Clinical characteristics of people with intellectual disability admitted to hospital with constipation: identifying possible specific high-risk factors

BACKGROUND

People with intellectual disabilities (ID) die on an average 20 years earlier to the general population. They have higher rates of multimorbidity and polypharmacy. Around 25% of people with ID report chronic constipation. The England Learning Disabilities Mortality Review found that nearly 25% of deaths identified constipation as a long-term health problem. However, the likely risk factors for constipation related harm are poorly enumerated. We sought to identify possible specific high-risk factors by examining the clinical characteristics of people with ID admitted to hospital with constipation.

METHODS

Data of people with ID admitted with constipation in two general hospitals covering a population of 1.3 million from 2017 to 2022 were reported using the STROBE guideline for cohort studies. Collected data included age, gender, intellectual disability severity, recorded medication, presenting complaint and co-morbidities. The medication anticholinergic burden was calculated using the anticholinergic burden scale. Continuous variables were summarised by mean and standard deviation if normally distributed, with categorical variables summarised by the number and percentage in each category.

RESULTS

Of 46 admissions (males 52%), 57% had moderate to profound ID, 37% had epilepsy, 41% prescribed antiseizure medication (ASM) and 45% were on laxatives. Average age was 46 years. The anticholinergic burden score mean was 2.3 and median, one.

CONCLUSIONS

We can hypothesise that people with more severe ID, suffering from epilepsy and on ASM may be more at risk of developing severe constipation. Some admissions may be avoided with earlier use of laxatives in the community.

High-resolution measurements of swordfish skin surface roughness

The three-dimensional morphology of swordfish skin roughness remains poorly understood. Subsequently, its importance to the overall physiology and hydrodynamic performance of the swordfish is yet to be determined. This is at least partly attributable to the inherent difficulty in making the required measurements of these complex biological surfaces. To address this, here two sets of novel high-resolution measurements of swordfish skin, obtained using a modular optical coherence tomography system and a gel-based stereo-profilometer, are reported and compared. Both techniques are shown to provide three-dimensional morphological data at micron-scale resolution. The results indicate that the skin surface is populated with spiny roughness elements, typically elongated in the streamwise direction, in groups of up to six, and in good agreement with previously reported information based on coarser measurements. In addition, our data also provide new information on the spatial distribution and variability of these roughness features. Two approaches, one continuous and another discrete, are used to derive various topographical metrics that characterize the surface texture of the skin. The information provided here can be used to develop statistically representative synthetic models of swordfish skin roughness.

Impact of retrotransposon protein L1 ORF1p expression on oncogenic pathways in hepatocellular carcinoma: the role of cytoplasmic PIN1 upregulation

BACKGROUND

Molecular characterisation of hepatocellular carcinoma (HCC) is central to the development of novel therapeutic strategies for the disease. We have previously demonstrated mutagenic consequences of Long-Interspersed Nuclear Element-1 (LINE1s/L1) retrotransposition. However, the role of L1 in HCC, besides somatic mutagenesis, is not well understood.

METHODS

We analysed L1 expression in the TCGA-HCC RNAseq dataset (n = 372) and explored potential relationships between L1 expression and clinical features. The findings were confirmed by immunohistochemical (IHC) analysis of an independent human HCC cohort (n = 48) and functional mechanisms explored using in vitro and in vivo model systems.

RESULTS

We observed positive associations between L1 and activated TGFβ-signalling, TP53 mutation, alpha-fetoprotein and tumour invasion. IHC confirmed a positive association between pSMAD3, a surrogate for TGFβ-signalling status, and L1 ORF1p (P < 0.0001, n = 32). Experimental modulation of L1 ORF1p levels revealed an influence of L1 ORF1p on key hepatocarcinogenesis-related pathways. Reduction in cell migration and invasive capacity was observed upon L1 ORF1 knockdown, both in vitro and in vivo. In particular, L1 ORF1p increased PIN1 cytoplasmic localisation. Blocking PIN1 activity abrogated L1 ORF1p-induced NF-κB-mediated inflammatory response genes while further activated TGFβ-signalling confirming differential alteration of PIN1 activity in cellular compartments by L1 ORF1p.

