Protracted diagnosis of ACNES: a costly exercise

This case report summarizes the course of events leading to diagnosis and eventual repair of anterior cutaneous nerve entrapment syndrome (ACNES) in a 58-year-old female. The time period elapsing from initial symptoms to final operative repair was 9 months. The diagnosis was missed by both medical and surgical specialists despite multiple outpatient appointments, investigative procedures and a battery of laboratory tests. The diagnosis of ACNES was first considered when reviewed by a hernia surgeon and subsequently confirmed following open exploration of the anterior abdominal wall. The nerve was released and pain symptoms resolved. Access to the NHS Scotland ISD register permitted an economic analysis of the diagnostic services utilized for this patient and these totalled nearly £11 500. At a time when the NHS is focused on cost effectiveness, this particular sequence of investigations illustrates a protracted and costly diagnostic pathway.

Adjuvant Chemotherapy and Immunotherapy for Colorectal Cancer: Preliminary Communication

Following surgical resection of Dukes’ B or C colorectal cancers 72 patients have been randomly allocated to receive: 5-fluorouracil; or 5-fluorouracil and levamisole; or no treatment. Adjuvant treatment was continued for one year. 66 patients remain evaluable for up to 24 months. Preliminary results show no significant differences in survival or recurrence rates. Two patients receiving 5-fluorouracil and levamisole developed severe, but reversible, neutropenia. Other side effects were uncommon.

The learning environment for junior doctor training--what hinders, what helps

As part of a larger study on learning outcomes for the first year of postgraduate medical training (already reported), semi-structured interviews with middle grade trainees were used to explore their perceptions of trainee development during this first training year. Data generated focused not only on learning outcomes, but also on important process issues. Dissatisfaction was expressed with formal and informal teaching and learning opportunities. Factors that enhance the learning environment were identified. These included being supported, a feeling of being a valued member of the team, being stretched but not over stretched, having a broad range of experiences, knowing the system, having a clear remit and being well organized. Factors inhibiting the learning environment included fractured working patterns, insufficient time with patients and seniors, as well as the converse of many of the enhancing factors. The process issues gathered in this paper will be of interest to those involved in the delivery of training for junior doctors.

Exit learning outcomes for the PRHO year: an evidence base for informed decisions

OBJECTIVE

To evaluate potential learning outcomes for pre-registration house officer (PRHO) training and develop an evidence base for informed decision making.

DESIGN AND SETTING

A 2-stage Delphi process was employed to establish the opinions of Scottish stakeholders with regard to learning outcomes for the PRHO year.

PARTICIPANTS

Doctors involved in the provision of PRHO training, including deans, postgraduate tutors and general practitioners (GPs) with trainees, were invited to participate in the study.

MAIN OUTCOME MEASURES

Respondents rated a range of outcomes according to which they believed should be included or excluded from the PRHO training year.

RESULTS

Learning outcomes identified for PRHOs were grouped under the 12-domain framework of the 3-circle model: 'What the doctor can do', 'How they approach their practice' and 'Their professionalism'. Based on the consensus opinions gained in the Delphi study, the ratings were classified into priority groupings. Priority 1 contained 45 of the original 81 learning outcomes, representing each area of the 3-circle model, with emphasis on the domains of clinical skills, patient investigation/management, communication, appropriate attitudes and personal development. Health promotion and disease prevention was the only domain not represented at priority 1. Priority 2 contained 24 outcomes with emphasis on the understanding of clinical skills, patient management and personal development. Priority 3 contained 12 outcomes indicating a lack of emphasis for some outcomes, particularly the role of the doctor and health promotion.

CONCLUSION

Consensus on the learning outcomes for PRHO training has been achieved, providing an evidence base for curriculum planning. The relative priority assigned to these outcomes can facilitate the use of the evidence. This evidence base should be referred to when reviewing any PRHO training programme.

New doctors' perceptions of their educational development during their first year of postgraduate training

The General Medical Council (GMC) in the UK describes a wide range of competences in which the new medical graduate should develop during the first postgraduate year. New graduates are known as pre-registration house officers (PRHOs). In this study, semi-structured open interviews with PRHOs approaching the end of their first postgraduate year were used to explore the trainees' perceptions of their development. After the interview their views on the importance given in their experience to the GMC's competences were explored though a questionnaire. Most noticeable from the interview data was the PRHOs'emphasis in the development of generic skills required of working in the 'real world'--skills such as communication, team working and the ability to cope with responsibility. In some outcomes, their noticeable progression, e.g. communication, or lack of progression, e.g. health promotion, reflected their views on the importance given. With other outcomes there was a paradox, e.g. practical skills were rated highly but were not noticeably developed; the role of the doctor was noticeably developed but was not highly rated. Overall the PRHOs developed most strongly in the 'professionalism' domain with not all the skills in the 'tasks' domain being similarly developed. This study helps to define the benefits and opportunities of the PRHO year, as currently perceived by the trainees, and should be of interest to those involved in the planning and delivery of postgraduate training.

