Requirement for postoperative imaging in an enhanced recovery programme.

AIM: Enhanced recovery after surgery (ERAS) produces benefits to patients by reducing the length of hospital stay and morbidity. Its effect on nursing and physiotherapy workload has been studied, but the demand upon radiology is unclear. We aimed to determine radiology use to understand possible hidden expenditure not included in existing ERAS cost-effectiveness analyses. METHOD: Two-hundred and sixty-five patients from a prospective multidimensional ERAS database were retrospectively assessed for postoperative radiology use. All had undergone colorectal surgery within an established ERAS programme from 2008 to 2009, with all data prospectively recorded. Laparoscopy was offered for all primary colon and rectal resections. All adverse events, including gut dysfunction, surgical site infection and reoperation, were assessed. All radiology within 30 days of surgery was recorded. RESULTS: Radiology data were absent in 12 patients, leaving 253 for analysis. Postoperative radiology was used in 71 (28%) patients, and 41 (16%) had CT of the abdomen and pelvis (A/P) within 30 days of surgery. In 33 (13%) patients this was required during the primary admission, including 30% of patients with any postoperative adverse event. Nine (27%; 3.6% of the whole cohort) of the 33 patients required reoperation. No patient required interventional radiology. The median time to CT (A/P) during primary admission was 5 (interquartile range, 3-8) days. Eight (3%) patients had CT (A/P) after readmission with one reoperation. Forty (16%) patients underwent plain radiology (chest or abdominal) and six (2%) had abdominal ultrasound. Using general estimates of CT and plain radiology total costs, these data suggest an overall radiology cost of over £22,000, amounting to a radiology cost of £90 per ERAS patient. CONCLUSION: Postoperative radiology is required in a significant proportion of ERAS patients, potentially reflecting a low threshold to investigate in the presence of an adverse event. Very few require subsequent intervention. Radiology costs incurred with ERAS should be considered in future economic analyses.

Early prediction of adverse events in enhanced recovery based upon the host systemic inflammatory response.

AIM: Early identification of patients experiencing postoperative complications is imperative for successful management. C-reactive protein (CRP) is a nonspecific marker of inflammation used in many specialties to monitor patient condition. The role of CRP measurement early in the elective postoperative colorectal patient is unclear, particularly in the context of enhanced recovery (ERAS). METHODS: Five hundred and thirty-three consecutive patients who underwent elective colorectal surgery between October 2008 and October 2010 within an established ERAS programme were studied. Patients were separated into a development group of 265 patients and a validation group of 268 patients by chronological order. CRP and white cell count were added to a prospectively maintained ERAS database. The primary outcome of the study was all adverse events (including infective complications, postoperative organ dysfunction and prolonged length of stay) during the initial hospital admission. Significant predictors for adverse events on univariate analysis were submitted to multivariate regression analysis and the resulting model applied to the validation group. The validity and predictive accuracy of the regression model was assessed using receiver operating characteristic curve/area under the curve (AUC) analysis. RESULTS: CRP levels >150 mg/l on postoperative day 2 and a rising CRP on day 3 were independently associated with all adverse events during the hospital admission. A weighted model was applied to the validation group yielding an AUC of 0.65 (95% CI 0.58-0.73) indicating, at best, modest discrimination and predictive accuracy for adverse events. CONCLUSION: Measurement of CRP in patients after elective colorectal surgery in the first few days after surgery within ERAS can assist in identifying those at risk of adverse events and a prolonged hospital stay. A CRP value of >150 mg/l on day 2 and a rising CRP on day 3 should alert the surgeon to an increased likelihood of such events.

Schizophrenia in general practice: a national survey of general practitioners in Ireland.

BACKGROUND: Chronic schizophrenia is challenging to manage in primary care. AIMS: We sought to establish the views of General Practitioners about managing patients with chronic schizophrenia in primary care. METHODS: A cross-sectional, postal survey questionnaire of a randomly selected sample of 20% of GPs was carried out. RESULTS: Most GPs (97.2%) have at least one person with schizophrenia attending their practice. A substantial number of GPs (22.2%) treat cases of schizophrenia without specialist input following an initial referral to psychiatric services. Almost all (88.7%) advised patients who had experienced multiple relapses to remain on medication indefinitely. One third of GPs reported that they always experience difficulties managing patients with schizophrenia in their practice. Non-adherence with prescribed medication and loss to follow-up were the commonest impediments to treatment encountered. CONCLUSION: GPs require appropriate back up from specialist services to enable their management of chronic schizophrenia.