DISCUSSION

Our data demonstrate a causal link between L1 ORF1p and key oncogenic pathways mediated by PIN1, presenting a novel therapeutic avenue.

Making Every Contact Count with people with MSK conditions: Exploring physiotherapist acceptability

 

There are known risk factors that are associated with the onset and exacerbation of musculoskeletal (MSK) conditions and pain. Physiotherapists are uniquely placed to deliver brief interventions with their patients. Healthy Conversation Skills is the main training component of the Wessex approach to Making Every Contact Count. Despite its potential for promoting MSK health and wellbeing, there is no evidence to support its acceptability within MSK services. This is the first known study to explore the use and perceptions of the Wessex model of MECC HCS within MSK services. A mixed method design was used. Phase one employed an online questionnaire, open to all professionals trained in MECC HCS, consisting of items relating to implementation outcomes. Barriers and facilitators to delivery were explored and mapped to the Theoretical Domains Framework. Phase two invited physiotherapists for a follow-up interview and qualitatively explored their acceptability of delivering MECC HCS to patients with MSK conditions. MECC HCS was found to be highly acceptable, appropriate, and feasible. Physiotherapists reported using their skills at least daily but missed opportunities for delivering MECC HCS were evident. Barriers mapped mostly to ‘Environmental Context and Resources’ on the Theoretical Domains Framework. Qualitative themes developed during phase two were: ‘Recognising the patient as the expert supports change', ‘MECC HCS improves physiotherapy practice', ‘MECC HCS shared problem solving reduces workload', ‘time as a perceived barrier to MECC HCS’ and ‘system-level support needed to sustain MECC HCS'. MECC HCS is a promising brief intervention for supporting people with MSK conditions. Further rollout of this intervention may be beneficial for meeting the goals of the NHS and Public Health England in prevention of MSK conditions and promotion of MSK health. Barriers associated with sustainability must, however, be addressed.

Key messages

• Making Every Contact Count Healthy Conversation Skills is considered a highly acceptable brief intervention for supporting behaviour change in people with musculoskeletal conditions.

• Organisational, system-level barriers to implementation must be addressed in order to increase sustainability and enhance future roll out of the brief intervention.

HCV Activates Somatic L1 Retrotransposition-A Potential Hepatocarcinogenesis Pathway

Hepatitis C virus (HCV) is a common cause of hepatocellular carcinoma (HCC). The activation and mutagenic consequences of L1 retrotransposons in virus-associated-HCC have been documented. However, the direct influence of HCV upon L1 elements is unclear, and is the focus of the present study. L1 transcript expression was evaluated in a publicly available liver tissue RNA-seq dataset from patients with chronic HCV hepatitis (CHC), as well as healthy controls. L1 transcript expression was significantly higher in CHC than in controls. L1orf1p (a L1 encoded protein) expression was observed in six out of 11 CHC livers by immunohistochemistry. To evaluate the influence of HCV on retrotransposition efficiency, in vitro engineered-L1 retrotransposition assays were employed in Huh7 cells in the presence and absence of an HCV replicon. An increased retrotransposition rate was observed in the presence of replicating HCV RNA, and persisted in cells after viral clearance due to sofosbuvir (PSI7977) treatment. Increased retrotransposition could be due to dysregulation of the DNA-damage repair response, including homologous recombination, due to HCV infection. Altogether these data suggest that L1 expression can be activated before oncogenic transformation in CHC patients, with HCV-upregulated retrotransposition potentially contributing to HCC genomic instability and a risk of transformation that persists post-viral clearance.

