxytryptamine antagonists (mepyramine and methysergide) which were without effect at the times measured. Furthermore, depletion of circulating neutrophils (using a rabbit anti-rat neutrophil antibody) abolished NGF induced hyperalgesia. These results indicate that neutrophils, which accumulate in response to a 5-lipoxygenase product, play a crucial role in NGF-induced hyperalgesia.

Axillary lymph node calcification due to metastatic papillary carcinoma

A case is presented in which calcification in an axillary lymph node seen on a screening mammogram was the presenting feature of metastatic papillary carcinoma, presumed to be of thyroid origin. The differential diagnosis of axillary lymph node calcification seen on mammography is reviewed.

The impact of molecular diagnosis on familial colorectal cancer

We have shown the impact of molecular diagnostics related to mutation detection in an extensive family with a strong history of colorectal cancer. The nature and presentation of the cancers suggested that hereditary nonpolyposis colorectal cancer was the most likely cause. The strategies employed have enabled the detection and characterisation of the causative mutation in the proband and predictive testing in the remaining relatives where requested. Using the chemical cleavage of mismatches technique and direct sequencing, the MSH2 and MLH1 genes of the proband were investigated. A single base substitution, C-->T at nucleotide 350, codon 117, of the MLH1 gene was identified. Across the family pedigree at specific points, 22 other relatives have been tested for the mutation by direct DNA sequencing from genomic DNA. Of the total of 23 patients tested to date, 11 have the mutation. In conjunction with appropriate genetic counselling, this service has clarified the genetic status of many individuals within this family. Predictive information provided prior to the development of symptoms enables individuals to make informed choices regarding disease management and the future, removing the anxiety associated with the unknown.

The role of peer review in internal quality assurance in cytopathology

In 1992 we set up a peer review system to address all the steps involved in the production of a cytopathology report. The aim of the study was to generate accurate, timely and clinically relevant cytopathology reports. During a four year period we monitored and recorded activities such as turnaround time and adequacy of sampling as well as errors including typographical, SNOMED, coding, technical, labelling of slides, clerical, macroscopic and microscopic errors. The findings were discussed at weekly laboratory meetings attended by technical, scientific, clerical and medical staff. Minor errors not needing immediate action were discussed and incorporated as future improvements into the workings of the laboratory. For major discrepancies with potential implications for patient management, supplementary reports were issued and the relevant clinician was informed of the outcome. Detailed peer review of 1.3% of the total workload, during the period of the study, led to comments on some aspects of the original report in 24.9% of the reviewed cases. The majority of comments (57%) were minor, concerning issues related to the pre-analytical (clinical history, demographics, clerical and technical) aspects of the cases. The post analytical (microscopic description, diagnosis, recommendation and coding) phase of cases attracted 43% of the comments. In 1.1% of cases, the reviewer made suggestions regarding the diagnosis, and in 0.4% of cases a different recommendation was made. Cost-benefit analysis revealed that our internal quality assurance (IQA) activities added $1.20 to the total cost of each cytopathology case received and processed in the laboratory. On the benefit side, analysis of the data showed a continuous fall in the number of errors in both the pre-analytical and post-analytical phases of report generation. Furthermore, the turnaround time fell from 3.0 days at the beginning of the study to 1.7 days at present. These IQA activities have highlighted the importance of such a review system in detecting errors in cytopathology reporting. Recognition of the fact that cytopathology suffers from observer variability has led to the adoption of a uniform approach to cytological reporting among cytotechnologists and pathologists.

Histopathological correlates of epileptogenicity as expressed by electrocorticographic spiking and seizure frequency

PURPOSE

To study the correlation between histopathology and epileptogenicity, as measured by seizure frequency and electrocorticography (EcoG), in patients with cortical dysplasia (CD) as compared with control patients with gangliogliomas or gliomas.

METHODS

The influence of the histopathological classification and the presence of balloon cells in CD on the frequency and extension of five predefined patterns of ECoG spiking, seizure frequency, age of seizure onset and 6-month postoperative outcome were analyzed in 32 patients with focal epilepsy undergoing presurgical evaluation with chronically implanted subdural electrodes.