A study of astrocytes in retinoblastomas using the immunoperoxidase technique and antibodies to glial fibrillary acidic protein.

We identified astrocytes in 12 of 14 randomly selected formalin-fixed Paraplast-embedded retinoblastomas, using the avidin-biotin-peroxidase complex of the immunoperoxidase techniques and antibodies to purified glial fibrillary acidic protein. In two of these eyes, both of which had extensive choroidal invasion by retinoblastoma, we found no tumor cells containing glial fibrillary acidic protein. Astrocytes were observed in metastases within the neurologic tissue of the central nervous system in two cases, but were rarely noted in metastatic foci within the subarachnoid space, and were not found in distant metastases to other sites. These findings suggested that although some astrocytes may become incorporated into retinoblastomas from the retina as the neoplastic cells proliferate and the tumor grows, others proliferate in response to the tumor. Although we found foci of cells containing glial fibrillary acidic protein in some retinoblastomas, convincing evidence of glial differentiation from tumor cells was not observed in any of the retinoblastomas we studied.

Whipple's disease presenting with isolated neurological symptoms. Case report.

Whipple's disease is infrequently considered in the differential diagnosis of patients presenting with progressive neurological deterioration. This is in part a result of the relative rarity of this entity and in part due to the more frequent initial presentation of the disease with gastrointestinal, musculoskeletal, or cardiovascular symptoms. A case is described in which the neurological symptoms of progressive dementia and weakness were seen in the relative absence of non-neurological symptomatology. The diagnosis of Whipple's disease was made from a brain biopsy. The neuropathology of Whipple's disease of the central nervous system is described and the importance of considering it as a treatable entity in the differential diagnosis of progressive neurological deterioration, despite the absence of systemic symptomatology, is stressed.

Life supporting first aid (LSFA) teaching to Brazilians by television spots.

Accidents in developing countries are frequent and have high mortality and morbidity rates. In Brazil, in 1995-1996, the year of this study, life supporting first aid (LSFA), which includes cardiopulmonary resuscitation (CPR) basic life support (BLS) was not taught in schools. With the population of 165 million, the only way to teach the adult population on a large scale would be by television (TV), that is widely viewed. This study compares two groups of factory employees - 86 controls without TV exposure to LSFA and 116 exposed to brief LSFA skill demonstrations on TV. Their ability to acquire eight LSFA skills was evaluated: external hemorrhage control; immobilization of a suspected forearm fracture; treatment of a skin burn by cold flush; body alignment after a fall; positioning for shock and coma; airway control by backward tilt of the head; and CPR (steps A-B-C). Simulated skill performance on the evaluating nurse or manikin was tested at 1 week, 1 month, and 13 months. In the control group, 1-31% performed individual skills correctly; as compared to 9-96% of the television group (P<0.001). There was excellent retention over 13 months. Over 50% of the television group performed correctly five of the eight skills, including positioning and hemorrhage control. Television viewing increased correct airway control performance from 5 to 25% of trainees, while it remained at 3% in the control group. CPR-ABC performance, however, was very poor in both groups. We conclude that a significant proportion of factory workers can acquire simple LSFA skills through television viewing alone, except for the skill acquisition of CPR steps B (mouth-to-mouth ventilation) and C (external chest compressions) which need coached manikin practice.

beta-Carotene transport in human lipoproteins. Comparisons with a-tocopherol.

The purpose of this study was to investigate the temporal relationships of the transport of beta-carotene in human lipoproteins. We administered 60 mg beta-carotene with breakfast to nine fasting subjects, then blood samples were collected at intervals of up to 75 h, lipoproteins were isolated, and beta-carotene was quantitated. beta-Carotene concentrations in chylomicrons and very low density lipoproteins (VLDL) peaked at 6 and 9 h, respectively. Nonetheless, at all time points the majority of plasma beta-carotene was contained in low density lipoproteins (LDL), while high density lipoproteins (HDL) carried a smaller portion (at 24 h, 73 +/- 8% in LDL as compared with 23 +/- 5% in HDL). In three subjects, transport of beta-carotene was compared with the results of earlier studies on the transport of stereoisomers of alpha-tocopherol. Unlike plasma RRR-alpha-tocopherol concentrations, which are maintained by the preferential incorporation of RRR-alpha-tocopherol into VLDL by the liver, beta-carotene increased and decreased in VLDL similarly to SRR-alpha-tocopherol, a stereoisomer whose concentrations are not maintained in plasma. In conclusion, beta-carotene is primarily transported in the plasma in LDL, but its incorporation by the liver into lipoproteins does not appear to be enhanced.

