Glucose Concentrations in Parotid Fluid and Venous Blood of Patients Attending a Diabetic Clinic1

Measurements of the glucose concentration in venous blood and parotid saliva taken from 31 diabetics attending a diabetic clinic showed values ranging respectively from 3.9 to 19.1 mmol/l and 0.06 to 0.83 mmol/l (means 9.6 mmol/l and 0.32 mmol/l respectively). Linear regression of salivary glucose on blood glucose gave a simple correlation coefficient of 0.18 (NS). Since salivary glucose levels did not reflect blood glucose levels, the possibility of diabetics regulating their metabolic control by the noninvasive technique of monitoring salivary glucose concentrations is not possible.

Clinical information transfer and data capture in the acute myocardial infarction pathway: an observational study

RATIONALE, AIMS AND OBJECTIVES

Acute myocardial infarctions (MIs) or heart attacks are the result of a complete or an incomplete occlusion of the lumen of the coronary artery with a thrombus. Prompt diagnosis and early coronary intervention results in maximum myocardial salvage, hence time to treat is of the essence. Adequate, accurate and complete information is vital during the early stages of admission of an MI patient and can impact significantly on the quality and safety of patient care. This study aimed to record how clinical information between different clinical teams during the journey of a patient in the MI care pathway is captured and to review the flow of information within this care pathway.

METHOD

A prospective, descriptive, structured observational study to assess (i) current clinical information systems (CIS) utilization and (ii) real-time information availability within an acute cardiac care setting was carried out. Completeness and availability of patient information capture across four key stages of the MI care pathway were assessed prospectively.

RESULTS

Thirteen separate information systems were utilized during the four phases of the MI pathway. Observations revealed fragmented CIS utilization, with users accessing an average of six systems to gain a complete set of patient information. Data capture was found to vary between each pathway stage and in both patient cohort risk groupings. The highest level of information completeness (100%) was observed only in the discharge stage of the MI care pathway. The lowest level of information completeness (58%) was observed in the admission stage.

CONCLUSION

The study highlights fragmentation, CIS duplication, and discrepancies in the current clinical information capture and data transfer across the MI care pathway in an acute cardiac care setting. The development of an integrated and user-friendly electronic data capture and transfer system would reduce duplication and would facilitate efficient and complete information provision at the point of care.

Techniques to aid the implementation of novel clinical information systems: a systematic review

BACKGROUND

This systematic review identifies and evaluates techniques that aid the implementation of novel clinical information systems (CIS) within healthcare.

METHODS

We searched electronic databases (MEDLINE, EMBASE, PsycINFO and HMIC Health Management Information Consortium). Desktop reviews for all potentially eligible studies were also conducted via reference lists and forward citation searches. 14,198 abstracts were identified through the initial electronic search. 63 articles were retained following title and abstract reviews, and submitted for full text evaluation. Of these, 18 papers met eligibility criteria.

RESULTS

The 5 techniques that emerged from the review and that can assist CIS implementation were: system piloting, eliciting acceptance, use of simulation, training and education, and provision of incentives. These techniques were evaluated with a range of study endpoints (including system utilisation, clinical effectiveness, user satisfaction, attitudes towards system training, and attitudes towards implementation). Consideration of the clinical context in which the CIS was implemented was a consistent theme in the evidence-base.

CONCLUSIONS

Although some evidence is available for the effectiveness of the 5 implementation techniques found in this review, the variable endpoints and the non-comparable study designs mean that the evidence-base needs further developing. We discuss the potential role of simulation and clinical leadership, particularly in relation to surgeons, in CIS implementation and we propose practical advice for CIS implementation and evaluation within hospital settings.

Emotional impact of screening: a systematic review and meta-analysis

BACKGROUND

There is a widely held expectation that screening for disease has adverse emotional impacts. The aim of the current review is to estimate the short (< 4 weeks) and longer term (> 4 weeks) emotional impact of such screening.

