Controls on the nutrient content of suspended sediment transported by British rivers.

Recent studies of nutrient fluxes from river basins have emphasised the importance of sediment-associated transport. In order to develop an improved understanding of sediment-associated nutrient transport in UK rivers and of contrasts between individual rivers, attention has been directed to spatial and temporal variations in the nutrient (N and P) content of suspended sediment transported by four rivers, which embrace a representative range of British conditions. Bulk samples of suspended sediment were collected during storm events and these were analysed for both total N and P content and for individual fractions of these nutrients. Significant temporal and spatial variability in these various measures of the nutrient content of suspended sediment has been documented. Spatial variability has been linked to catchment characteristics, which in turn influence sediment sources. Patterns of temporal variability, which are reasonably consistent among the different rivers, have been related both to variations in other sediment properties and to hydrometeorological conditions.

A study of home care quality management data-collection systems.

A recent study reveals that home care agencies have inconsistent standards for quality management and inefficient data-collection systems. Are currently available data-collection systems suited for home care needs, or should they be redesigned?

Anorectal malignant melanoma has a poor prognosis.

Clinicopathologic features and surgical treatment of 15 patients with primary anorectal malignant melanoma were studied retrospectively. There was a female preponderance (2:1). The median age was 66 years. Common initial symptoms were rectal bleeding (87%) and/or anal pain (33%); 25% of the melanomas were amelanotic. The maximum tumor size ranged between 0.8 and 8.4 cm (median 3.0 cm). Of the tumors evaluated histologically (n = 12), tumor thickness ranged from 0.9 to 11.3 mm (median 6.1 mm). All melanomas invaded at least into the subepithelial tissue (n = 8) and/or the submucosa of the distal rectum (n = 4), with extension into the internal anal sphincter (n = 5) and lamina propria (n = 3). Endoluminal ultrasound accurately demonstrated depth of invasion in 3 of 3 patients. Three (20%) patients with distant metastases at initial presentation had a mean survival of 8 mo; one of these primary melanomas measured 0.8 cm. Of 12 patients undergoing "curative" treatments--4 by abdominoperineal resection (APR) and 8 by local excision (LE), the incidence of loco-regional recurrence was similar (2/4 and 5/8). All these 7 patients with loco-regional recurrence developed distant metastases within 3 months. The mean survival was similar between APR and LE in the total group (25 mo vs 20 mo), in the decreased (27 mo vs 24 mo) and in those treated with a curative intent (29 mo vs 22 mo). There was no long-term survivor but four patients remained tumor-free up to 19 mo after APR (n = 1) or LE (n = 3).(ABSTRACT TRUNCATED AT 250 WORDS)

Atheroembolism from the ascending aorta. An emerging problem in cardiac surgery.

As the ages of patients undergoing cardiac operations have increased, noncardiac causes of death have increased. To identify these causes of death, we analyzed the autopsy findings in 221 patients undergoing myocardial revascularization or valve operations between 1982 and 1989. Mean age was 65.6 +/- 9.5 years and the range was from 32 to 94 years; 130 patients (58.8%) were male. Autopsies were complete in 129 patients (58.4%) and limited to the chest and abdomen in the remainder. Embolic disease was identified in 69 patients (31.2%). Atheroemboli or abnormalities consistent with atheroemboli were identified in 48 patients (21.7%). Fourteen patients had thromboembolism and 7 had disseminated intravascular coagulation. The prevalence of atheroembolic disease increased dramatically from 4.5% in 1982 to 48.3% in 1989 (p = 0.001). Atheroembolic disease was found in the brain in 16.3% of patients, spleen in 10.9%, kidney in 10.4%, and pancreas in 6.8%. Thirty (62.5%) of the 48 patients had multiple atheroembolic sites. Atheroemboli were more common in patients undergoing coronary artery procedures (43/165; 26.1%) than in those undergoing valve procedures (5/56; 8.9%) (p = 0.008). There was a high correlation of atheroemboli with severe atherosclerosis of the ascending aorta. Atheroembolic events occurred in 46 of 123 patients (37.4%) with severe disease of the ascending aorta but in only 2 of 98 patients (2%) without significant ascending aortic disease (p less than 0.0001). Forty-six of 48 patients (95.8%) who had evidence of atheroemboli had severe atherosclerosis of the ascending aorta. There was a direct correlation between age, severe atherosclerosis of the ascending aorta, and atheroemboli. Incremental risk factors for atheroembolic are peripheral vascular disease and severe atherosclerosis of the ascending aorta.

The Patterson syndrome, leprechaunism, and pseudoleprechaunism.

A bizarre syndrome has hitherto masqueraded as leprechaunism, and although it is a quite different disorder it has been used as the prototype of leprechaunism in some birth defects atlases. It is proposed that this condition is designated the Patterson syndrome and details of a second case are reported. The features of this connective tissue and neuroendocrine disorder include bronzed hyperpigmentation, cutis laxa of the hands and feet, bodily disproportion, severe mental retardation, and major bony deformities. Radiographs revealed a unique and gross generalised skeletal dysplasia, unlikely to be confused with any other disorder. This endocrine abnormality comprised hyperadrenocorticism, cushingoid features, and diabetes mellitus in the first case, and premature adrenarche in the second case. The pathogenesis and aetiology of the Patterson syndrome are unknown, although quantitative and qualitative abnormalities of mucopolysaccharide excretion were found in the second case.

The outpatient use of digitalis: a chart audit.

In order to establish the appropriateness of the use of digitalis, the charts of 337 patients with heart disease from the Family Health Center at the University of Maryland were reviewed. The results revealed that several patients were on digitalis for weak or borderline reasons or for poorly documented reasons. Although few attempts had been made to discontinue digitalis, a high perc:ntage of those patients who had discontinued digitalis did so without morbidity or mortality, and without having to have digitalis reinstituted. The necessity for continuous evaluation and reassessment of each patient's need for digitalis was clearly illustrated. Chart audit was also a significant means of self as well as group education, through dissemination of the information obtained. Ideally, chart audits will improve patient care, both immediately as a result of the audit and long term as a result of increased awareness of possible problems and pitfalls. Further study is needed to verify this latter premise.

Medical evaluation for outpatient dental procedures.

Family physicians are often consulted to evaluate medically a patient for various dental procedures. The majority of the referrals are for diseases of the cardiovascular system. General guidelines have been established at the University of Maryland Family Health Center for the evaluation of these patients. These guidelines pertain to the use of local anesthetics and prophylaxis for endocarditis, as well as to the evaluation of patients with cardiac disease, hypertension, pulmonary disease, endocrine disease, neurological disease, hepatic disease, pregnancy, and anticoagulant therapy.