A prospective analysis of inpatient consultations to a gastroenterology service

The provision of a formal consultation service for inpatients between subspecialists is little studied. We prospectively surveyed the pattern of inpatient consultations from hospital-based generalists and surgeons to the gastroenterology (GI) service for inpatients in a large urban teaching hospital over a 5 month period. There are two GI consultants/attendings and five GI registrars/fellows on the service. A formal consultation is made by the requesting team to the GI service using the hospital computer network. All referrals over a 5 month period were prospectively analysed. 242 consecutive inpatient referrals were sent to the GI service over 5 months. Average age was 56 years, 48.8% males. 32 consultants/attendings from other disciplines sent referrals. Most patients were seen within one working day. Urgent referrals were seen without delay. The commonest reasons for referral were abdominal pain (15.8%), percutaneous endoscopic gastrostomy (PEG) tube insertion (13.6%), diarrhoea (12.8%), abnormal liver blood tests (10%), nausea and vomiting (8.2%), anaemia (6.2%), and melaena (4.9%). Iatrogenic diseases accounted for 6.2% of consultations. Ongoing patient care was assumed by the GI team in 9.5% of referrals. 15.3% required a second consultation visit before discharge. 22.7% of referrals were followed in the GI outpatients' clinic after discharge. 51.2% underwent an endoscopic procedure. 13.6% of referrals were for PEG tube insertion. A quarter of these were considered unsuitable for immediate PEG tube insertion. Subspecialty consultation provides an expert opinion, encourages discussion and learning, and improves patient care. In our experience, the provision of specialist advice and reassurance often speeded up a patient's work-up and expedited discharge. However, evaluating referral patients and subsequently providing ongoing inpatient and outpatient care and provision of endoscopy for these referrals contributes significantly to the workload of the GI service.

Social trends in singleton births and birth weight in Wirral residents, 1990-2001

OBJECTIVE

To examine social trends in the number of singleton births and birth weight in an English health district between 1990 and 2001, using an area based deprivation index.

DESIGN

Analysis of routinely collected hospital data.

SETTING

Wirral Health District in north west England.

PARTICIPANTS

All 48 452 live births to Wirral residents from 1990 to 2001.

MAIN OUTCOME MEASURES

Birth numbers, birth weight, and standard deviation score for birth weights for singleton births. Townsend material deprivation scores derived from postcodes.

RESULTS

The number of singleton births fell by 28% over the 12 years. The fall in the least deprived Townsend quartile (45%) was more than triple that in the most deprived quartile (gamma = 0.045; 95% confidence interval (CI) = 0.036 to 0.054; p < 0.001). Over the study period, the mean birth weight in the least deprived Townsend quartile was 141 g higher than in the most deprived quartile. There was a highly significant association between the standard deviation score for birth weight and Townsend quartile (tau-b = -0.062; 95% CI = -0.068 to -0.055; p < 0.001). Numbers of low birth weight babies in the least deprived quartile fell disproportionately compared with those from the most deprived quartile (gamma = 0.17; 95% CI = 0.09 to 0.25; p < 0.001).

CONCLUSION

The reduction in birth rate in the Wirral was significantly less in the most deprived districts. This was accompanied by related differences in mean birth weight and the number of low birth weight babies, indicating increasing social inequality in birth trends. Previously described social inequity in birth weight and the number of low birth weight babies continues in the north west of England.

Sudden infant death syndrome: bed sharing with mothers who smoke

AIM

To examine the sleeping arrangements of sudden infant death syndrome (SIDS) cases on the Wirral. In particular to determine the prevalence of bed sharing with mothers who smoke, a known risk factor for SIDS.

METHODS

Retrospective study of postmortem determined cases of SIDS from 1995 to 2000 on the Wirral peninsula (population 350 000, 3500 annual births). Ambulance crew reports, case notes, health visitor reports, postmortem reports, and case discussion records were studied for each case.

