It is not worthwhile to perform ileoscopy on all patients.

BACKGROUND: It remains controversial whether ileoscopy should be attempted in all patients. Although the ease of ileoscopy and the diagnostic yield have been well described, there have been no studies describing the value of the diagnostic yield in altering clinical management. We carried out a study to ascertain whether it is worthwhile to perform ileoscopy in all patients having a colonoscopy. METHODS: We carried out a retrospective study of all patients who had a colonoscopy between January 1, 2002, and December 31, 2003. The patient details, indications, findings, and complications of the procedure were recorded, together with the histopathology reports of colonic and terminal ileal biopsies. Clinical case note of patients with a positive diagnosis was reviewed to ascertain whether there was a change to the patient's management following an abnormal biopsy result. RESULTS: A total of 2,149 colonoscopies were performed. In 346 patients (16.1%), the terminal ileum was intubated. There were 16 abnormal findings on histology, which gave a diagnostic yield of 4.6% of all ileoscopies. A change to management occurred in only half of these patients. CONCLUSION: Ileoscopy should only be attempted in situations in which the indication is warranted and that would alter management. It is not cost-effective to carry out ileoscopy on all patients.

Colonoscopy in the very old: why bother?

OBJECTIVES: To evaluate the use of colonoscopy in patients aged at least 85 years. Does the ideal of an ageism free service apply? DESIGN: A retrospective audit. SETTING: Department of gastroenterology that carries out about 1000 colonoscopies annually in a district general hospital serving a population of about 320 000. SUBJECTS: All patients aged at least 85 years who underwent colonoscopy over five years to 2003. MAIN OUTCOME MEASURES: The indications for colonoscopy and its findings. The outcome of patients found to have colonic cancers. RESULTS: Colonoscopy was completed in 219 cases (69%). The main reasons for failure were poor bowel preparation and severe diverticular disease. Normal findings occurred in 65 (30%) of the 219 cases that had had a complete examination. Colonoscopy identified a problem that explained the patient's symptoms in 116 (37%) cases. Polyps were found in 45 (14.2%) cases and malignancy in 28 (8.8%). CONCLUSIONS: The absence of significant complications and comparatively high yield of colonic malignancies and polyps reinforces the value of colonoscopy as a diagnostic tool even after 85 years of age and despite the technical challenges of the procedure in this age group that limited completion. Increasing age alone should not preclude a patient from colonoscopy.

Intravenous hyoscine as a premedication for colonoscopy: a randomized double-blind controlled trial.

BACKGROUND AND STUDY AIMS: There is wide variation in the use of antispasmodics to facilitate colonoscopy, both within and between countries, and its use before such procedures remains controversial. The aim of this study was to determine whether there was any objective benefit in using hyoscine as a premedication for colonoscopy in a district general hospital. PATIENTS AND METHODS: Consecutive day-case patients undergoing colonoscopy were included in the study. They were prospectively randomly allocated to receive either intravenous hyoscine (n = 61) or intravenous placebo (n = 56) as part of their premedication. RESULTS: Our analysis demonstrated no statistically significant difference between the two groups with respect to the median time from colonoscope insertion to caecal intubation (9.7 minutes in the hyoscine group vs. 8.3 minutes in the placebo group) or the median total procedure time (14.8 minutes in the hyoscine group vs. 13.8 minutes in the placebo group). There was also no statistically significant difference in success rates for caecal intubation between the two groups ( P < 0.06). However a type II error cannot be excluded because of the small sample size. CONCLUSION: This study demonstrated no obvious benefit in the routine use of hyoscine as a premedication for colonoscopy in a district general hospital setting.

Exercise-induced rhabdomyolysis: even the fit may suffer.

Keeping fit has its risks. We describe the case of a 29-year-old woman who presented with rhabdomyolysis following non-exhaustive exercise. Cases of exercise-induced rhabdomyolysis have been reported in unfit individuals or those attempting exhaustive exercise such as marathon running or weight lifting but are unusual in fit individuals making modest changes to their normal fitness routine. Renal failure is the most serious complication of rhabdomyolysis but is apparently rarer when the rhabdomyolysis is caused by exercise. Surprisingly the published literature does not help us advise patients on the risk of suffering further episodes of acute rhabdomyolysis with further exercise. We suggest that, regardless of a person's fitness, when starting a new exercise he or she does so gradually.

What the SHO really does.

BACKGROUND: Five years ago we described the acute caseload of a typical general medical senior house officer (SHO) post. This follow-up report assesses the effects of changes since then on SHOs' training. We also look at the opportunities for all medical SHOs to learn and practise the practical procedures suggested as being necessary during a six month unselected general medical take. RESULTS: In six months 752 patients presented, up by 29% in five years. They fell into 87 diagnostic categories. The ten most common categories accounted for 53% of cases seen, indicating little change over five years. The numbers of patients seen by the firm had increased from a mean of 14 to 20 on each take day, but with the appointment of a second SHO to the firm the numbers seen by each SHO fell to 10. Some techniques such as lumbar puncture were used frequently. Others listed as recommended training for all SHOs, such as vital capacity measurement, were not needed. Five procedures that our take patients did require, including Sengstaken tube insertion, are listed only under specialist training requirements. CONCLUSIONS: An SHO post in a DGH continues to offer good exposure to common medical problems but little to more rare conditions. The reduction in hours worked and other changes in the NHS have not altered this. Further thought may be required to formulate achievable recommendations for experience of practical procedures, or specific arrangements made for SHOs to be taught and allowed to practise those techniques for which there is little day-to-day patient need. Our findings support the recent changes to the Royal College of Physicians' requirements for general professional training and the use of log books to identify gaps in experience.