METHODS

Studies selected for inclusion were (a) randomised controlled trials in which (b) participants in one arm underwent screening and received test results, and those in a control arm did not, and (c) emotional outcomes were assessed in both arms. MEDLINE via PubMed (1950 to present), EMBASE (1980 to present), PsycINFO (1985 to present) using OVID SP, and CINAHL (1982 to present) via EBSCO were searched, using strategies developed with keywords and medical subject headings. Data were extracted on emotional outcomes, type of screening test and test results.

RESULTS

Of the 12 studies that met the inclusion criteria, six involved screening for cancer, two for diabetes, and one each for abdominal aortic aneurysms, peptic ulcer, coronary heart disease and osteoporosis. Five studies reported data on anxiety, five [corrected] on depression, two on general distress and eight on quality of life assessed between one week and 13 years after screening (median = 1.3 years).Meta-analyses revealed no significant impact of screening on longer term anxiety (pooled SMD 0.01, 95% CI -0.10, 0.11), depression (pooled SMD -0.04, 95% CI -.12, 0.20), or quality of life subscales (mental and self-assessed health pooled SMDs, respectively: 0.03; -0.01, (95% CI -.02, 0.04; 0.00, 95% CI -.04, 0.03).

CONCLUSION

Screening does not appear to have adverse emotional impacts in the longer term (> 4 weeks). Too few studies assessed outcomes before four weeks to comment on the shorter term emotional impact of screening.

General surgeons and the management of head injuries

Most head injuries in Great Britain and Ireland are managed either by orthopaedic or general surgeons. In response to growing anxiety about the arrangements for the management of head injuries, the Royal College of Surgeons of England late in 1997 set up a working party to report to the Senate of Surgery. The results of that survey are presented here.

Technetium-99m sestamibi parathyroid localization is accurate enough for scan-directed unilateral neck exploration

A retrospective study was conducted into technetium-99m sestamibi imaging of primary hyperparathyroidism to determine the accuracy of identification and localization of parathyroid pathology. Of 56 patients studied, 48 had full preoperative scan data, operative data and pathological results analysed. Overall scan accuracy was 96 per cent. For single gland pathology (adenoma) imaging had a sensitivity of 97 per cent, a specificity of 100 per cent and a positive predictive value of 100 per cent. For single gland disease the side was correctly identified in 100 per cent of cases and the site in 94 per cent, but the respective values were only 82 and 79 per cent for multiple gland pathology. Technetium-99m sestamibi imaging is highly sensitive and accurate for primary hyperparathyroidism, with sufficient positive predictive value and accuracy in single gland disease to allow scan-directed unilateral neck exploration.

Surgeons and the new deal--good deal or raw deal?

New regulations concerning the training of junior doctors are being introduced. The effect of some of these is already beginning to be noted and the new style Calman training will be introduced shortly. In the South East Thames the implications of Calman type training programme have been piloted in a unified registrar training grade in general surgery for the last three years. It seems an appropriate time to reflect on the changes already operational and the impact of those to come.

'Unseen' on-call workload of a general surgical team

Over a four-month period, we assessed the contribution made to the on-call workload of a general surgical team, by referrals and assessments of patients who had not been admitted under surgical care and were therefore not recorded in current audits of general surgical activity--the 'unseen workload'. Up to 5 1/2 hours per day on-call (mean 101 minutes) was spent assessing these referrals. There was a mean number of 3.6 referrals (range 1 to 7). Although 51 percent of these referrals were deemed to be non-surgical after assessment, the majority (77 percent) were believed to be appropriate. The Accident & Emergency Department referred 46 per cent of patients with only 7 percent requiring surgical management. This study shows that while hours of work are important in assessing the workload of a junior doctor on-call, the intensity of the workload is just as important in determining the impact on staff. There is a greater workload than revealed by audit of just surgical admissions and operations alone.