RESULTS

There were 25 cases of SIDS in the postneonatal age group over the six year period. In nine cases the baby was bed sharing with the mother, of whom seven were smokers. Five of these mothers reported using alcohol or illicit drugs on the night of their infant's death. In two further cases the baby slept on a sofa with a parent.

CONCLUSIONS

Bed sharing and smoking remain important risk factors for SIDS. Mothers should be advised ante- and postnatally of this combination of risk factors. Such advice should also include a recommendation not to sleep with their baby if under the influence of alcohol or illicit drugs, and never to sleep on a sofa with their baby. All "Child Health Record" books given to parents on the Wirral now include this advice. "Reduce the Risk" advice leaflets given to parents pre- and postnatally also now carry the recommendation, and health visitors and midwives have been educated with respect to these additions.

Acute effects of low-dose interferon-alpha on serum cortisol and plasma interleukin-6

Major depression is associated with both hypothalamic-pituitary-adrenal (HPA) axis overactivity and immune system activation. Depression is a common occurrence following interferon (IFN)-a treatment. While IFN-alpha is known to stimulate the HPA axis, little is known about the effects of exogenous IFN-a in humans on the proinflammatory cytokine interleukin (IL)-6, a marker of immune system activation. This study examined the acute effects of IFN-alpha on cortisol and IL-6 release, and the time course of any changes in these variables. Serum cortisol and plasma IL-6 were assessed in healthy volunteers over an 8-h period following 3 million units subcutaneous IFN-alpha or placebo using a double-blind, placebo-controlled crossover design. IFN-alpha resulted in a significant increase in both cortisol and IL-6. Regular sampling over 8 h did not delineate any sequential effect of the rise in these variables over time. We conclude that IFN-alpha acutely stimulates both the HPA axis and proinflammatory cytokine release. The hypothesis that the effect of IFN-alpha on the HPA axis is indirect and mediated by IL-6 was not supported by this study. Our findings are nonetheless of relevance to the aetiology of depression following IFN-alpha.

Family screening is effective in picking up undiagnosed Asian vitamin D deficient subjects

Vitamin D deficiency has been described in the Asian migrants to the UK from the early 1960s. In spite of some suggestions that this problem is declining, we continue to see clinical cases of vitamin D deficiency with osteomalacia presenting to hospital. As the aetiology of this condition is associated with social, cultural and dietary factors, we screened associated family members of 18 index cases (three males 15 females, age range 12-73 years) who presented with clinical vitamin D deficiency to hospital. Of the 36 (21 females, 15 males) screened, 67% of these had evidence of vitamin D deficiency as judged by a 25(OH)VitD of < 5 microg L-1 (5-40). Some subjects also had hypocalcaemia (n=2), low PO4 (n=7), raised PTH (n=8) and raised alkaline phosphatase (n=11), indicating severe symptomatic, but unrecognized, vitamin D deficiency. Family screening seems an effective way of identifying Asian subjects with vitamin D deficiency who otherwise remain undiagnosed. A preventative policy with implementation is long overdue for this easily treatable condition.

Chronic inflammatory bowel disease and the 'over-clean' environment: rarity in the Irish 'traveller' community

The causes of ulcerative colitis and Crohn's disease are unknown. Current research is focused on genetic factors but environmental factors may also be important. Exposure to infections in early life is believed to reduce the incidence of bronchial asthma. We hypothesised that exposure to enteric bacteria and infections in early life may also reduce the incidence of idiopathic inflammatory bowel disease. Chronic inflammatory bowel disease may be a by-product of our over-clean environment. Social groups with poorer living standards might be expected to have a lower prevalence of this condition. The "traveller" or itinerant community in Ireland is one such group. We therefore attempted to estimate the prevalence of inflammatory bowel disease in the traveller population. Twenty five of 30 gastroenterologists or surgeons in Ireland responded to requests for information. None could recall ever seeing a "traveller" with idiopathic inflammatory bowel disease. While genetic factors cannot be excluded, a low prevalence of idiopathic inflammatory bowel disease would support the environmental hypothesis.