Technique and outcome of day case laparoscopic hiatus hernia surgery for small and large hernias: a five-year retrospective review from a high-volume UK centre

INTRODUCTION

Laparoscopic anti-reflux surgery is the standard surgical treatment for gastro-oesophageal reflux disease in patients for who long-term pharmacotherapy is intolerable or ineffective. Advances in anaesthesia and minimally invasive surgery have led to day case treatment being adopted by some centres. The objective of this study is to describe our day case pathway and peri- and postoperative outcomes.

MATERIALS AND METHODS

This is a single centre, retrospective case series review of a prospectively collected database from October 2014 to August 2019 performed in a tertiary centre for upper gastrointestinal surgery. Data collected included demographics, comorbidities, indications, complications, length of stay and readmission.

RESULTS

A total of 362 patients underwent laparoscopic anti-reflux surgery with or without hiatus hernia repair of up to 10cm, with day case rates of 59%. Unplanned admission following day surgery was 5.1% (13/225) and 30-day readmission was 2.2% (8/362); 90.6% of patients remained in hospital for less than 24 hours. There was one intraoperative complication and one patient required revisional surgery within 30 days. The rate of all postoperative complications was 1.38% (5/362) with one postoperative mortality.

DISCUSSION

The inclusion of larger hernias is unusual, as most studies limit size to 5cm or less. Our results show the safety and feasibility of the procedure even when applied to hiatus hernias up to 10cm. Success was multifactorial and based on standardisation of procedures and support from dedicated specialist nursing staff.

CONCLUSION

Laparoscopic anti-reflux surgery can be performed safely as a day case procedure even in larger hiatus hernias, with a dedicated care pathway and specialist nurse practitioners to support it.

Resilience and return-to-work pain interventions: systematic review

BACKGROUND

Resilience is a developing concept in relation to pain, but has not yet been reviewed in return-to-work (RTW) contexts.

AIMS

To explore the role of resilience enhancement in promoting work participation for chronic pain sufferers, by reviewing the effectiveness of existing interventions.

METHODS

Resilience was operationalized as: self-efficacy, active coping, positive affect, positive growth, positive reinforcement, optimism, purpose in life and acceptance. Five databases were searched for randomized controlled trials (RCTs) whose interventions included an element of resilience designed to help RTW/staying at work for chronic pain sufferers. Study appraisal comprised the Cochrane risk of bias (RoB) tool and additional quality assessment. Findings were synthesized narratively and between-group differences of outcomes were reported. Heterogeneous PICO (population, intervention, comparator, outcome) elements precluded meta-analysis.

RESULTS

Thirty-four papers from 24 RCTs were included. Interventions varied; most were multidisciplinary, combining behavioural, physical and psychological pain management and vocational rehabilitation. Four found RTW/staying at work improved with intensive multidisciplinary interventions compared with less intensive, or no, treatment. Of these, one had low RoB; three scored poorly on allocation concealment and selective outcome reporting. Four trials had mixed results, e.g. interventions enabling reduced sick leave for people on short-term not long-term leave; 16 showed no improvement. Five trials reported resilience outcomes were improved by interventions but these were not always trials in which RTW improved.

CONCLUSIONS

Effectiveness of resilience interventions for chronic pain sufferers on RTW is uncertain and not as helpful as anticipated. Further agreement on its conceptualization and terminology and that of RTW is needed.

Population-based cohort study of variation in the use of emergency cholecystectomy for benign gallbladder diseases

Background

The aims of this prospective population-based cohort study were to identify the patient and hospital characteristics associated with emergency cholecystectomy, and the influences of these in determining variations between hospitals.

Methods

Data were collected for consecutive patients undergoing cholecystectomy in acute UK and Irish hospitals between 1 March and 1 May 2014. Potential explanatory variables influencing the performance of emergency cholecystectomy were analysed by means of multilevel, multivariable logistic regression modelling using a two-level hierarchical structure with patients (level 1) nested within hospitals (level 2).

