Tools of the trade

An unhurried, deft, economical technique allied to efficient use of available resources, surgical instruments and support staff is the hallmark of a 'good' surgeon. To achieve this sense of fluency, surgeons need to be familiar with the tools of their profession so that these can be employed appropriately for the task at hand. The range of instruments available in obstetrics and gynaecology is no less wide or complex than in any other branch of surgery, but formal teaching in the full range of surgical hardware is frequently lacking and an individual's exposure is generally limited to the instruments used in his or her own training hospital. This chapter sets out to describe key technical areas with which surgeons need to be familiar.

The emergency department as an asthma surveillance tool at the community level: a decline in the burden of pediatric asthma in halifax, Canada

We report pediatric emergency department (PED) asthma visit and inpatient asthma (AS) admission data in our area over a 5-year period. AS visits decreased by 33.9%, AS admissions by 24.6%, both significant compared with the decline in elementary school enrollment. The decrease in asthma visits was due to a decrease in the number of asthmatic patients, not a decline in repeat visits, or use of alternate venues of care. Explanations include a decrease in the burden of disease or an improvement in ambulatory care, but not alternate treatment venues or improvement in acute (PED) care. Readily available, emergency department data are useful in the community surveillance of asthma.

What happens to my patients? An automated linkage between emergency department and mortality data

A simple application linking mortality data from the Bureau of Vital Statistics with data from the emergency department information system is described. This application has been used to supplement the regular mortality review process, identify deaths of patients who left without being seen, and perform outcome studies looking at specified clinical conditions.

Agreement between emergency physician diagnosis and radiologist reports in patients discharged from an emergency department with community-acquired pneumonia

To evaluate the level of concurrence between radiologist reports and the diagnosis of community-acquired pneumonia (CAP) in patients discharged from an emergency department (ED), a retrospective chart audit of patients discharged with a diagnosis of 'pneumonia' or 'possible pneumonia' from the ED during a 2-year period was conducted. Emergency physician (EP) and radiology report (RR) diagnoses were categorized as 'pneumonia', 'possible pneumonia', 'non-pneumonia' and 'normal', and categories from each were compared. 815 charts were analyzed. Of 671 EP diagnoses of 'pneumonia', 304 (45.3%) RR's reported 'pneumonia' and 82 (12.2%), 'possible pneumonia'. Of 815 EP diagnoses of 'pneumonia' or 'possible pneumonia', 426 (52.3%) RRs were in agreement, while 216(26.5%) were of diagnoses other than pneumonia and 173 (21.1%) were read as normal. EPs and radiologists frequently disagree on whether a patient has pneumonia or not. Perhaps it is time to revisit the gold standard status of plain chest X-ray.

Transitions in care during the end of life: changes experienced following enrolment in a comprehensive palliative care program

Background

Transitions in the location of care and in who provides such care can be extremely stressful for individuals facing death and for those close to them. The objective of this study was to describe the distribution of transitions in care experienced by palliative care patients following admission to a comprehensive palliative care program (PCP). A better understanding of these transitions may aid in reducing unnecessary change, help predict care needs, enhance transitions that improve quality of life, guide health care system communication links and maximize the cost-effective utilization of different care settings and providers.

Methods

Transition and demographic information pertaining to all patients registered in the PCP at the Queen Elizabeth II Health Sciences Centre (QEII), Halifax, Nova Scotia, Canada between January 1, 1998 and December 31, 2002 and who died on or prior to December 31, 2002 was extracted from the PCP database and examined. A transition was defined as either: (1) a change in location of where the patient was cared for by the PCP or, (2) a change in which clinical service provided care. Descriptive analysis provided frequencies and locations of transitions experienced from time of PCP admission to death and during the final two and four weeks of life, an examination of patient movement and a summary of the length of stay spent by patients at each care location.

Results

Over the five year period, 3974 adults admitted to the QEII PCP experienced a total of 5903 transitions (Mean 1.5; standard deviation 1.8; median 1). Patients with no transitions (28%) differed significantly from those who had experienced at least one transition with respect to survival time, age, location of death and diagnosis (p < 0.0001). The majority of patients were admitted to the PCP from various acute care units (66%). Although 54% of all transitions were made to the home, only 60% of these moves included care provided by PCP staff. During the last four weeks of life, 47% of patients experienced at least one transition; 36% during the final two weeks of life. Shorter stays in each location were evident when care was actively provided by the PCP.

Conclusion

A relatively small number of patients under the care of the PCP at the end of life, made several transitions in care setting or service provider. These particular patients need closer scrutiny to understand why such transitions take place so that clinical programs may be designed or modified to minimize the transitions themselves or the impact transitions have on patients and families.