Snapshots of five clinical ethics committees in the UK

Each of the following papers gives an account of a different UK clinical ethics committee. The committees vary in the length of time they have been established, and also in the main focus of their work. The accounts discuss the development of the committees and some of the ethical problems that have been brought to them. The issues raised will be relevant for other National Health Service (NHS) trusts in the UK that wish to set up such a committee.

Loss of signaling through the G protein, Gz, results in abnormal platelet activation and altered responses to psychoactive drugs

Heterotrimeric G proteins mediate the earliest step in cell responses to external events by linking cell surface receptors to intracellular signaling pathways. G(z) is a member of the G(i) family of G proteins that is prominently expressed in platelets and brain. Here, we show that deletion of the alpha subunit of G(z) in mice: (i) impairs platelet aggregation by preventing the inhibition of cAMP formation normally seen at physiologic concentrations of epinephrine, and (ii) causes the mice to be more resistant to fatal thromboembolism. Loss of G(zalpha) also results in greatly exaggerated responses to cocaine, reduces the analgesic effects of morphine, and abolishes the effects of widely used antidepressant drugs that act as catecholamine reuptake inhibitors. These changes occur despite the presence of other G(ialpha) family members in the same cells and are not accompanied by detectable compensatory changes in the level of expression of other G protein subunits. Therefore, these results provide insights into receptor selectivity among G proteins and a model for understanding platelet function and the effects of psychoactive drugs.

Randomised controlled trial of patient triggered and conventional fast rate ventilation in neonatal respiratory distress syndrome

AIM

To compare patient triggered, with conventional fast rate, ventilation in a randomised controlled trial using the incidence of chronic lung disease as the primary outcome measure.

METHODS

Three hundred and eighty six preterm infants with birthweights from 1000 to 2000 g, and requiring ventilation for respiratory distress syndrome within 24 hours of birth, were randomised to receive either conventional or trigger ventilation with the SLE 2000 ventilator.

RESULTS

There were no significant differences in the incidence of chronic lung disease (28 day and 36 week definitions), death, pneumothorax, intraventricular haemorrhage, number of ventilator days, or length of oxygen dependency between groups.

CONCLUSIONS

Patient triggered ventilation in preterm infants with respiratory distress syndrome is feasible. No significant differences, when compared with conventional fast rate ventilation in important medium and longer term outcome measures, were evident.

Digital teledermatology for skin tumours: a preliminary assessment using a receiver operating characteristics (ROC) analysis

A low-cost store-and-forward teledermatology system using digital images for the remote diagnosis and management of skin tumours was evaluated. Two hospitals participated in the trial. Patients were seen face to face at one hospital, and had their images and clinical history viewed remotely by a different dermatologist at a second hospital. A preliminary receiver operating characteristics (ROC) analysis revealed clinical agreement between the teledermatologist and face-to-face dermatologist in 93% of cases in terms of their assessment of the benign/malignant nature of the lesions. Sensitivity of the judgements was 88% and specificity was 80%. These preliminary findings indicate the potential for remote management of skin tumours using a low-cost system in the National Health Service.

Psychosocial, substance use, and delinquency differences among Anglo, Hispanic White, and African-American male youths entering a juvenile assessment center

Using data collected on nearly 4,000 Anglo, Hispanic White, and African-American male youths processed at the Hillsborough County Juvenile Assessment Center, we examine their psychosocial, substance use, and other delinquent behavior differences. In extending the results of previous research in a manner consistent with the concept of relative deviance, significant differences in these variables are found across the three groups. Implications of the findings for theory, service delivery, and policy are also considered.

