Clinical governance and palliative care: a question of synergy

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

Sex differences in renal transplantation in Canada

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

Reduced gastric mucosal vascularity in patients with chronic gastritis

OBJECTIVES/DESIGN

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

Myxoid malignant fibrous histiocytoma mimicking papular mucinosis

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

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

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

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

OBJECTIVES AND METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Breaking bad news to patients with cancer

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

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

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