Referral letters to the emergency department: is the medication list accurate?

Medication errors are common when patients transfer across healthcare boundaries. This study was designed to investigate the quality of information on medicines provided by general practitioners (GPs) on emergency department (ED) referral letters. A convenience sample of referral letters to the ED of a teaching hospital was reviewed. The medication list and/or patient's drug allergy status were noted. Medicines reconciliation including patient (or carer) interview was conducted to determine the patient's actual home medication list. This was compared with the GP list and any discrepancies were identified and addressed. A total of 92 referral letters were included in the analysis of which 60 were computer-generated and 32 were hand-written. GPs provided dose and frequency of administration information in 47 (51%) of the letters sampled i.e. 44 (71%) computer-generated versus 3 (10%) hand-written; p < 0.001. In addition, the patient was taking their medicines exactly as per the GP list in 20 (22%) of cases. The patient's drug allergy status was documented in 13 (14%) of the letters.

Exomphalos major: the Northern Ireland experience

PURPOSE

In exomphalos major (EM), closure of the defect in the abdominal wall presents a challenge. The aim of this study is to evaluate a single centre experience of EM.

MATERIALS

A 15-year retrospective case-note review; data presented as median (range).

RESULTS

Fourteen infants (7 female) were born with EM: birth weight 2.9 (1.2-3.8) kg, gestational age 38 (31-39) weeks. One infant died in utero and one within the first hour of life. Severe pulmonary hypoplasia was present in 7/13 (54%), and there was a mortality of 6/13 (46%) live births. Infants were treated non-operatively primarily. Two infants underwent early surgery: one infant, born with a ruptured sac, had a surgical silo constructed on day 1 and closure on day 8, while a second infant had partial closure (skin only) on day 11. Ten infants had application of silver sulphadiazine to the sac 2-3 times per week. Enteral feeds were established soon after birth. They were discharged from hospital to allow granulation. Ventral hernia closure was performed on a subsequent admission.

CONCLUSIONS

Exomphalos major can be successfully treated non-operatively, allowing immediate enteral feeding and early discharge while granulation takes place. In this series, exomphalos major has an incidence of 1 in 26,000, mortality is 46% and severe pulmonary hypoplasia is present in 54% of infants.

Preservation of hearing among agricultural workers: a review of literature and recommendations for future research

A review of literature was conducted to summarize the progress to date in hearing preservation among agricultural workers, including previously published reports and studies in progress. Types of studies reviewed include noise exposure studies, hearing acuity studies, studies focusing on the use of hearing protection, and intervention studies designed to increase hearing protector use. Recommendations for future research are presented.

Functioning adrenocortical neoplasms in children

OBJECTIVE

To describe the clinical features, treatment and outcome of functioning adrenocortical tumours in children, and to assess the value of tumour size as a marker for malignant potential.

PATIENTS AND METHODS

Twenty-one children (mean age at presentation 4.9 years, range 0.6-11; 12 girls and nine boys) who presented with a functioning adrenal mass over a 29-year period (1972-2000) were assessed. Clinicopathological features and outcome information were obtained from a structured review of the case-notes. Before 1980 the diagnosis and staging was mainly obtained by intravenous pyelography and plain X-ray. Since 1980, ultrasonography, computed tomography and more recently magnetic resonance imaging were the methods of choice.

RESULTS

The mean (range) duration of symptoms before diagnosis was 31 (2-108) months. The symptoms and signs at presentation comprised virilization (18 children), Cushingoid features (three), precocious puberty (three) and hypertension (four). Three children had malignant neoplasms, one presented with metastasis and of the other two, one died from the disease within 6 months, despite adjuvant chemotherapy and radiotherapy. The third girl is disease-free 11 years after complete excision of the neoplasm. Eighteen children had a benign neoplasm and all are alive and free of recurrence. In most of the children surgical extirpation was relatively simple, blood loss minimal, recovery uneventful and the hospital stay short (mean 5 days). The virilizing effects of all the neoplasms gradually resolved after surgery within a median (range) of 27 (6-108) months.

CONCLUSIONS

Functioning adrenocortical neoplasms in children are rare, with a peak incidence in the first decade, are predominantly unilateral and more common in girls. Most are benign, but both benign and malignant lesions can present with virilizing and Cushingoid features. The malignant neoplasms have an extremely poor prognosis, especially if excision is incomplete, despite adjuvant chemotherapy and radiotherapy. Although there is an association between tumour size and malignancy, this cannot be used as a reliable individual discriminator.

Antenatal identification of a cervical oesophageal duplication

Duplications of the alimentary tract can occur from mouth to anus, and often are undetected until they present with complications. We report duplication of the cervical oesophagus presenting as dyspnoea and stridor in a two year old. In retrospect, this had been detected on ultrasound antenatally, but no specific diagnosis had been made. We review the present literature to raise awareness of duplication as one cause of cysts identified antenatally in this region.