Spinal dorsal horn neurone targets for nociceptive primary afferents: do single neurone morphological characteristics suggest how nociceptive information is processed at the spinal level

It has become increasingly clear that nociceptive information is signalled by several anatomically distinct populations of primary afferents that target different populations of neurones in the spinal cord. It is probable that these different systems all give rise to the sensation pain and hence, an understanding of their separate roles and the processes that they employ, may offer ways of selectively targeting pain arising from different causes. The review focuses on what is known of the anatomy of neurones in LI-III of the spinal dorsal horn that are implicated in nociception. The dendritic geometry and synaptic input of the large LI neurones that receive input from primary afferents containing substance P that express neurokinin 1 (NK(1)) receptors suggests that these neurones may monitor the extent of injury rather than the specific localisation of a discrete noxious stimulus. This population of neurones is also critically involved in hyperalgesia. In contrast neurones in LII with the morphology of stalked cells that receive primary afferent input from glomerular synapses may be more suitable for fine discrimination of the exact location of a noxious event such as a sting or parasite attack. The review focuses as far as possible on precisely defined anatomy in the belief that only by understanding these anatomical relationships will we eventually be able to interpret the complex processes occurring in the dorsal horn. The review attempts to be an accessible guide to a sometimes complex and highly specialised literature in this field.

Survey of the needs of patients with spinal cord injury: impact and priority for improvement in hand function in tetraplegics

OBJECTIVE

To investigate the impact of upper extremity deficit in subjects with tetraplegia.

SETTING

The United Kingdom and The Netherlands.

STUDY DESIGN

Survey among the members of the Dutch and UK Spinal Cord Injury (SCI) Associations. MAIN OUTCOME PARAMETER: Indication of expected improvement in quality of life (QOL) on a 5-point scale in relation to improvement in hand function and seven other SCI-related impairments.

RESULTS

In all, 565 subjects with tetraplegia returned the questionnaire (overall response of 42%). Results in the Dutch and the UK group were comparable. A total of 77% of the tetraplegics expected an important or very important improvement in QOL if their hand function improved. This is comparable to their expectations with regard to improvement in bladder and bowel function. All other items were scored lower.

CONCLUSION

This is the first study in which the impact of upper extremity impairment has been assessed in a large sample of tetraplegic subjects and compared to other SCI-related impairments that have a major impact on the life of subjects with SCI. The present study indicates a high impact as well as a high priority for improvement in hand function in tetraplegics.

HIV Lipodystrophy Case Definition using Artificial Neural Network Modelling

Objective

A case definition of HIV lipodystrophy has recently been developed from a combination of clinical, metabolic and imaging/body composition variables using logistic regression methods. We aimed to evaluate whether artificial neural networks could improve the diagnostic accuracy.

Methods

The database of the case-control Lipodystrophy Case Definition Study was split into 504 subjects (265 with and 239 without lipodystrophy) used for training and 284 independent subjects (152 with and 132 without lipodystrophy) used for validation. Back-propagation neural networks with one or two middle layers were trained and validated. Results were compared against logistic regression models using the same information.

Results

Neural networks using clinical variables only (41 items) achieved consistently superior performance than logistic regression in terms of specificity, overall accuracy and area under the ROC curve. Their average sensitivity and specificity were 72.4 and 71.2%, as compared with 73.0 and 62.9% for logistic regression, respectively (area under the ROC curve, 0.784 vs 0.748). The discriminating performance of the neural networks was largely unaffected when built excluding 13 parameters that patients may not have readily available. The average sensitivity and specificity of the neural networks remained the same when metabolic variables were also considered (total 60 items) without a clear advantage against logistic regression (overall accuracy 71.8%). The performance of networks considering also body composition variables was similar to that of logistic regression (overall accuracy 78.5% for both).

Conclusions

Neural networks may offer a means to improve the discriminating performance for HIV lipodystrophy, when only clinical data are available and a rapid approximate diagnostic decision is needed. In this context, information on metabolic parameters is apparently not helpful in improving the diagnosis of HIV lipodystrophy, unless imaging and body composition studies are also obtained.

Developing palliative care surveillance in Canada: results of a pilot study

OBJECTIVE

A pilot study compiled data from six palliative care centres across Canada to assess the feasibility of developing a national surveillance system.

METHODS

Data provided for the three-year period between 1993-1997 were combined into a comparative minimum data set. Analyses included 6,369 care episodes from five centres, plus 948 patients from one centre.

RESULTS

Care was provided in various settings including acute care wards, dedicated palliative care units, tertiary care, chronic care, and at home. Palliative care patients comprised equal numbers of men and women, with a median age of 69 years; 92% had cancer diagnoses. Median length of stay (LOS) for each care episode was 13 days, increasing to 40-43 days for a patient's entire time in care. LOS varied greatly, by care setting, from seven days (dedicated unit), to 19 days (tertiary unit), 37 days (home), and 54 days (chronic care). Our findings are similar to those reported from national surveys in Australia and the United Kingdom.