Results

Data were collected on 4744 cholecystectomies from 165 hospitals. Increasing age, lower ASA fitness grade, biliary colic, the need for further imaging (magnetic retrograde cholangiopancreatography), endoscopic interventions (endoscopic retrograde cholangiopancreatography) and admission to a non-biliary centre significantly reduced the likelihood of an emergency cholecystectomy being performed. The multilevel model was used to calculate the probability of receiving an emergency cholecystectomy for a woman aged 40 years or over with an ASA grade of I or II and a BMI of at least 25·0 kg/m2, who presented with acute cholecystitis with an ultrasound scan showing a thick-walled gallbladder and a normal common bile duct. The mean predicted probability of receiving an emergency cholecystectomy was 0·52 (95 per cent c.i. 0·45 to 0·57). The predicted probabilities ranged from 0·02 to 0·95 across the 165 hospitals, demonstrating significant variation between hospitals.

Conclusion

Patients with similar characteristics presenting to different hospitals with acute gallbladder pathology do not receive comparable care.

Illness action rediscovered: a case study of upper limb pain

Theoretical frameworks provide generalised accounts of illness action although empirical studies of the process are still in short supply. This study of upper limb pain provided a case study of illness action; as it is a common condition, there is uncertainty about its treatment and management, orthodox and non-orthodox care are seen as legitimate sources of help and it is linked with a range of causes. Face-to-face informal interviews were carried out with 47 informants with upper limb pain and their practitioners (n= 19). The data were analysed in two different ways. The general stages of the illness action process were identified through a descriptive analysis of the upper limb pain sufferers' accounts and the policies and practices reported by their practitioners. Then, case studies were constructed to depict individual pathways through healthcare and consequences for sufferers. The illness action process was characterised by the normalisation and accommodation of pain informed by a discourse that predominantly invoked ageing and the wear and tear of the body. Practitioners also preferred to adopt a biomechanical approach and were reluctant to attribute psychosocial labels. The case studies illustrated the divergent, negotiated and opportunistic nature of the process and showed that the use of both orthodox and non-orthodox care formed only part of strategies used to manage upper limb pain. Sufferers evaluated the care they received in terms of pain alleviation, and were resigned to searching for the best way of living with their pain.

Upper limb pain in primary care: health beliefs, somatic distress, consulting and patient satisfaction

BACKGROUND

Beliefs and mental well-being could influence decisions to consult about upper limb pain and satisfaction with care.

OBJECTIVES

To describe beliefs about upper limb pain in the community and explore associations of beliefs and mental health with consulting and dissatisfaction.

METHODS

Questionnaires were mailed to 4998 randomly chosen working-aged patients from general practices in Avon. We asked about upper limb pain, consulting, beliefs about symptoms, dissatisfaction with care, somatizing tendency (using elements of the Brief Symptom Inventory) and mental well-being (using the Short-Form 36). Associations were explored by logistic regression.

RESULTS

Among 2632 responders, 1271 reported arm pain during the past 12 months, including 389 consulters. A third or more of responders felt that arm pain sufferers should avoid physical activity, that problems would persist beyond 3 months, that a doctor should be seen straightaway and that neglect could lead to permanent harm. Consulters were significantly more likely to agree with these statements than other upper limb pain sufferers. The proportion of consultations attributable to such beliefs was substantial. Dissatisfaction with care was commoner in those with poor mental health: the OR for being dissatisfied (worst versus best third of the distribution) was 3.2 (95% CI 1.2-8.5) for somatizing tendency and 2.4 (95% CI 1.3-4.7) for SF-36 score. Both factors were associated with dissatisfaction about doctors' sympathy, communication and care in examining.

CONCLUSIONS

Negative beliefs about upper limb pain are common and associated with consulting. Somatizers and those in poorer mental health tend, subsequently, to feel dissatisfied with care.

Making sense of aches and pains

BACKGROUND

The uncertainty about the status of upper limb disorders (ULDs), particularly the non-specific conditions, is believed to have consequences for clinical management and patient care.