Analysis of methylphenidate and its metabolite ritalinic acid in monkey plasma by liquid chromatography/electrospray ionization mass spectrometry

Methylphenidate (MP, Ritalin) is a psychotropic drug widely prescribed to children for treating the symptoms of attention deficit disorder with and without hyperactivity. Because little information exists about the effects of chronic MP administration on cognitive function in children, measures of behavior changes in non-human primates are important surrogates. An essential component of such studies is the determination of MP plasma levels under chronic and acute dosing conditions. An analytical method was developed that provided sufficient sensitivity to measure low levels of the active parent drug (lower limit of quantitation = 0.25 ng/mL) and the inactive metabolite, ritalinic acid (RA), in monkey plasma as well as the ability to conveniently analyze large numbers of samples. The method uses a polymeric reversed-phase sorbent for solid phase extraction, an efficient reverse-phase high performance liquid chromatography (HPLC) separation, deuterated internal standards for isotope dilution quantification of MP and RA, and detection by sensitive electrospray ionization mass spectrometry (ES-MS) with a single quadrupole instrument. The method responses are linear over the range of plasma concentrations of MP and RA observed in monkeys, gives respective analyte recoveries of 75 and 60% with reasonable precision and accuracy, and demonstrates robust MS performance for rapid determination of MP/RA plasma levels. The average peak MP concentration (ca. 16 ng/mL) and half-lives for MP and RA elimination in monkeys (1.79 and 2.31 h, respectively) were not significantly different under acute vs. chronic dosing conditions and were comparable to values previously reported from human studies.

Median nerve compression in Proteus syndrome

Proteus syndrome is a multi-organ disorder, a prime feature of which is localized gigantism, usually clinically obvious. Symptoms secondary to hypertrophy of nerves has not been previously recognized as a part of the syndrome.

Cystic mesothelioma of the peritoneum: a rare cause of 'ascites' in children

A 2-year-old girl presented with a 3-month history of progressive painless abdominal distension. Results of the clinical examination suggested massive ascites, but no other symptoms or signs could be elicited. There was no history of any other illness preceding the onset of distension. Ultrasonography and a computed tomography scan confirmed gross ascites, with multiple thin-walled loculi throughout the abdomen, from the diaphragm to the pelvis. The preoperative diagnosis was intraabdominal lymphangioma. During laparotomy, multiple transparent cysts were found throughout the peritoneum. There was no evidence of malignancy in any organ, and the cysts appeared almost completely avascular. Histological and ultrastructural appearances were those of benign cystic mesothelioma of the peritoneum, a condition that hitherto has been recognized only in adults. It is thought to represent a borderline variant between a truly benign adenomatoid lesion and the better-known malignant mesothelioma. The experience with adult cases suggests a high potential for recurrence but no progression to malignancy. It is possible that some cases of intraabdominal lymphangioma may have been misdiagnosed in the past; future cases should be fully evaluated, both immunohistochemically and ultrastructurally, to establish the true incidence of mesothelial proliferative disease in children.

A new method of intestinal salvage for severe small bowel ischemia

The morbidity and mortality in short bowel syndrome are directly related to the length of the remaining small bowel and to the duration of total parenteral nutrition. We describe the successful salvage of an infant with extensive small bowel infarction for whom a new technique was used to preserve all viable mucosal surfaces. The infant, with gastroschisis, was found to have a tight volvulus of the extruded bowel and extensive small bowel ischemia at the time of delivery. Forty-eight hours after reduction of the volvulus and abdominal decompression, a second-look laparotomy was performed. Although only the terminal 13 cm of ileum was completely viable, 25% of the circumference of a further 23 cm of proximal jejunum/ileum was considered salvageable. After debridement of the dead tissue, the remaining gutter of jejunum was divided at its midpoint, and the two halves were anastomosed longitudinally to provide a "neojejunum" of 12 cm in length, which was anastomosed between the duodenum and terminal ileum. Full enteral feeding was tolerated from day 47. Although the neojejunum was excised on day 149, after becoming dilated and atonic, by that time the remaining small bowel had elongated to 30 cm. Because of the early institution of full enteral feeding, there were no long-term complications related to total parenteral nutrition.