The use of a Hemocue blood glucose analyser in a neonatal unit

Near patient testing for glucose is now a widely accepted procedure in hospital wards and clinics. However, in a neonatal ward where the detection of hypoglycaemia rather than hyperglycaemia is of paramount importance, it is more difficult to find a suitable glucose monitoring instrument. We compared two Hemocue blood glucose analysers (Hemocue Ltd) in our special care baby unit (SCBU) with the laboratory procedures and found that the Hemocue may overestimate the glucose by as much as 2.5 mmol/L. In addition, Hemocue analysers are costly to run. We feel these analysers may be more useful in a general ward rather than in a SCBU.

Examination of the reliability of the Problem Oriented Screening Instrument for Teenagers (POSIT) among arrested youths entering a juvenile assessment center

The Problem Oriented Screening Instrument for Teenagers (POSIT) serves as a key aspect of the preliminary screening activities at the Hillsborough County Juvenile Assessment Center. We report on a reliability study of POSIT, involving an examination of the relationships between the youths' initial and second admission POSIT results for different time intervals between administration of the instrument. The results indicate the POSIT provides consistent indication of potentially troubled youths who are in need of in-depth assessment and intervention or treatment services.

Development and evaluation of a classification of high risk youths entering a juvenile assessment center

We report the results of developing and evaluating a classification of high risk youth entering a Juvenile Assessment Center in Hillsborough County, Florida, involving over 2,000 youths processed at the center during its first 8 months of operation. Cluster analysis of the youths' potential problems probed by the Problem Oriented Screening Instrument for Teenagers defined four groups. The usefulness of the typology was supported by a discriminant analysis and by recidivism information. The research implications of these results are discussed.

Predictors of recidivism to a juvenile assessment center

We report the results of a study of the predictors of recidivism to a Juvenile Assessment Center in Hillsborough County, Florida, involving over 2,000 youths processed at the center during its first 8 months of operation. Consistent with previous research, younger aged youths, youths with abuse or neglect histories, with previous arrests for property, violence, or drug offenses, with potential vocational, leisure-recreation, and family problems, or who were arrested on property felony charges were likely to recidivate. The program activity and policy implications of these results are discussed.

The heterotrimeric G-protein Gi is localized to the insulin secretory granules of beta-cells and is involved in insulin exocytosis

Mastoparan, a tetradecapeptide found in wasp venom that stimulates G-proteins, increases insulin secretion from beta-cells. In this study, we have examined the role of heterotrimeric G-proteins in mastoparan-induced insulin secretion from the insulin-secreting beta-cell line beta-TC3. Mastoparan stimulated insulin secretion in a dose-dependent manner from digitonin-permeabilized beta-TC3 cells. Active mastoparan analogues mastoparan 7, mastoparan 8, and mastoparan X also stimulated secretion. Mastoparan 17, an inactive analogue of mastoparan, did not increase insulin secretion from permeabilized beta-TC3 cells. Mastoparan-induced insulin secretion from permeabilized beta-TC3 cells was inhibited by pretreatment of the cells with pertussis toxin, suggesting that mastoparan-induced insulin secretion is mediated through a pertussis toxin-sensitive G-protein present distally in exocytosis. Enriched insulin secretory granules (ISG) were prepared by sucrose/nycodenz ultracentrifugation. Western immunoblotting performed on beta-TC3 homogenate and ISG demonstrated that G alpha i was dramatically enriched in ISG. Levels of G alpha o and G alpha q were comparable in homogenate and ISG. Mastoparan stimulated ISG GTPase activity in a pertussis toxin-sensitive manner. Mastoparan 7 and mastoparan 8 also stimulated GTPase activity in the ISG, while the inactive analogue mastoparan 17 had no effect. Selective localization of G alpha i to ISG was confirmed with electron microscopic immunocytochemistry in beta-TC3 cells and beta-cells from rat pancreas. In contrast to G alpha o and G alpha q, G alpha was clearly localized to the ISG. Together, these data suggest that mastoparan may act through the heterotrimeric G-protein G alpha i located in the ISG of beta-cells to stimulate insulin secretion.