RESULTS

Comparison of patients with CD, gangliogliomas, and gliomas showed that the seizure frequency was greatest in patients with CD and ECoG spiking and was most extensive in patients with gangliogliomas. The onset of epilepsy was earlier in patients with CD and with gangliogliomas. None of these differences was significant. However, in patients with CD, the presence of balloon cells was associated with significantly greater seizure frequency (p=0.009), and a significantly greater number of electrodes recording continuous frequent spiking (p=0.03). The presence of continuous very frequent spiking correlated with the duration of the epilepsy and the number of seizures recorded during monitoring. No significant correlation was detected between histopathology, seizure frequency, or ECoG activity and postoperative outcome, which was relatively favorable in patients with balloon cells.

CONCLUSIONS

CD refers to a variety of histopathological patterns associated with different epileptogenicity. In CD, increased clinical and ECoG epileptogenicity correlates with the presence of balloon cells. This finding confirms that balloon cells should be considered in the histopathological classification of CD. The predefined ECoG were not specific for any of the histopathologies investigated.

Schistosomal myelitis: findings at MR imaging

Schistosomal spinal cord involvement is a rare complication of infection by Schistosoma mansoni. This work reports the MR imaging findings in a patient with schistosomal myelitis involving the lower spinal cord and conus medullaris. MR imaging showed a focal mass with a slightly nodular surface and which had peripheral enhancement after contrast administration. The MR appearance of this complication of schistosomal infection is important to recognize so that early medical therapy can be started in an attempt to maximize neurologic recovery.

Piezoelectric response of scleral collagen

The piezoelectric coefficients (d31) for a number of bovine and human scleral collagen samples were determined as a function of drying time at room temperature. The measured values of d31 decreased with drying time. There were significant differences in the values of the d-coefficient between the human and bovine eyes as well as in the values obtained from different regions of the eye.

Survival after gastrointestinal mucormycosis in a neonate

Gastrointestinal mucormycosis has been reported more frequently in adults than in children. Due to the high mortality diagnosis is usually made at autopsy. Only one case of a neonate surviving this disease has been described. We report a premature infant presenting clinically with enterocolitis but lacking the radiological characteristics of necrotizing enterocolitis (NEC) Gastrointestinal mucormycosis was diagnosed on the histological specimen. The infant survived after surgery and 6 weeks of antifungal treatment. A high level of suspicion and early surgical intervention are necessary to make the correct diagnosis and commence appropriate treatment.

Moderate drinking in women: a concept analysis

This analysis clarifies the concept of moderate drinking in women. The literature reflects a variety of definitions of moderate drinking and refers largely to drinking in men. Several strategies for concept analysis suggested by Walker and Avant (1995) resulted in the formulation of a theoretical definition of moderate drinking in women applicable to practice and research. The defining attributes of women's moderate drinking in contemporary U.S. culture include (1) minimization of risks of alcohol-related problems, (2) a desire for any potential health benefits, (3) deliberate adoption of personal drinking guidelines based on some knowledge of the effects of alcohol, (4) control of when and how much alcohol is consumed, (5) sensitization to special drinking considerations faced by women, and (6) having at least one interpersonal relationship with another moderate drinker.

Phyllodes tumor with lobular carcinoma in situ and liposarcomatous stroma

We describe a patient with a malignant phyllodes tumor with both lobular carcinoma in situ and liposarcomatous stromal differentiation. Although lobular carcinoma in situ and adipose differentiation have been reported as separate features rarely seen in the phyllodes tumor, we are unaware of any cases in which both of these features have been seen within the same tumor. The prognosis for this patient related not only to the malignant stromal component of the tumor but also to her increased risk of developing carcinoma in the remaining breast tissue.

Analysis of agonist-agonist interactions: the crucial influence of curve shape

The two-receptor:one-transducer model (Leff, 1987) is here extended to analyze interactions between agonists displaying E[A] curves of different shapes, by incorporating slope factors into the separate and common parts of the transduction pathway. Interactions were modelled as the effect of one agonist, at fixed concentration, on the curve to the other. A variety of patterns of position and slope changes are predicted. These do not depend on the shape of the control curve, rather, they depend on the slope factors in the separate and common pathways. The following specific predictions are made: (1) when the common pathway is steep, curves undergo potentiation and flattening; (2) when the common pathway is flat, curves undergo right-shift and steepening; (3) when the common pathway is hyperbolic, curves undergo right-shift, with no slope change; (4) when the slope depends on the separate pathways, curves only undergo right-shift with no change in slope. The model provides a sound basis for classifying agonist interactions and for detecting additional, synergistic or antagonistic properties. This analysis indicates that methods based on dose-additivity or independence are less reliable for these purposes. The model provides a practical test, based on slope changes, to detect and quantify additional properties.