Accuracy of prenatal diagnosis of congenital cystic adenomatoid malformation

A series of 13 consecutive patients with a prenatal diagnosis of congenital cystic adenomatoid malformation (CCAM) were reviewed with respect to prenatal ultrasound findings, clinical features at birth, and postnatal outcome. In two cases (15%) the abnormality regressed in utero. Only three infants (23%) showed any respiratory distress at birth. After a mean of 25 months postnatal follow up, 11 patients (85%) were found to have a definite pulmonary abnormality. In seven patients (54%) the specific prenatal diagnosis of CCAM has been confirmed (five histologically, two radiologically). Four infants (31%) were found to have other types of pulmonary abnormality and in two (15%) the lungs remain apparently normal. Prenatal ultrasound appears reliable in the detection of pulmonary abnormalities but the variety of conditions identified postnatally suggests that specific prenatal diagnoses and prognoses should be avoided; prenatal counselling and perinatal management should be adapted accordingly.

Collaborating to develop a community-based health service for rural homeless persons

In the current healthcare environment, public health nursing administrators are called on to create and manage programs and services while reducing cost and improving access. Public health science provides a framework on which to base program planning and management. Using this approach, the authors describe the establishment of a health services center to meet an identified gap in service to homeless persons in a rural area.

Management of diffuse esophageal spasm with balloon dilatation

Of 1200 patients referred to the esophageal laboratory at Guy's Hospital for investigation of suspected esophageal motility disorders, 61 (5.1%) were diagnosed as diffuse esophageal spasm. Twenty of these patients whose symptoms were severe did not respond to conservative treatment and were treated by balloon dilatation. Results were good in 14 and poor in six patients, which included one esophageal perforation. Diffuse esophageal spasm was diagnosed where more than 30% nonperistaltic activity was demonstrated by manometry. Lower esophageal sphincter pressure and relaxation were normal in all cases except one. Gastroesophageal reflux was present in four of five poor responders who were examined by 24-h ambulatory pH monitoring, and in only one of 10 good responders. Three of the six patients in whom balloon dilatation was successful proceeded to full-length myotomy, with relief of symptoms in two. The indications for, and results of, balloon dilatation in this condition are discussed, and a new radiological sign is described.

Acid perfusion and edrophonium provocation tests in patients with chest pain of undetermined etiology

During the last five years, 672 patients were referred to our esophageal investigation unit; 110 patients (16.3%) of these presented with chest pain of undetermined etiology (CPUE) alone. Since the nature of this pain is intermittent and rarely present during the diagnostic study, acid perfusion and intravenous edrophonium tests were added as provocative tests after baseline esophageal manometry. Following completion of the motility studies, 24-hr pH study was performed to detect gastroesophageal reflux (GER). Twenty-nine patients (26.4%) had positive acid perfusion (APT) test whereas 26 patients (23.6%) had positive edrophonium test (ET). In the group of patients with positive acid perfusion test, 12/29 (41.3%) had GER, 8/29 (27.5%) had both motility disorder and GER, 2/29 (6.8%) had motility disorder, and 7/29 (24.1%) had normal esophageal motility and 24-hr pH studies. In the other group, 13/26 (50%) had motility disorder and 13/26 (50%) had both motility disorder and GER. There were no significant differences between the two tests as far as reproducibility of symptoms was concerned. We conclude that ATP and ET showed the esophageal origin of CPUE in half of our patients and therefore in a substantial percentage of patients the esophageal origin of chest pain will remain very difficult to prove.

Alternative method of positioning the pH probe for oesophageal pH monitoring

The most reliable method of positioning a pH probe for oesophageal pH monitoring is to use manometry to determine the upper margin of the lower oesophageal sphincter and to place the probe 5 cm above this point. Manometry is expensive, however, requires special equipment and training, and is not widely available. An alternative cheaper way of determining the site of the lower oesophageal sphincter has been evaluated. A fine bore nasogastric tube with a latex balloon at its tip was inserted transnasally into the stomach. The balloon was inflated with 10 ml of water and the tube withdrawn until resistance was met. The distance from the nose (in cm) was noted and compared with the upper margin of the lower oesophageal sphincter as determined by oesophageal manometry. The manometric distance agreed closely with the balloon distance minus 1 cm (bias 0.29 cm; 95% CI of bias, 0.03 to 0.55 cm; 2 SD, limits of agreement, 1.58 cm). We conclude that where oesophageal manometry is not available, balloon localisation is a suitably accurate way of identifying the lower oesophageal sphincter.

Transition from nutcracker esophagus to achalasia

Nutcracker esophagus is essentially a manometric diagnosis characterized by high-amplitude, often prolonged duration of peristaltic contractions in the distal two thirds of the esophagus. Its association with noncardiac chest pain and/or dysphagia has been recognized and reported by numerous esophageal motility laboratories. There are very few long-term studies of the natural history of this abnormality. We report a patient who presented with dysphagia and, on initial investigation, was found to have classical nutcracker esophagus. On reinvestigation three years later, however, he had developed achalasia of the cardia. The transition from nutcracker esophagus to achalasia has not previously been reported.