OBJECTIVE

This paper presents evidence about how sufferers with ULDs respond to their pain, how their pain is managed, when and who they go to for formal help and how sufferers evaluate the care they receive.

METHODS

The data analysis is derived from face-to-face, informal interviews with sufferers with a broad spectrum of upper limb disorders (n = 47). These informants were selected according to strict criteria from a 'screening' postal survey of the working population (25-64 years) in south-west England (n = 2781).

RESULTS

Ideas about causation were crucial to understanding patterns of illness action and help seeking behaviour. The common strategy was to wait and see what happens as the pain was believed to be a natural part of the ageing process. Explanations invoking psychosocial and work related causes were less common and tended to be used when biomechanical explanations were no longer appropriate. Self-management was the preferred strategy but orthodox practitioners were usually the first choice for formal care. Complementary and alternative medicines (CAM) were popular but were used to complement orthodox care. Practitioners were evaluated mainly in terms of their ability to alleviate pain.

CONCLUSION

There is a need for orthodox and non-orthodox care to be closely integrated in primary care and GPs should not depend on orthodox medications alone when caring for patients with upper limb pain.

Evaluating health-care: the perspectives of sufferers with upper limb pain

BACKGROUND AND AIMS

There is considerable uncertainty over the diagnosis, treatment and management of upper limb pain, which has implications for patient care. Research into patient experiences and evaluation of health-care has been neglected and the study presented here aims to fill this gap.

METHODS

A two-staged, mixed methodology was adopted. Phase 1 involved a postal survey of a random sample (n = 2781) of the working age population (25-64) of an area in south-west England. Phase 2 consisted of follow-up, informal face-to-face interviews with a purposive sample of 47 informants identified, according to pre-defined criteria, from the survey sample.

RESULTS

Our data showed that concerns about the effectiveness of treatments for alleviating pain were fundamental to users' evaluations of both orthodox and non-orthodox health-care. This took priority over the need for a diagnosis and other information. There was a general recognition that the treatments available were, at least, only partially effective and the pragmatic approach led some to eventually withdraw from both orthodox care and complementary and alternative medicines (CAM).

CONCLUSION

Patients' priorities for health-care, in this context, were perceived to involve the provision of treatments which alleviated pain and were safe and painless. Orthodox and non-orthodox care needed to be more closely integrated into primary care services.

Mental health and stress in the workplace: the case of general practice in the UK

This study adopted a 'workforce' perspective in a study of job strain in primary care (general practice) in the UK. It explored the level of stress amongst workers in general practice and between practices and examined the relationship between level of stress and work characteristics. Postal questionnaires were sent to a random sample of general practices (n = 81) in southern England. The study showed that 23% of all responders could be classified, according to the GHQ-12, as suffering from mental distress with practice managers having the highest level of stress and clerical and administrative staff the lowest. Work characteristics as measured by Karasek's Job Content Instrument were shown to be significant predictors of job stress as were marital status and health status. The implications of these findings are discussed, particularly focusing on the value of the job strain model for explaining job stress in general practice.

General practice. All stressed up and nowhere to go?

A survey of 1,545 staff in general practices in South East region found that GPs and practice managers were the most stressed. GPs believed that dealing with difficult patients was particularly stressful. The relationships between the senior partner and practice manager and the GP-nurse relationship were seen as crucial. The relationship between GPs and nurses is characterised by ambivalence and uncertainty. The division of labour between GPs and practice managers needs clarification if the government's proposals for improving general practice are to succeed.