New doctors' perceptions of their educational development during their first year of postgraduate training

The General Medical Council (GMC) in the UK describes a wide range of competences in which the new medical graduate should develop during the first postgraduate year. New graduates are known as pre-registration house officers (PRHOs). In this study, semi-structured open interviews with PRHOs approaching the end of their first postgraduate year were used to explore the trainees' perceptions of their development. After the interview their views on the importance given in their experience to the GMC's competences were explored though a questionnaire. Most noticeable from the interview data was the PRHOs'emphasis in the development of generic skills required of working in the 'real world'--skills such as communication, team working and the ability to cope with responsibility. In some outcomes, their noticeable progression, e.g. communication, or lack of progression, e.g. health promotion, reflected their views on the importance given. With other outcomes there was a paradox, e.g. practical skills were rated highly but were not noticeably developed; the role of the doctor was noticeably developed but was not highly rated. Overall the PRHOs developed most strongly in the 'professionalism' domain with not all the skills in the 'tasks' domain being similarly developed. This study helps to define the benefits and opportunities of the PRHO year, as currently perceived by the trainees, and should be of interest to those involved in the planning and delivery of postgraduate training.

Early graft function and patient survival following cadaveric renal transplantation

BACKGROUND

The influence of events that occur early following renal transplantation such as delayed graft function (DGF) and acute rejection on long-term graft survival has been widely reported, but its association with patient survival has received less attention.

METHODS

We studied 589 patients who received their first cadaveric transplants between 1984 and 1993, all of whom received cyclosporine-based immunosuppression and who had a median follow-up of seven years. The following factors were identified, and both univariate and multivariate analyses were used to determine their association with long-term patient and graft survival: age, sex, duration of pretransplant dialysis, primary renal disease, immediate graft function (IGF), DGF, primary nonfunction (PNF), acute rejection, and serum creatinine at 3, 6, and 12 months.

RESULTS

Patients with PNF had a poorer survival than those with DGF and IGF (P = 0.01), but there was no difference in survival between DGF and IGF (P = 0.54). Good graft function (serum creatinine of less than 200 mumol/liter) at three months was predictive of better long-term patient survival (P = 0.03). Other factors associated with poor patient outcome were older age, diabetes, adult polycystic kidney disease, male gender, and acute rejection. Cardiovascular disease was the most common cause of death (51.8%). Good graft function at three months (P < 0.001) and an absence of rejection episodes (P = 0.01) were associated with better graft survival.

CONCLUSION

Patients with poor levels of early graft function (but not DGF) and those with either acute rejection episodes or early graft loss are at an increased risk of early death. These high-risk groups should be targeted for interventional studies in an attempt to improve patient survival.

Long-term outcome of the use of OKT3 to treat steroid-resistant acute renal allograft rejection

OKT3 was used to treat steroid-resistant acute renal allograft rejection in 30 of 496 adult patients transplanted over a 6-year period. Rejection was reversed (defined as a fall in serum creatinine by 50% or more within 30 days of treatment with OKT3) in 40% of cases. Successful reversal was significantly more likely when rejection occurred shortly after transplantation (t ratio -2.53; P = 0.019). The long-term outcome was disappointing; the actuarial graft survival at 1 year from the start of treatment with OKT3 was 42%, and no grafts have thus far survived longer than 3 years. Graft survival was shorter in older patients (coefficient/standard error 2.226; P < 0.05), and no other predictor of long-term outcome was identified. Patient survival at 3 years was 88%. Serious infection occurred in 33% of patients, with two deaths. Our experience suggests that treatment with OKT3 is unlikely to reverse acute renal allograft rejection in more than half of patients where rejection is resistant to steroids. Although long-term graft survival occurred in a few cases, the overall long-term outcome was disappointing, particularly in older patients. Finally, our analysis indicates the difficulty of predicting which patients will derive long-term benefit when OKT3 is used to treat steroid-resistant rejection.