Studies on the transfer of tocopherol between lipoproteins.

The net transfer of labeled alpha-tocopherol from donor to acceptor lipoproteins at physiological concentrations was investigated. Labeled lipoproteins were isolated i) following in vitro addition of [3,4-3H] all rac-alpha-tocopherol to plasma, or ii) from plasma obtained 12-16 h after ingestion by normal subjects of an oral dose (100 mg each) of 2R,4'R,8'R-alpha-[5,7-(C2H3)2]tocopheryl acetate and 2S,4'R,'R-alpha-[5-C2H3]tocopheryl acetate. A constant amount (on a protein basis) of labeled lipoprotein was incubated with an increasing amount of unlabeled acceptor lipoprotein for 2 h at 37 degrees C. No discrimination between stereoisomers of alpha-tocopherol was detected. Labeled VLDL and labeled LDL (very low and low density lipoproteins, respectively) tended to retain their labeled tocopherol. Labeled high density lipoproteins (HDL) readily transferred the labeled tocopherol to VLDL (> 60% transferred), while the transfer to LDL was dependent upon the ratio of labeled HDL/LDL with a lower net transfer at higher ratios. This dependency of the distribution of tocopherol upon the ratio of HDL/LDL was also observed in vivo. The tocopherol/mg HDL protein was measured in 11 subjects with varying HDL levels. As the % HDL in the plasma increased from 14 to 50%, the tocopherol/HDL protein also increased (r2 = 0.37, P < 0.05).

The seat belt syndrome in children.

Lap belts, fitted to the centre seats of Australian cars for the past 22 years, have come under criticism as being injurious to children. The weight of evidence is that lap belts provide substantial protection, though less than three-point belts. A specific injury, the seat belt syndrome (SBS), to abdominal viscera and/or lumbar spine has been particularly associated with lap belts, an association confirmed by a hospital-based study in Melbourne. Roadside observations of belt use and Transport Accident Commission claims permitted the calculation of the incidence of SBS and the relative risks of SBS by seated position. The centre rear seat (lap belt) carried about twice the risk of SBS as outboard rear seats (three-point belts), which in turn have 2.7 times the risk of the outboard front seat. The number of SBS cases in Victoria has increased with penetration of the car fleet by 1971 and later cars. Suggestions are made for improvements in the restraint system.

Probability of casualties in an airport disaster.

World airline accident statistics for the period 1960 to 1970 indicate the number of seriously, but nonfatally injured is unlikely to exceed 25% of the occupant capacity of the largest aircraft using an airport. In only 1 accident out of 20 will this number be an underestimate. This estimate may be of value in medical planning for an airport disaster and in the assessment of loads on hospitals.

Post-mortem blood alcohol in general aviation pilots.

Blood alcohol concentrations are reviewed from a series of 250 consecutive fatal accidents, involving 259 pilots, for the years 1962 through 1975. BACs were obtained in 150 of 213 fatally injured pilots whose bodies were recovered. Positive BACs were 18% of total estimations. Impairment by alcohol was probably a factor in about 9% of accidents in which valid BACs were obtained. These percentages are not significantly different from lumped U.S. data. Comparison with fatal accidents in other modes of personal transportation shows alcohol plays a part in the following descending order: cars in single-vehicle accidents, all cars, motorcycles, general aviation aircraft.

Anxiety-related behavioral inhibition in rats: a model to examine mechanisms underlying the risk to develop stress-related psychopathology.

Behavioral inhibition (BI) is an adaptive defensive response to threat; however, children who display extreme BI as a stable trait are at risk for development of anxiety disorders and depression. The present study validates a rodent model of BI based on an ethologically relevant predator exposure paradigm. We show that individual differences in rat BI are stable and trait-like from adolescence into adulthood. Using in situ hybridization to quantify expression of the immediate early genes homer1a and fos as measures of neuronal activation, we show that individual differences in BI are correlated with the activation of various stress-responsive brain regions that include the paraventricular nucleus of the hypothalamus and CA3 region of the hippocampus. Further supporting the concept that threat-induced BI in rodents reflects levels of anxiety, we also show that BI is decreased by administration of the anxiolytic, diazepam. Finally, we developed criteria for identifying extreme BI animals that are stable in their expression of high levels of BI and also show that high BI (HBI) individuals exhibit maladaptive appetitive responses following stress exposure. These findings support the use of predator threat as a stimulus and HBI rats as a model to study mechanisms underlying extreme and stable BI in humans.

