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.

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.

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.

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.

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.

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.

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.