Laurin-Sandrow syndrome--a surgical challenge

We describe the sixth reported case of Laurin-Sandrow syndrome. This spectrum of congenital abnormalities includes complex syndactyly, often associated with ulnar duplication, mirror feet and columella deformities. We discuss Laurin-Sandrow syndrome and report on its surgical management.

Confidential inquiry into quality of care before admission to intensive care

OBJECTIVE

To examine the prevalence, nature, causes, and consequences of suboptimal care before admission to intensive care units, and to suggest possible solutions.

DESIGN

Prospective confidential inquiry on the basis of structured interviews and questionnaires.

SETTING

A large district general hospital and a teaching hospital.

SUBJECTS

A cohort of 100 consecutive adult emergency admissions, 50 in each centre.

MAIN OUTCOME MEASURES

Opinions of two external assessors on quality of care especially recognition, investigation, monitoring, and management of abnormalities of airway, breathing, and circulation, and oxygen therapy and monitoring.

RESULTS

Assessors agreed that 20 patients were well managed (group 1) and 54 patients received suboptimal care (group 2). Assessors disagreed on quality of management of 26 patients (group 3). The casemix and severity of illness, defined by the acute physiology and chronic health evaluation (APACHE II) score, were similar between centres and the three groups. In groups 1, 2, and 3 intensive care mortalities were 5 (25%), 26 (48%), and 6 (23%) respectively (P=0.04) (group 1 versus group 2, P=0.07). Hospital mortalities were 7 (35%), 30 (56%), and 8 (31%) (P=0.07) and standardised hospital mortality ratios (95% confidence intervals) were 1.23 (0.49 to 2.54), 1.4 (0.94 to 2.0), and 1.26 (0.54 to 2.48) respectively. Admission to intensive care was considered late in 37 (69%) patients in group 2. Overall, a minimum of 4.5% and a maximum of 41% of admissions were considered potentially avoidable. Suboptimal care contributed to morbidity or mortality in most instances. The main causes of suboptimal care were failure of organisation, lack of knowledge, failure to appreciate clinical urgency, lack of supervision, and failure to seek advice.

CONCLUSIONS

The management of airway, breathing, and circulation, and oxygen therapy and monitoring in severely ill patients before admission to intensive care units may frequently be suboptimal. Major consequences may include increased morbidity and mortality and requirement for intensive care. Possible solutions include improved teaching, establishment of medical emergency teams, and widespread debate on the structure and process of acute care.

Year to end budget forecasting: income and expenditure

The introduction of devolved management structures within the NHS has exposed many clinical staff to the disciplines of financial management. This short article looks at the principles behind the preparation of budgets, the purpose of the income and expenditure account and the tools used to monitor expenditure at directorate and department level within a hospital.

Increase in Mallampati score during pregnancy

A photographic version of the Mallampati test was developed and applied to 242 pregnant patients at 12 weeks' gestation and again at 38 weeks' gestation. At 38 weeks the number of grade 4 cases had increased by 34% (P < 0.001). This is in agreement with other evidence which suggests that difficult laryngoscopy is slightly more frequent in obstetrics (1.7%) than in general surgery (1.3%). The increase in Mallampati score correlated with gain in body weight (r = 0.3, P < 0.001), which gives some support to the concept that fluid retention is the underlying cause. We conclude that pharyngeal oedema causes some hindrance to tracheal intubation in obstetrics, but not enough to explain the high failure rate reported. A case is made for rationalizing the management of difficult intubation. Our data also show that more research is needed on factors which affect Mallampati's test, particularly neck extension.

Absence of immunoglobulin and T-cell receptor gene rearrangements in myelodysplastic syndromes and acute nonlymphocytic leukemias

The arrangement of the immunoglobulin and T-cell receptor genes has been analysed in 72 cases of primary myelodysplastic syndrome and 17 cases of acute nonlymphocytic leukemia. DNA was extracted from bone marrow aspirates, digested with at least two restriction enzymes, and hybridised with probes for the joining region of the immunoglobulin heavy chain gene, the constant region of the T-cell receptor beta chain gene, and the joining region of the T-cell receptor gamma chain gene. All cases showed germline arrangements of the immunoglobulin and the T cell receptor genes. Thus, true interlineage infidelity, myeloid to lymphoid, is a rare occurrence in myelodysplasia and in myeloid leukemias.

Detection of chromosomal 7 loss in myelodysplasia using an extremely polymorphic DNA probe

Chromosomal loss is a characteristic feature of the myelodysplastic syndromes (MDS). A method is described which detects chromosomal 7 loss in MDS by DNA analysis using a specific hypervariable region gene probe which has been cloned from a human DNA fingerprint. Loss of one of the chromosomal 7 homologues was demonstrated in 10/118 MDS patients; the ten patients include all the five patients which had previously been shown to have monosomy 7 by cytogenetic analysis. This technique makes it feasible to study serial samples from large numbers of patients for loss of chromosomal material and could be readily applied to the study of other human malignancies.

Allele-specific DNA identity patterns

A method of genetic analysis is presented which involves digestion of DNA with a single restriction enzyme (PvuII) and hybridisation with a mixture of five probes. Four of the five probes chosen recognise hypervariable regions (HVRs) of the human genome and hence an allele-specific DNA identity pattern results. An advantage of this approach to genetic characterisation is that the complex identity patterns may be broken down into simple allelic systems of known chromosomal localization by hybridisation with the individual probes. Also different probes may be included in a combined probe designed for particular types of investigation.