Receptor tyrosine kinase signaling regulates different modes of Groucho-dependent control of Dorsal

Transcriptional control of the Drosophila terminal gap gene huckebein (hkb) depends on Torso (Tor) receptor tyrosine kinase (RTK) signaling and the Rel/NFkappaB homolog Dorsal (DI). DI acts as an intrinsic transcriptional activator in the ventral region of the embryo, but under certain conditions, such as when it is associated with the non-DNA-binding co-repressor Groucho (Gro), it is converted into a repressor. Gro is recruited to the enhancer element in the vicinity of DI by sequence-specific transcription factors such as Dead Ringer (Dri). We examined the interplay between DI, Gro and Dri on the hkb enhancer and show that when acting over a distance, Gro abolishes rather than converts DI activator function. Reducing the distance between DI- and Dri-binding sites, however, switches DI into a Gro-dependent repressor that overrides activation of transcription. Both of the distance-dependent regulatory options of Gro - quenching and silencing of transcription - are inhibited by RTK signaling. These data describe a newly identified mode of function for Gro when acting in concert with DI. RTK signaling provides a way of modulating DI function by interfering either with Gro activity or with Dri-dependent recruitment of Gro to the enhancer.

hairy stripe 7 element mediates activation and repression in response to different domains and levels of Krüppel in the Drosophila embryo

The Drosophila gap gene Krüppel (Kr) encodes a zinc finger-type transcription factor required for controlling the spatial expression of other segmentation genes during early blastoderm stage. Here we show that two independent and transferable repressor domains of Krüppel act to control expression of the pair-rule gene hairy, and that the minimal cis-acting element of hairy stripe7 (h7) mediates either Krüppel-dependent activation or repression in different regions of the blastoderm embryo. The C-terminal region of Krüppel which encompasses the predominant repressor domain is not essential for activation, but is required to fully suppress h7-mediated transcription in response to high levels of Krüppel activity. This domain contains an interaction motif for dCtBP, a homologue of the human co-repressor CtBP. dCtBP activity is, however, dispensable for Krüppel-mediated repression in the embryo since Krüppel-mediated repression functions in the absence of dCtBP. Possible modes of h7-mediated gene regulation in response to the different domains and levels of Krüppel are discussed.

How tumor cells make use of CD44

A variant of CD44 containing exon v3 sequences is expressed in the apical ectodermal ridge of the limb bud during embryogenesis. This variant is modified by heparan sulfate moieties and acts as low affinity receptor for FGFs. These FGFs are presented by CD44 to mesenchymal cells which induces their proliferation and limb outgrowth. We suggest that a similar growthfactor presentation mechanism accounts for the function of CD44 variants on metastasizing tumor cells.

Disenchantment, ambivalence, and the precautionary principle: the becalming of British health policy

Before the election of May 1997, Britain's Conservative government was committed to giving general practitioners a lead role in health service development. However, a qualitative study of managers and primary care workers, charged with implementing the initiative in the south of England, revealed that while many relished the opportunity to make service provision more responsive to local needs, they were concerned that such changes might fragment the National Health Service and damage the relationship between doctor and patient. This ambivalence gave rise to a precautionary principle, in which innovative change was stifled by the desire to avoid adverse consequences. This "becalming" of health policy stemmed from disenchantment with both rational comprehensive planning and quasi-market incrementalism, leaving the government without an ideological basis on which to develop a new organizational form for health sector decision-making. The new Labour government pledged to eradicate the irrationality associated with the internal market. However, a return to the old NHS planning model is not proposed, and Labour is equally committed to involving GPs in commissioning health services at the local level, suggesting that the tension between centralized planning and local incrementalism may continue to undermine the development and implementation of health policy.

A splice variant of CD44 expressed in the apical ectodermal ridge presents fibroblast growth factors to limb mesenchyme and is required for limb outgrowth

Signals from the apical ectodermal ridge (AER) of the developing vertebrate limb, including fibroblast growth factor-8 (FGF-8), can maintain limb mesenchymal cells in a proliferative state. We report here that a specific CD44 splice variant is crucial for the proliferation of these mesenchymal cells. Epitopes carried by this variant colocalize temporally and spatially with FGF-8 in the AER throughout early limb development. A splice variant containing the same sequences expressed on model cells binds both FGF-4 and FGF-8 and stimulates mesenchymal cells in vitro. When applied to the AER, an antibody against a specific CD44 epitope blocks FGF presentation and inhibits limb outgrowth. Therefore, CD44 is necessary for limb development and functions in a novel growth factor presentation mechanism likely relevant in other physiological and pathological situations where a cell surface protein presents a signaling molecule to a neighboring cell.