Unilateral breast atrophy

This represents the only known case of acquired unilateral breast atrophy described after previously normal bilateral breast development. Our patient developed left breast atrophy with normal microscopic examination (biopsy) subsequent to infectious mononucleosis. Her reconstruction utilized tissue expansion followed by prosthetic augmentation of the affected side. Despite an exhaustive search, no definitive cause to explain these findings has been found. Perhaps there is some unknown underlying viral etiology that may have further implications for other breast pathology.

Surgical outpatient practices--a time for change?

Outpatient services are becoming increasingly overburdened and delays for appointments are commonplace. The recent NHS reforms have laid down stricter guidelines on waiting times for hospital services and reorganisation of healthcare provision is necessary in order to meet some of these recommendations. The outpatient service is a case in need. Open access referral for minor cases, endoscopy and vascular assessment, for example, may help to utilise more usefully consultations for new referrals. Follow-up in outpatient clinics should become rationalised with clear objectives being made for investigation and reintervention. The long-term follow-up of patients should rest with their general practitioners. Recommendations have been made for a consultant-based service and more patients are expecting to be seen by a consultant. Until an expansion in consultant numbers is forthcoming patients will continue to experience delays in their management. The current service has scope for improvement and some suggestions are made in this paper.

123I-methylene blue: an unsatisfactory parathyroid imaging agent

This study was designed to examine the possible use of 123I-labelled methylene blue as a parathyroid imaging agent. Five patients were studied, all of whom had parathyroid adenomas which were successfully localized preoperatively with 201Tl and 99Tcm-sestamibi, and which were subsequently proven at surgery. The 123I-labelled methylene blue localized only one of these adenomas, was negative in two and had equivocal uptake in the remaining two patients. It is therefore concluded that compared to other radionuclide methods for localizing parathyroid adenomas this agent is unsatisfactory.

Parathyroid imaging with technetium-99m-sestamibi: preoperative localization and tissue uptake studies

The accepted radionuclide method for imaging abnormal parathyroid tissue has been the combined use of [99mTc]pertechnetate 201Tl-chloride. Various problems with this approach, however, have suggested the need for an improved parathyroid imaging agent. This study examined the use of 99mTc-sestamibi as a parathyroid imaging agent compared with 201Tl-chloride. Fifty-seven patients were scanned with both 99mTc-sestamibi and 201Tl preoperatively. There were 40 adenomas, of which 37 were localized with 201Tl and 39 with sestamibi. Fifteen patients had hyperplastic glands, of which 29 glands were localized with 201Tl and 32 with sestamibi. Possible differences in uptake of the two agents by thyroid and parathyroid tissue were examined by administering 10 MBq of each agent to patients undergoing surgical exploration and biopsy. Preoperatively 20 patients were studied (13 adenomas and 7 with hyperplasia). Thallium-201 uptake was higher in both the parathyroid and thyroid tissue than sestamibi. However, the uptake per gram of parathyroid tissue of sestamibi was higher than the uptake per gram of thyroid tissue. This was not true for 201Tl. Technetium-99m-sestamibi was at least as effective as 201Tl in parathyroid localization. This may be partly due to a higher target-to-background ratio, but also to the superior physical characteristics of 99mTc.

Use of operating theatres: the effects of case-mix and training in general surgery

Details of theatre occupancy times for a surgical unit in a district general hospital and associated cottage hospital were recorded over a 4-month period. The average time of the procedures individually and reclassified within the BUPA schedule showed that both the severity of the procedure and the grade of surgeon influenced future theatre needs. For almost every type of procedure, as expected, consultants were quicker than registrars, who in turn were faster than SHOs. The hidden cost of training surgeons in general surgical operative procedures can be estimated as a result. It is concluded that current measures of resource use which rely only on the bed use and ignore operating theatre needs and training requirements for non-consultant grades will be misleading, particularly in relation to the large element of minor or intermediate surgery which constitutes the bulk of most district health authorities' workload.