Acute torsion of the gallbladder

Acute torsion of the gallbladder is an acute surgical emergency which may be encountered more frequently in the presence of an ageing population. We report a 98-year-old patient in whom the diagnosis was made at exploratory laparotomy performed for unexplained peritonism. Emergency cholecystectomy was followed by an uncomplicated post-operative recovery.

Kidney transplantation in the United Kingdom

The National Health Service (NHS) supplies the majority of health care in Great Britain but is virtually the monopoly provider of high technology and disaster services such as treatment for chronic renal failure or end-stage renal disease (ESRD).

Malignant phaeochromocytoma

Malignant phaeochromocytoma is a rare tumour and experience in its management is therefore limited. Five patients are discussed in whom the development of metastases was associated with rapidly progressive disease.

Chlorhexidine in methanol for the preoperative cleansing of surgeons' hands: a clinical trial

A clinical trial has shown that a technique of preoperative hand disinfection using a methanolic solution of chlorhexidine is faster, cheaper and more acceptable to users than the conventional aqueous detergent chlorhexidine preoperative scrub regime. The wound infection rate in general surgical patients was not influenced by the method used.

Morbidity and mortality in renal transplant patients after incidental surgery

Sixty-five further surgical procedures were carried out in 39 renal transplant patients without mortality and with low morbidity. There was a 9 per cent incidence of clean wound infection, and minor chest infection occurred in another 9 per cent. Stay in hospital for these procedures was not prolonged. The function of the transplanted kidney showed no deterioration after these further surgical procedures. The successfully transplanted patients is thus a good candidate for further surgery despite the previous renal failure and the continuing immunosuppressive therapy.

Studies on infiltrating host cells harvested from acutely rejecting rat cardiac allografts

Although the cellular events of rejection of organ allografts have been fully described histologically, little information exists regarding actual mechanisms of graft destruction. Available concepts are based primarily upon assays performed in vitro. This study describes a model designed to correlate such in vitro information with events occurring in vivo within acutely rejecting organ allografts. Infiltrating host cells had been harvested by two techniques from heterotopic cardiac allografts in rats. The various cell classes have been noted and their differential rates of accumulation compared to serial histological observations. Subpopulations of cells have been identified by surface markers, and specific cytotoxicity against donor alloantigen has been determined as a T lymphocyte function. These techniques may be of aid in unraveling the complexities of graft rejection.

Surface properties and functional characteristics of infiltrating cells harvested from acutely rejecting cardiac allografts in inbred rats

Viable, functioning effector cells exerting donor specific cytotoxic properties have been removed, with their surface properties intact, from acutely rejecting cardiac allografts in rats to define immunological events occurring within the grafts themselves. Macrophages comprised 15 to 25% of the cells harvested; lymphocytes comprised about 75%. A few polymorphonuclear leukocytes (approximately 5%) were present consistently. Lymphocytes bearing surface Ig, B cells, made up 35 to 47% of the mononuclear cells collected. The remaining lymphocytes were presumptive T cells. The surfact attributes of the infiltrating cells were compared to those of cells from recipient peripheral blood, spleen and lymph nodes, and to those from isografted controls. Many of the B lymphocytes possessed Fc receptors but were virtually unable to form erythrocyteantibody complement (EAC) rosettes, in contrast to splenocytes which formed approximately 30% EAC rosettes. Specific cytotoxicity against donor alloantigen-bearing cells, as tested in a 51Cr release assay, was shown to be a T cell function by serial fractionation experiments. Peak cytotoxicity of infiltrating T cells occurred early during the rejection process, while that of cells from recipient blood and lymphoid tissues occurred only following complete graft destruction. Antibody-dependent lymphocyte-mediated cytotoxicity (Ab-LMC) was demonstrated following gentle trypsinization or overnight incubation of the cells. Differing effector cell populations could be distinguished by treatment of anti-Ig and complement; direct donor-specific lymphocyte-mediated cytotoxicity was not disrupted by this treatment, while Ab-LMC was abolished.

Renal transplantation: an analysis of 33 cases

Thirty-three patients with end-stage renal failure have had transplants over a three-year period, four patients receiving kidneys from siblings and the remainder cadaver organs. Twenty-seven kidneys survived with stable function for periods of six months to three years. Graft survival at one year was 85% and at two years 82%. One patient died and five were returned to dialysis. Complications included rejection episodes, technical problems, respiratory and wound infections, gastrointestinal disorders, and side effects of steroids.