The CD44 protein family

The designation CD44 describes a group of type I transmembrane proteins which share N-terminal and C-terminal sequences. These molecules differ in the central extracellular domain by the use of sequences encoded by ten variant exons which may be completely absent or included in various combinations and by cell type specific addition of glycosaminoglycan and carbohydrate moieties. Expression of variant proteins is observed in normal tissues such as on keratinocytes, dendritic cells and activated lymphocytes in the adult organism and on morphogenetically active epithelium such as the apical ectodermal ridge (AER) in the embryo. Certain CD44 proteins expressed on the AER can act as low affinity fibroblast growth factor receptors and are vital for epithelial-mesenchymal cell communication. CD44 variant proteins have also been implicated in tumour growth and metastasis and we speculate that CD44 mediated growth factor presentation may also be decisive in metastasis formation. Molecular strategies designed to block growth factor presentation by CD44 may aid in the therapy of metastatic cancer.

Clinical evaluation of an acellular allograft dermal matrix in full-thickness burns

A multicenter clinical study assessed the ability of an acellular allograft dermal matrix to function as a permanent dermal transplant in full-thickness and deep partial-thickness burns. The study consisted of a pilot phase (24 patients) to identify the optimum protocol and a study phase (43 patients) to evaluate graft performance. Each patient had both a test and a mirror-image or contiguous control site. At the test site, the dermal matrix was grafted to the excised wound base and a split-thickness autograft was simultaneously applied over it. The control site was grafted with a split-thickness autograft alone. Fourteen-day take rates of the dermal matrix were statistically equivalent to the control autografts. Histology of the dermal matrix showed fibroblast infiltration, neovascularization, and neoepithelialization without evidence of rejection. Wound assessment over time showed that thin split-thickness autografts plus allograft dermal matrix were equivalent to thicker split-thickness autografts.

Information management and technology in England's large acute NHS hospitals. National strategy versus local reality

Discusses the NHS Executive's information management and technology (IM&T) strategy and its relationship to the 1991 reforms. Examines the recommendation for large acute hospitals to adopt integrated hospital information support systems (HISS). Reports that a recent census of these hospitals, undertaken by the authors, suggests that the implementation of the strategy's recommendations has been slow at the local level. Attempts to diagnose the factors that are impeding implementation, using the evidence provided by the census. Identifies four main problem areas: the lack of success of past IM&T initiatives undermines confidence in the current strategy; the strategy is poorly aligned with other policy initiatives; the legacy of discrete, proprietary information systems within hospitals makes the creation of an integrative information environment difficult to accomplish without massive investment in new systems; and there are implicit contradictions between the following: the absence of a comprehensive post-implementation evaluation of the economic, technological and cultural feasibility of HISS at any of the three HISS pilot sites; the strategy's advocacy of HISS as the way forward for large acute hospitals; the requirement for a comprehensive business case to support any substantial investment in IM&T. Concludes that a massive rethink of policy is required, with a much greater emphasis on research, development and independent evaluation.

Do the teaching hospitals of the University of Queensland really want a four-year medical course? A guarded yes

OBJECTIVE

To gauge the measure of support among clinical teaching staff for the University of Queensland's proposals to introduce a four-year graduate entry integrated medical curriculum.

SETTING

The three largest teaching hospitals of the University of Queensland Faculty of Medicine.

METHODS

A questionnaire was sent to 565 consultants and 493 junior medical staff regarding deficiencies of the present six-year course, deficiencies in present methods of selecting students, and possible solutions.