Design of Support Pillar Arrays in Flat Evacuated Windows

Flat evacuated glazing consists of two plane sheets of glass separated by a narrow evacuated space. These structures must incorporate an array of support pillars in order to maintain the separation of the glass plates under the influence of atmospheric pressure forces. A design procedure is outlined for determining the dimensions of this pillar array. Two important constraints in the design process are the mechanical tensile stress on the outside of the glass plates near the pillar, and the thermal conductance through the array of support pillars. A third constraint arises because of stress concentration near the pillars on the inside of the window. Evacuated windows having usefully low values of thermal conductance through the pillar array and tolerably small levels of exterior tensile stress can only be produced if large stresses exist on the inside of the structure in the region of the glass plates near the support pillars. The implications of these stresses are discussed. It is concluded that it is possible to design a pillar array for which the localised tensile stresses and overall thermal conductance have usefully small values.

99Tcm sestamibi--a new agent for parathyroid imaging

Parathyroid imaging using 99Tcm sestamibi has been carried out prior to surgery in five patients with hyperparathyroidism and the results compared with a standard preoperative localization technique using 201Tl (thallous chloride). The 99Tcm sestamibi correctly localized all abnormal glands and showed higher parathyroid to thyroid uptake in three of four parathyroid adenomas. Both agents showed localization in a thyroid adenoma. The higher uptake of sestambi and better imaging properties of its 99Tcm radiolabel means that the agent may replace thallium for routine preoperative parathyroid localization.

The use of myocutaneous flaps by general surgeons

This is a study of the use of myocutaneous flaps by general surgeons in a district general hospital over a 5 year period, and shows that such work can be satisfactorily performed by general surgeons.

Silver-magnesium fluoride cermet films. 1: Preparation and microstructure

We have prepared and studied seventeen thin films ranging in composition from pure silver to pure magnesium fluoride. Using mass thicknesses based on quartz crystal oscillators and physical thicknesses obtained from a stylus profilometer, we have measured the void volume fraction of the films as a function of their composition. We have shown the Ag-MgF(2) system to be capable of incorporating a high volume fraction of voids. We report on the results of electron microscope studies of the films, which show the dependence of film microstructure on composition, thickness, and the nature of its substrate.

Silver-magnesium fluoride cermet films. 2: Optical and electrical properties

We discuss the optical properties of Ag-MgF(2) and voided silver cermets. We show that the former system is intrinsically three phase, because of the presence of voids, and that it cannot be regarded as made up of two synthesized phases. We show that the optical behavior of our voided silver cermets is not in keeping with the Maxwell-Garnett and effective media models, but that it can be used in a model-independent way to yield structural information about the cermets. We discuss the interesting optical properties of one cermet in the transition or optical crossover region. We also present data on the electrical resistivity of both types of cermet.

Cardiovascular changes during mental stress: correlations with presence of coronary risk factors and cardiovascular disease in physicians and dentists

Stress may play a role in the etiology of cardiovascular disease. Research showing that mental stress administered in laboratory settings causes great change in cardiovascular and hemodynamic functioning supports this hypothesis. In a small sample of physicians and dentists, those who showed greater cardiovascular reactivity (hot reactors) to stress were more likely to be hyperlipidemic or to have had a myocardial infarction or coronary bypass surgery. In addition, some of the nonreactive group were hypertensives taking medication, which may have blunted their response to stress. Persons with higher cholesterol, higher triglyceride levels, and lower HDL levels all showed greater increases in blood pressure (BP) in response to stress. Also, the reactive group reported less emotional support and experienced greater numbers of family-related stressful events in the previous year. The degree of aerobic fitness influenced resting hemodynamics and percentage of body fat but not reactivity to stress. Likewise, smoking did not affect reactivity, but former smokers did have a significantly elevated total systemic resistance at rest. While it is impossible to say whether reactivity causes disease, is the result of the presence of risk factors and disease, or is caused by some other factor which also contributes to disease, these results suggest that the presence of cardiovascular reactivity to mental stress is a sign of potential illness and indicates the need for further medical and risk factor study of the patient.