Community-acquired Clostridium difficile-associated diarrhoea in a patient with colonic carcinoma.

In the vast majority of cases, Clostridium difficile-associated diarrhoea and pseudomembranous colitis develop following the use of antibiotics. We report a case in which C. difficile-associated diarrhoea was diagnosed in the absence of previously reported predisposing factors. It transpired that the patient had a colonic carcinoma. We suggest that a diagnosis of C. difficile-associated diarrhoea in the absence of a history of antibiotics or other established causes should prompt a colonoscopy to search for alternative explanations for the alteration in bowel flora which such an infection indicates.

Ward based X-ray facilities can improve services.

As part of a wider experiment, a satellite X-ray facility, run by 2 part-time radiographers (1 whole time equivalent), was established to provide all plain radiographs on inpatients in a patient focused unit of 114 beds created from 4 medical wards of a 370-bed district general hospital providing acute services to a local population of about 200,000. Fewer staff were needed to provide an X-ray and report on the ward, the number of steps was reduced from 54 to 42 and the time taken from 104 to 62 minutes. Radiographers spent a smaller proportion of their time on professional duties but freed up substantial time for other members of staff. The reactions of all involved, staff and patients, were favourable. With present technology, the patient focused approach brings net benefits and possibly decreases costs, but the balance may swing back to centralisation when picture archiving and communication systems (PACS) become more widely available.

The patient focused approach: a better way to run a hospital?

It can take 2 hours of hospital staff time to obtain a routine chest X-ray, up to 47 clinical staff may be involved with a patient during a 5-day stay, and only a quarter of total costs may be for direct patient care, so some hospitals are experimenting with patient focused care by relocating services such as X-ray to the bedside, training ward staff in a wider range of skills, and managing care itself by using multidisciplinary protocols. Potential benefits can be measured in terms of reduced process times and faster turn-round, but duplication of, for example, high-tech pathology and radiology equipment is expensive, as is releasing staff for training. Proponents say that higher quality patient care will result without increased cost, and theoretical analyses suggest that advantages should outweigh disadvantages. The more established patient focused units in the UK are now over a year old; practical analyses of their quality and cost are under way.

Khat chewing delays gastric emptying of a semi-solid meal.

BACKGROUND: The leaves of Khat are chewed for their central stimulant effect, but their use may cause anorexia and constipation. METHODS: Gastric emptying of a radio-labelled semi-solid meal was measured in 12 healthy volunteers on two occasions a week apart. Subjects chewed either Khat leaves (Catha edulis) or lettuce for 2 h before the study. RESULTS: Gastric emptying was significantly (P < 0.02) prolonged after chewing Khat compared with lettuce. CONCLUSION: The sympathomimetic action of cathinone in Khat may cause the observed delay in gastric emptying.

It's not cricket! Myocardial infarction following non-penetrating blunt chest trauma.

While playing a game of cricket, a 42-year-old man was struck on the chest by the ball. The blunt trauma precipitated a myocardial infarct in the absence of other risk factors or evidence of pre-existing coronary artery disease. Probable pathophysiological mechanisms and potential problems of immediate treatment are discussed.

What the SHO saw.

As discussions about junior doctors' training and duty hours continue, we have looked at the actual 'on take' case load and case mix of a medical senior house officer (SHO) in a district general hospital (DGH) over a six-month period. In our DGH, on a one in four rota, exposure to a few common conditions is high and exceeds the minimum requirements for a post to be approved for general professional training. Limited but useful experience may also be gained in the management of many other conditions. The benefits in terms of structured training and lifestyle resulting from the implementation of the Calman report and the junior doctors' hours initiative need to be set against a possible reduction in patient exposure and in the associated opportunities to learn that may occur with a decrease in SHOs' 'front line' exposure.

Cardiac tamponade after thrombolysis.

Thrombolysis has been very effective in reducing the morbidity and mortality from acute myocardial infarction. Serious adverse events are not uncommon, however. We describe a case in which a haemopericardium and tamponade developed in a patient with a history of recurrent idiopathic pericarditis and to whom streptokinase had been administered following a suspected myocardial infarction. The case highlights the need for caution in the administration of thrombolytics to patients with a documented history of pericarditis.

Clinical protocols are key to quality health care delivery.

The use of clinical protocols allows health care providers to offer appropriate diagnostic treatment and care services to patients, variance reports to purchasers and quality training to clinical staff. Such protocols provide a locally agreed standard to which clinicians and the organization can work and against which they can be audited. By embedding protocols into patients' records and reporting by exception, the use of protocols may help to tackle a raft of other issues successfully such as the reduction in junior doctors' hours, and the facilitation of shared care. It may also bolster the medico-legal robustness of the health care delivered. If the protocols are sufficiently detailed, costing, coding and other resource usage information can flow directly from the clinical records. Such benefits may be maximized by using protocols within the framework of an electronic patient record system.