RESULTS

154 (68%) full-time consultants, 174 (51%) visiting consultants and 197 (40%) junior staff replied. Ninety per cent of the consultants and 60% of the junior staff were current teachers. Respondents strongly supported the need for major change, the integration of biomedical sciences into clinical teaching and the use of problem-based learning. Regarding selection, over 80% of respondents considered graduate entry to have no advantage over undergraduate entry, but there was strong support for an external examination including sciences. There was also strong support for broadening entry criteria to include common sense, motivation and empathy. Seventy-two per cent of consultants and 82% of juniors opposed the proposals in their present form. However, 52% of consultants (but only 23% of juniors) would support the concept of a four-year integrated course if the issue of selection criteria could be resolved.

CONCLUSION

A majority of consultants support the concept of a four-year integrated curriculum which uses problem-based learning methods. They do not support the proposed selection criteria based upon graduate entry, but would support a predominantly science-based selection process, not necessarily restricted to graduate applicants, but incorporating broader personal characteristics than are used at the present time.

Fundholding in northern region: the first year

OBJECTIVE

To describe the experiences of 10 fundholding practices in the Northern region during 1991-2 and to elicit subjective assessments of the impact of their change in status on practice management and patient care.

DESIGN

Semistructured interviews were conducted with clinicians and practice managers; other staff in the practices were asked to fill in questionnaires. Questions were asked about the preparatory year, the impact of fundholding on clinical practice and practice management, perceptions of the costs and benefits of fundholding, and views about the future of the scheme.

SETTING

10 of the 28 first wave fundholding practices in the Northern region, March-July 1992.

RESULTS

Two interviews were conducted in nine practices and one interview in the tenth practice. Replies to the questionnaire were received from 35 general practitioners (73%) and 89 (58%) nonmedical staff. Practices sought independence in applying for fundholding status and found the preparatory year challenging and time consuming. General practitioners thought that the greatest change had occurred in relationships with consultants and the least change in relationships with patients. Most respondents thought that fundholding had changed the way they worked. The perceived benefits of fundholding were mentioned more often than the perceived costs.

CONCLUSIONS

The results offer some encouragement to the proponents of fundholding, but more longitudinal studies are needed to evaluate the misgivings of critics of the scheme. Fundholders are uncertain about their ability to make savings year after year, particularly in an increasingly cost contained environment.

The shelf operation for hip dysplasia in adolescence

Failure of normal acetabular development is inevitable in congenital dislocation of the hip when it is unrecognised until late infancy or early childhood. Numerous stabilising procedures have been described, one of the first being the shelf operation or acetabuloplasty. This procedure fell into disrepute because the shelf was often located too high or was too small to prevent upward migration of the femoral head. The technique described emphasises the importance of resecting the thickened capsule and exposing the lateral margin of the acetabulum to allow a substantial portion of the outer cortex of the ilium to be turned down both laterally and anteriorly over the femoral head. Twenty cases of acetabuloplasty have been followed up for an average period of nine years. The results have been assessed from the point of view of function, relief of pain, and degree of support of the femoral head as demonstrated radiologically. The shelf operation is a simple and safe procedure, and provided it gives adequate support to the subluxated femoral head it will ensure a stable, mobile joint capable of standing up to reasonable use for many years. If deterioration should occur in later life, total hip replacement may be undertaken more easily than if the joint had been allowed to undergo progressive subluxation.

Severe irreducible slipping of upper femoral epiphysis: a review of 14 cases treated by subtrochanteric osteotomy

Children with signs of slipping of the upper femoral epiphysis often present in an Accident Service, particularly after a severe, acute slip. In some cases the displacement is irreducible and correction of the persistent deformity by either cervical or trochanteric osteotomy is required. This paper is a review of 14 cases of irreducible slipped upper femoral epiphysis treated by subtrochanteric osteotomy. Clinical and radiological assessment of these cases some years later shows a high proportion of successful results and suggests that this is a safe and satisfactory method of treating this condition.