Temperature Limitation in Evacuated Solar Collector Tubes

A recent innovation in evacuated tubular solar collector technology is described. A desorbable gas, which specifically adsorbs on the graphitic solar selective surface, can reversibly degrade the vacuum by providing a heat conduction path at elevated temperatures. The stagnation temperature of the system is thus limited in a controllable manner without significantly degrading the low temperature performance. A simple theory incorporating the Langmuir adsorption isotherm and the Knudsen free molecule transport regime is used to describe the phenomenon.

Leiomyoma of the broad ligament in an obturator hernia presenting as a lump in the groin

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Surgical relief of obstructive jaundice in a district general hospital

Fifty consecutive patients with obstructive jaundice treated by operation in Canterbury & Thanet Health District hospitals under the care of one surgeon (RECC) over a 6-year period have been studied. The pathology was found to be common bile duct (CBD) stone in 22 patients (44%); pancreatic carcinoma in 15 (30%), 3 of whom also had CBD stones; chronic pancreatitis in 4 (8%); extrahepatic CBD carcinoma in 4 (8%); ampulla of Vater carcinoma in 3 (6%); primary duodenal carcinoma in 1 (2%); and portahepatis obstruction in 4 (8%). The 8 postoperative deaths (16%) were found to be associated with high preoperative levels of serum bilirubin, but all occurred in patients with malignant disease. Complications occurred in 20 patients (40%) and bile culture state was found to be intimately related to the morbidity rather than operative mortality. The study represents a careful audit of the pathology distribution and the surgical management of obstructive jaundice as seen in district hospitals.

Location of parathyroid adenomas by 201Tl and 99mTc subtraction scanning

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Location of parathyroid adenomas by thallium-201 and technetium-99m subtraction scanning

Solitary parathyroid adenomas were correctly located before surgery in 20 out of 21 cases by using 201mT1 and 99mTc in a subtraction technique. The technique was not useful in identifying hyperplastic parathyroid glands. The technique is recommended as a useful procedure before surgery for primary hyperparathyroidism.

The P3 iso-enzyme of serum amylase in the management of patients with acute pancreatitis

The concept of the P3 index and its use in separating acute pancreatitis from other causes of hyperamylasaemia is described. The mean P3 index of 12 healthy volunteers was 94.8 per cent. All 69 patients with acute pancreatitis had a P3 index below 80 per cent with a mean value of 67.9 per cent. The P3 index is abnormal longer than the raised serum amylase, which increases diagnostic accuracy. Causes of hyperamylasaemia other than acute pancreatitis have been studied and most patients have a P3 index above 80 per cent, although certain false positive values have been obtained. No patient with acute pancreatitis has had a P3 index above 80 per cent on admission. Five cases of acute pancreatitis have been studied in whom the P3 index remained abnormal; all had continuing pancreatic disease, usually with pseudocyst formation. The test has proved most valuable in identifying those patients at risk of developing subsequent problems. To date, the test cannot be relied upon to help in deciding upon the severity of an attack of acute pancreatitis.

Chest injuries in a district general hospital

Patients with chest injuries requiring admission to the Kent and Canterbury Hospital over a period of one year have been reviewed. Good survival figures are possible when these patients are managed by general surgeons and anaesthetists once the initial traumatic insult and immediate resuscitation period are survived. Among the 54 patients admitted there were 11 deaths, of which 10 occurred within a few hours of the patient's reaching hospital. It seems unlikely that even with specialist facilities the outcome would have been different in these 10 patients. Provided that a combination of experienced surgical and anaesthetic teams supported by intensive care facilities are mobilised quickly enough the absence of specialised cardiothoracic expertise is not important.

Bilateral arterial injury in the lower limbs associated with open pelvic fractures: a case report

The complications of pelvic fracture include blood loss, urinary tract injury, nerve injury and orthopaedic disability. Bleeding is quoted as the cause of death in 65 per cent of patients dying with a fractured pelvis (Rothenberger et al., 1978a). In a fifth of these patients disruption of the iliac or femoral vessels is the major source of bleeding. However, the incidence of major vessel injury in pelvic fractures is only 1 per cent. Arterial injury in both lower limbs is reported here, in association with an open fracture of the pelvis.