Social epidemiology: directions for the future in academic and "shoe-leather" risk analysis.

In the past, social epidemiology has been a field of interest to only a few professionals, notably sociologists and a select few epidemiologists. Expansion of the scope of epidemiology beyond infectious diseases and a few chronic diseases has made social epidemiology vitally important in the work of a host of professionals in public health and preventive medicine. These include persons doing risk analysis, persons working in environmental and occupational health, health educators, and persons working in institutions such as labor unions and schools which mediate the effects of risk factors upon population groups. With the expansion of the field, it is becoming apparent that the interrelationships among social risk factors are complex. Some social factors are both predictors of health status and outcome factors. This complexity will require new analytic methods, some of which are outside the present repertoire of most epidemiologists and biostatisticians. This paper examines the changing scope and impact of social epidemiology and suggests directions for the future of teaching and research in the field. If these new directions, guide research and teaching in the field, public health professionals will be able to bring a host of newly acquired skills to their "shoe-leather" epidemiology. Using those skills will require broad interdisciplinary cooperation in health promotion and disease prevention.

Migraine in the athlete.

Migraine in the athlete may occur secondary to effort, prolonged exertion, or trauma or as a posttraumatic event. The chemistry is probably akin to that of spontaneous migraine. The purpose of this discussion is to outline the differential diagnosis of the athlete presenting with headache. Appropriate treatment can enhance athletic performance and enable the migraineur to participate in athletic endeavors.

Mercy flights.

Mercy flights are flights undertaken for humane relief, which cannot be completed without breaching the normal rules of flying safety. We review the mercy flights that were made in Australia during 1980. Most flights were made for medical reasons, and the causes were largely divided between trauma and other medical conditions. The requests for most, but not all flights, were justified. Many had to be declared mercy flights because of mostly remediable deficiencies in outstation airfields.

[Experience with an innovation in the evaluation process at the Faculty of Medical Sciences of the State University of Campinas]. / Experiência de inovação no processo de avaliação da Faculdade de Ciências Médicas da Universidade Estadual de Campinas.

One way in which the university can perform its function of providing the community with competent professionals is to impart to the student during the educational process not only the knowledge he needs to exercise his profession, but also confidence to function in the area of his training and an awareness of his limitations. In an attempt to do this, the School of Medical Sciences at Campinas State University (São Paulo, Brazil) has established experimentally an evaluation by which it can be determined whether instructional objectives are being attained and, at the same time, needed adjustments to the teaching-learning process can be identified. Introduced in 1971 and modified several times since in the light of experience, the system is based on the identification of objectives, and of procedures and resources for attaining them, through questionnaires that are filled in not only by the teacher as in traditional procedures, but by the student as well. On the completion of each course, the student is required to answer questions that establish his progress in the acquisition of theoretical and practical knowledge and, at the same time, bring out his perceptions and attitudes in relation to the teaching process and its objectives. The system met with some resistance when it was being introduced and hence has not yet been made a prerequisite for admission to medical internship. The initial results showed that, in most cases, closer monitoring of the student's progress is needed, and a fresh evaluation of his knowledge afterwards if the community is to be minimally assured as to the overall performance of the new professional.

The effectiveness of bicyclist helmets: a study of 1710 casualties.

During the 1980s, a sustained campaign increased the rates of helmet use of Victorian bicyclists. The efficacy of helmet use was evaluated by comparison of crashes and injuries (AIS-1985) in 366 helmeted (261 Australian Standard approved and 105 non-approved) and 1344 unhelmeted casualties treated from 1987 through 1989 at Melbourne and Geelong hospitals or dying before hospitalization. Head injury (HI) occurred in 21.1% of wearers of approved helmets and in 34.8% of non-wearers (p < 0.001). The AIS scores were decreased for wearers of approved helmets (p < 0.001), face injuries were reduced (p < 0.01), and extremity/pelvic girdle injuries increased (p < 0.001) and the overall risk of HI was reduced by at least 39% and face injury by 28%. When casualties with dislodged helmets were excluded, HI was reduced 45% by approved helmets. Head injury reduction by helmets, although substantial, was less than that found in a similar study in Seattle, Washington.