SUMMARY

This study generated useful baseline data and identified key issues requiring resolution before establishing a national surveillance system, including the need to track patients across care settings.

Spinal lamina I neurones that express neurokinin 1 receptors: II. Electrophysiological characteristics, responses to primary afferent stimulation and effects of a selective mu-opioid receptor agonist

Intracellular recordings were made from neurones in laminae I and II of the dorsal horn of a longitudinal, parasagittal spinal cord slice from the neonatal rat. Their responses to peripheral nerve stimulation were first tested. Then the responses to bath application of [Sar(9),Met(O(2))(11)]-substance P and [D-Ala(2),N-MePhe(4),Gly-ol(5)]-enkephalin, neurokinin 1 (NK(1)) and mu-opioid receptor agonists respectively, were studied. Finally, the structure of each neurone was investigated by injecting neurobiotin intracellularly following recording, and immunocytochemical studies were performed on post-fixed tissues to reveal whether they expressed the NK(1) receptor. Nine lamina I neurones where shown to express NK(1) receptor and these were depolarised by [Sar(9),Met(O(2))(11)]-substance P. These neurones typically received a powerful C-fibre input that was strongly inhibited, presynaptically, by the mu-opioid receptor agonist.The structure, afferent input, opioid sensitivity and intrinsic properties of these neurones are all consistent with the view that they are a major relay for nociceptive information leading to intense pain. The characteristics of 10 other neurones studied in which the NK(1) receptor was not found to be expressed at levels detectable by immunocytochemistry are briefly described for comparison. These results contribute to the emergent view that the large neurones in the most dorsal neuronal layer (lamina I) of the spinal cord, which express the principal receptor for substance P (NK(1)) over their entire soma and dendrites, are a major relay for information leading to intense pain. Inhibition of the relay of information by these neurones would be predicted to result in analgesia and hence, a detailed knowledge of their unique neurochemical characteristics is of paramount importance.

The challenge of developing a regional palliative care data system: a tale of two cities

This article reviews the purposes of health care databases and the findings from a literature review of the use of patient databases in palliative care. We present the history and goals of databases developed in two Canadian settings, Hamilton and Halifax. We present data on the strengths, limitations, and difficulties encountered in each setting. We review the types of data collected and the potential of these databases, and we offer practical recommendations for others looking to set up such systems.

Association between presence of HLA-B*5701, HLA-DR7, and HLA-DQ3 and hypersensitivity to HIV-1 reverse-transcriptase inhibitor abacavir

BACKGROUND

The use of abacavir--a potent HIV-1 nucleoside-analogue reverse-transcriptase inhibitor--is complicated by a potentially life-threatening hypersensitivity syndrome in about 5% of cases. Genetic factors influencing the immune response to abacavir might confer susceptibility. We aimed to find associations between MHC alleles and abacavir hypersensitivity in HIV-1-positive individuals treated with abacavir.

METHODS

MHC region typing was done in the first 200 Western Australian HIV Cohort Study participants exposed to abacavir. Definite abacavir hypersensitivity was identified in 18 cases, and was excluded in 167 individuals with more than 6 weeks' exposure to the drug (abacavir tolerant). 15 individuals experienced some symptoms but did not meet criteria for abacavir hypersensitivity. p values were corrected for comparisons of multiple HLA alleles (p(c)) by multiplication of the raw p value by the estimated number of HLA alleles present within the loci examined.

FINDINGS

HLA-B*5701 was present in 14 (78%) of the 18 patients with abacavir hypersensitivity, and in four (2%) of the 167 abacavir tolerant patients (odds ratio 117 [95% CI 29-481], p(c)<0.0001), and the HLA-DR7 and HLA-DQ3 combination was found in 13 (72%) of hypersensitive and five (3%) of tolerant patients (73 [20-268], p(c)<0.0001 ). HLA-B*5701, HLA-DR7, and HLA-DQ3 were present in combination in 13 (72%) hypersensitive patients and none of the tolerant patients (822 [43-15 675], p(c)<0.0001). Other MHC markers also present on the 57.1 ancestral haplotype to which the three markers above belong confirmed the presence of haplotype-specific linkage disequilibrium, and mapped potential susceptibility loci to a region bounded by C4A6 and HLA-C. Within the entire abacavir-exposed cohort (n=200), presence of HLA-B*5701, HLA-DR7, and HLA-DQ3 had a positive predictive value for hypersensitivity of 100%, and a negative predictive value of 97%.

INTERPRETATION

Genetic susceptibility to abacavir hypersensitivity is carried on the 57.1 ancestral haplotype. In our population, withholding abacavir in those with HLA-B*5701, HLA-DR7, and HLA-DQ3 should reduce the prevalence of hypersensitivity from 9% to 2.5% without inappropriately denying abacavir to any patient.