Stable inheritance of an HLA-"blank" phenotype associated with a structural mutation in the HLA-A*0301 gene

A serological family study identified an HLA-A "blank" segregating through three generations of apparently healthy individuals. The HLA-A*0301 allele was assigned by DNA genotyping in each of the three individuals. Complete absence of cellular expression of the HLA-A3 antigen was associated with a 6 nucleotide deletion in exon 3 of the A*0301 gene. The in-frame deletion of nucleotides 373-378 results in the absence of residues C101 and D102 from the mature HLA-A heavy chain. Cysteine 101 is involved in the formation of the highly conserved disulfide bridge in the alpha 2 domain of the class I molecule, and deletion of this residue is believed to be highly disruptive to proper folding and function of the class I molecule.

Effects of short-term supplementation with coenzyme Q10 on myocardial protection during cardiac operations

BACKGROUND

Coenzyme Q10 (CoQ10) is a naturally occurring vitamin-like substance that may have a beneficial role in ischemia-reperfusion injury. Coenzyme Q10 administered either as an additive to cardioplegia or as long-term preoperative oral supplementation has been reported to ameliorate myocardial injury after cardiac operations.

METHODS

To determine whether short-term supplementation with large doses of CoQ10 (600 mg in divided doses 12 hours before operation) was effective in myocardial protection, 20 patients with well-preserved left ventricular function (ejection fraction greater than 0.50) undergoing elective coronary revascularization were enrolled in a prospective, double-blind, placebo-controlled randomized trial. Serial concentrations of CoQ10, myoglobin, creatine kinase MD fraction, and cardiac troponin T were measured preoperatively and 1, 6, 24, 72, and 120 hours postoperatively. Efficacy of myocardial protection was also assessed by clinical outcome and serial changes in electrocardiographic indices.

RESULTS

The patient groups were similar with respect to preoperative and intraoperative characteristics. There was no significant difference in the preoperative plasma levels of CoQ10. These levels fell significantly in both groups after operation, although the magnitude of the decrease was less in the CoQ10-supplemented group (43% versus 60%). In both groups, there were significant postoperative increases in myoglobin, creatine kinase MB fraction, and cardiac troponin T. The magnitude of increases in cardiac troponin T was greater in the CoQ10-supplemented group, reaching marginal overall statistical significance (p = 0.06).

CONCLUSIONS

Short-term supplementation with large doses of CoQ10 does not lead to improved myocardial protection in patients undergoing coronary revascularization with well-preserved ventricular function and relatively short ischemic times.

The Norton score and pressure sore prevention: Critique II

The prevention and management of pressure sores presents enormous challenges to health professionals, particularly those working in specialties such as elderly care or spinal Injuries. Bringing together the findings of three investigations and offering practical guidance to nursing colleagues, this frequently quoted study has become established as a key contribution to pressure area care. Certainly the work displays great foresight and conviction that something could, and indeed should, be done about pressure area care. Given the importance attached to this work, however, it is of concern that a number of methodological and analytical oversights cast doubt on the validity of the conclusions.

Smoking policy and cessation in an inner-city hospital

Hospital policies regarding cigarette smoking can affect the smoking habits of employees, patients, and visitors. Successful smoking policy development and impact have been reported in a number of hospitals. These reports have been from financially secure or university hospitals. This article reports on the policy experience at Interfaith Medical Center, a public hospital serving an economically disadvantaged black inner-city community. Policy implementation and smoking cessation efforts were directed by a broad-based hospital committee. An employee survey demonstrated support for a policy restricting but not banning smoking (89% of nonsmokers, and 80.2% of smokers). Among smoking employees, 87.6% wanted to quit. A policy restricting smoking to designated areas in the cafeteria and coffee shop was enacted. Health fairs and smokeout contests were enthusiastically received and resulted in short-term cessation verified by exhaled carbon monoxide levels. Assemblies where ex-smokers were given "Hall of Fame" certificates, "stop smoking" art contests, and a "stop smoking hotline" generated further cessation activity. The department of medicine, in cooperation with the National Heart, Lung, and Blood Institute's Smoking Education Program, set up a training program for residents on how to help patients quit. Overall, the smoking prevalence, attitudes, and enthusiasm to quit were similar to previous reports in financially secure hospitals. Unfortunately, lack of resources and staff turnover led to dissolution of the program. Institutional stability and a funding source are critical for the long-term success of hospital smoking cessation programs.