Melanosis coli in a child of four years

A case of melanosis coli in a girl of 4 years is described. The condition is usually considered a disease of the aging bowel. In this case there was a history of constipation, and anthracene abuse.

In vivo assessment in sheep of thromboresistant materials by determination of platelet survival

The thromboresistance of 13 potentially blood-compatible polymers was assessed in sheep by determining survival of 51Cr-labeled platelets. Polymer tubing (120-150 cm x 2.0-2.3 mm i.d.) coiled around the neck was incorporated into the circulation through silicone rubber connectors as a carotid artery-external jugular vein shunt. The mean platelet half-life in control animals ("shunt control") was 78.2 +/- 2.8 (SEM) hours. Eleven of the 13 polymers tested significantly shortened platelet half-life. Polyvinyl chloride (T1/2 = 45.4 +/- 3.0 hours), polyperfluoro ethylene (T1/2 = 47.0 +/-1.6 hours), and a polymethylacrylate (PMA)/acrilonitrile copolymer (T1/2 = 50.7 +/- 7.0 hours) produced the greatest shortening. Only silica-free polydimethyl siloxane (T1/2 = 74.7 +/- 4.9 hours) and PMA (T1/2 = 81.5 +/- 3.4 hours) were indistinguishable from shunt controls. Pretreatment of PMA tubing with autologous plasma in a paired trial significantly increased platelet half-life (P less than 0.05 vs. untreated PMA). This system offers an economical, reproducible, sensitive, and biologically relevant method for assessment of the reactivity of artificial surfaces with platelets.

Thrombosis of leg arteries after prolonged travel

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Prevention of deep vein thrombosis in neurosurgical patients: a controlled, randomized trial of external pneumatic compression boots

A prospective, randomized clinical trial in 95 patients undergoing neurosurgical operative procedures was performed to investigate the efficacy of external pneumatic compression (EPC) of the calves as compared with results in a control group that received no specific form of prophylaxis for prevention of deep vein thrombosis (DVT). The diagnosis of DVT was established by the I125 fibrinogen scan and radiographic contrast phlebography. The data indicate that EPC provides significant protection against the development of DVT in comparison with results in the control group (p less than 0.005). There were no known pulmonary emboli in any of the EPC-treated patients. There were no complications of EPC.

Prevention of deep vein thrombosis in urological patients: a controlled, randomized trial of low-dose heparin and external pneumatic compression boots

A prospective, randomized clinical trial in 83 patients undergoing open urological operations was performed to compare the relative prophylactic efficacy of low-dose heparin and external pneumatic compression (EPC) of the calves in comparison to no treatment in the prevention of deep vein thrombosis (DVT). The diagnosis of deep vein thrombosis was established by the I125 fibrinogen scan and contrast phlebography. The data indicate that EPC is more effective than no treatment (p less than 0.04) and more effective than low-dose heparin (p less than 0.04) in the prevention of DVT. There was one pulmonary embolus in each of the three groups, and in the treatment groups this occurred without evidence of DVT.

Electrocardiography during manual dilatation of the anus

Manual dilatation of the anus was carried out on 50 unpremedicated outpatients under propanidid, nitrous oxide, and halothane anaesthesia with E.C.G.monitoring. About half of the patients received intravenous atropine with the propanidid. The operation induced a variety of changes in heart rate but in the whole experiment only two isolated cardiac arrhythmic complexes were seen-a single defect of conduction and a solitary ventricular extrasystole. Changes in rate were not modified by atropine. It is concluded that manual dilatation of the anus is a safe procedure when carried out under the anaesthetic described and that prior medication with atropine is not necessary. This work supports the view that propanidid protects patients from most abnormalities of heart action which result from intense visceral stimulation.