Screening for trisomy 21: the significance of a positive second trimester serum screen in women screen negative after a nuchal translucency scan

Screening of pregnancies for trisomy 21 is now an accepted part of antenatal care. Measurement of fetal nuchal translucency in the first trimester and analysis of maternal serum biochemistry in the second trimester are both established methods of screening. The performance characteristics of both tests in an unselected population are well described and the choice of test offered is usually determined by local policy and resources. We present data from a screening programme offering women with a low risk result from nuchal translucency measurement a second trimester serum screen. There were eight cases of trisomy 21 in the 2683 women screened, all of which presented with a high-risk nuchal screen result. Serum screening of 1057 women who screened negative by nuchal translucency gave 46 high-risk results, all of which were, therefore, false positive for trisomy 21. Second trimester biochemistry screening following a negative nuchal translucency screen did not increase the detection of trisomy 21.

Late termination for fetal abnormality: providing essential information for parents

Termination of pregnancy for fetal abnormality in the second half of pregnancy is a distressing experience for parents who are often fearful of the process of termination. Some of this fear may be engendered by a lack of information, and staff caring for couples in this situation may not feel sufficiently sure of the likely course of late termination to answer their questions. There is little existing literature to provide guidance. We studied all late terminations for abnormality occurring in our unit over an 18-month period in order to provide parents and staff with appropriate information.

Renal function following pregnancy in renal transplant recipients

We set out to analyse the effect of pregnancy and hypertension in renal transplant recipients and review serum creatinine levels as a marker of graft function, before, during and after pregnancy. The study was conducted at a major tertiary referral centre in London. This was a retrospective analysis of renal transplant patients who had achieved a successful pregnancy. During the period 1967-1998, there have been 272 women of childbearing age with successful renal transplants functioning for over 1 year. Within this population there have been 66 pregnancies in 41 patients resulting in 53 births. Among the pregnancies that progressed beyond 24 weeks, preterm delivery occurred in 32 (60.4%). The mean gestation was 35.7 (range 30-41), mean birth weight was 2365 grams (range 908-3430 grams) with 47%of infants weighing <2500 grams. There were vaginal deliveries in 14 (26%), the rest delivered by caesarean section. Patients that developed hypertension in late pregnancy tended to have higher pre-pregnancy creatinine levels and a deterioration of graft function postpartum. Serum creatinine levels greater than 130 micromol/l before pregnancy predict deteriorating renal function postpartum. Kaplan-Meier life survival analysis showed that the risk of subsequent graft loss is associated with increased serum creatinine levels (130-180 micromol/l) before pregnancy. Pregnancy figures in our unit are favourable compared to those reported in the literature. Poor pre-pregnancy renal function (creatinine 130-180 micromol/l) and previous hypertension is associated with a significant risk of graft failure. Creatinine levels currently deemed as being acceptable during the pregnancy of renal transplant recipients may need to be reappraised.

Pallister-Killian syndrome presenting through nuchal translucency screening for trisomy 21

Pallister-Killian syndrome (tetrasomy 12p) is an uncommon aneuploidy, which may present in the prenatal period with an ultrasonographically detected fetal abnormality or following karyotyping for maternal age. We report a case that presented with increased nuchal translucency and hydrops at a first trimester screening scan for trisomy 21.

Fetal penile length

OBJECTIVE

To construct a reference range for fetal penile length.

METHODS

The length of the penis was measured during ultrasound assessment of 95 structurally normal male fetuses of gestational ages 16-38 weeks. Two fetuses with bladder outflow obstruction were also examined.

RESULTS

Fetal penile length increases significantly with gestational age, from a mean value of 6.0 mm at 16 weeks to 26.4 mm at 38 weeks. One fetus with urethral agenesis had a penile length on the 0.3rd centile.

CONCLUSIONS

Measurement of the fetal penis is easy and not time-consuming. In cases of bladder outflow obstruction, assessment of penile length assists in the differentiation between urethral agenesis and posterior urethral valves.

Programmes in chronically vulnerable areas: challenges and lessons learned

In the 'chronically vulnerable areas' (CVAs) of East Africa a smooth linear transition away from emergency programming towards rehabilitation and long-term development is difficult, if not impossible. This makes uncritical application of the 'relief-to-development' continuum to programming unhelpful at best, and perhaps counter-productive. This paper is the result of CARE's efforts to review its own programmes--and those of some of its sister agencies--in chronically vulnerable areas in the East Africa region, to derive important lessons learned and to identify areas where improvements are needed. The paper focuses on strategic considerations and decision-making in relation to entry, programme design and strategies for transition and exit.