Muscarinic regulation of Alzheimer's disease amyloid precursor protein secretion and amyloid beta-protein production in human neuronal NT2N cells

The Alzheimer amyloid precursor protein (APP) undergoes complex processing resulting in the production of a 4-kDa amyloid peptide (A beta) which has been implicated in the pathogenesis of Alzheimer's disease. Recent studies have shown that cells can secrete carboxyl terminus truncated APP derivatives (APP-S) in response to physiological stimulus. We have used human central nervous system neurons (NT2N) derived from a teratocarcinoma cell line (NT2) to study the signal transduction pathways involved in APP-S secretion and A beta production. Muscarinic receptors (m2 and m3) as well as the heterotrimeric GTP-binding protein Gq and the beta 1 isoform of phospholipase C were present in NT2N neurons. Stimulation of the muscarinic receptor with carbachol resulted in phospholipase C activation as shown by a transient increase in the second messengers 1,2-diacyl-sn-glycerol and inositol 1,4,5-trisphosphate. Carbachol also caused an increase in intracellular Ca2+ levels measured in single NT2N neurons. Under these conditions, carbachol caused a time-dependent 2-fold increase in APP-S secretion into the medium. In contrast, prolonged treatment with carbachol caused a decrease in A beta production into the medium. These results suggest that APP-S secretion and A beta production in NT2N neurons are regulated by the muscarinic/phospholipase C signal transduction pathway. Furthermore, activation of this pathway results in dissociation of APP-S secretion and A beta production.

Comparison of serum osteocalcin with total and bone specific alkaline phosphatase and urinary hydroxyproline:creatinine ratio in patients with Paget's disease of bone

Osteocalcin or bone Gla protein (BGP) is secreted by osteoblasts, and its serum concentration is elevated in a number of conditions with high bone turnover. A comparison of serum osteocalcin with total (TALP) and bone specific alkaline phosphatase (BALP) and urinary hydroxyproline/creatinine (OHP/Cr ratio) was performed in 13 patients with active Paget's disease of bone. BGP did not correlate significantly with either BALP or TALP, but did show a significant correlation with OHP/Cr ratio (r = 0.76; P < 0.01). BGP does not appear to be as sensitive a marker as BALP or TALP in Paget's disease.

Making the new deal for junior doctors happen

How can the new deal for juniors be implemented in today's overstretched health service? How do you get clinicians and management to work together? On the Wirral falling house officer morale and recruitment stimulated a new approach, action learning, which proved to be highly successful. Action learning is not a new approach in management terms, but it is rarely used in the health service. Guided by an experienced facilitator, a group of people learn management skills by exploring and resolving practical problems relevant to them. A group of general practitioners and consultants used action learning to teach themselves more about management and at the same time to make changes which addressed many of the junior doctors' difficulties and solved the hospital recruiting problem.

The hemoglobins of the bullfrog, Rana catesbeiana. Deoxygenation-linked association of tetrameric components B and C to form the trimer BC2: sedimentation analysis and oxygen equilibria

Hemolysates from the adult bullfrog, Rana catesbeiana, show an unusually high degree of cooperativity of oxygen binding with Hill coefficients greater than 4. The principal components of the tetrameric hemoglobin, B and C, do not show this high cooperativity when isolated, but it reappears when the components are mixed. Sedimentation velocity measurements show that the unusual behavior results from the mixed association of components B and C to form complexes larger than tetramers. Computer simulation of the sedimentation behavior of mixtures of deoxygenated B and C components shows that the gradient profiles can be satisfactorily described in terms of an equilibrium between the B and C tetramers and a BC2 trimer. The simplest model consistent with the results is the mixed association: B + C<-->BC and BC + C<-->BC2, with the second binding constant being higher than the first, indicating significant cooperativity. The extent of association is highest at low pH and low temperature. The dissociation of the B.C complex with low oxygen affinity to higher affinity B and C molecules during oxygenation results in greatly increased cooperativity of oxygen binding with higher Hill coefficients than possessed by either component alone in equilibria measured between 5 and 25 degrees C and between pH 6 and 8.