Prevalence and risk factors for meticillin-resistant Staphylococcus aureus in adult emergency admissions--a case for screening all patients?

In this study we describe the prevalence and frequency of risk factors for meticillin-resistant Staphylococcus aureus (MRSA) colonization in emergency admissions during a one-year MRSA screening programme. Overall, 7801/13 826 (56.4%) adult emergency admissions by 6469 patients were screened for MRSA. Of those screened, 670/7801 (8.6%) admissions by 433 patients (6.7%) were colonized with MRSA. Risk factors studied were previous hospital admission, previous MRSA colonization and residence in care homes. Patients with any risk factor (MRSA positive: 366/3952 (9.3%) vs MRSA negative: 67/2450 (2.7%), P<0.001), advanced age (mean ages for MRSA positive and negative patients were 74.4 and 56.2 years, respectively (P<0.001)), and increasing frequency of hospital admissions (P<0.001), patients from care homes (41/184, 22.2%) and previous MRSA colonization (232/1855, 12.5%) had a significantly higher MRSA colonization rate. The cost of the screening programme was nearly 24,500 pounds. It was noticed that there was a substantial reduction in hospital-acquired MRSA and MRSA bacteraemia during the study period. The study was not designed to establish whether this reduction was causally associated with the screening programme. We conclude that there is a high MRSA colonization rate among emergency admissions, especially those with risk factors. Using a selective risk factor based screening strategy more than 60% of the patients would have to be screened but still 3952/6469, 67 (15.5%) MRSA carriers would have been missed. Screening of all emergency admissions to detect MRSA colonization is preferable to selective screening, relatively inexpensive, and might reduce the MRSA colonization rate of hospital-acquired MRSA and MRSA bacteraemia among emergency admissions.

Biochemical markers in the management of suspected acute myocardial infarction in the emergency department.

OBJECTIVES: To compare cardiac troponin T, myoglobin, CK, CKMB activity, CKMB mass and the initial electrocardiogram in the early diagnosis of myocardial infarction in the emergency department. Methods-Biochemical markers were measured at presentation in patients with a possible diagnosis of acute myocardial infarction. Based on the clinical notes, patients were grouped as "definite myocardial infarction" (n = 50), "definite no myocardial infarction" (n = 81) and "uncertain" (n = 96). Sensitivity and specificity and positive and negative predictive values were calculated using the 131 patients with definitely present or absent myocardial infarction. RESULTS: The initial electrocardiogram was more sensitive than any of the markers in the first six hours from symptom onset-sensitivity 74% (95%CI 61% to 88%). The positive predictive value of the initial electrocardiogram was 97% in the first six hours; the markers ranged from 47% to 67%. The negative predictive value of the initial electrocardiogram was 85% in the first six hours; the markers ranged from 61% to 70%. Four patients with non-diagnostic electrocardiograms presenting beyond six hours after pain onset had a myocardial infarct detected by at least three of the biochemical markers in each case. CONCLUSIONS: The electrocardiogram is of more diagnostic use than biochemical markers in the first six hours after the onset of pain, but biochemical markers give additional positive diagnostic information in patients presenting later than this. The negative predictive accuracy of biochemical markers is too low for a single sample to be useful for excluding myocardial infarction in the first six hours after onset of symptoms.

A potential role for the plasmin(ogen) system in the posttranslational cleavage of the neural cell adhesion molecule L1.

L1 is a neural recognition molecule that promotes neural developmental and regenerative processes. Posttranslational cleavage of L1 is believed to be important for regulating its function in vivo, but little is known of the proteolytic systems responsible. In this study we present evidence that plasmin can regulate both L1 expression and function. The addition of plasmin to cell lines results in a dose-dependent loss of surface L1 expression, with the simultaneous appearance of soluble L1 species. The addition of plasminogen to primary neurons and melanoma cells also resulted in the generation of plasmin and the concomitant release of L1. One product of plasmin-mediated cleavage is an amino-terminal fragment of approximately 140 kDa that has been previously described as a natural posttranslational cleavage product in vivo. This fragment was confirmed to result from cleavage at two sites in the middle of the third fibronectin-like domain of L1. Cleavage at a further site, proximal to the transmembrane domain of L1, was also observed at higher plasmin concentrations. Plasmin was further confirmed to abrogate homophilic L1 interactions required for cellular aggregation. Based on these findings we propose that plasmin is likely to be an important regulator of L1-mediated processes including those documented in the nervous system.

Telephone follow-up of relatives after sudden death: a survey of relatives' views.

The report of the Working Group on Bereavement Care in A&E departments recommended both the provision of follow-up for relatives and the audit of bereavement care as examples of good practice. In our adult A&E department follow-up contact is made by support workers, who have often been involved with the family at the time of death, making telephone contact four to five days later. This paper describes the role of the support workers and the results of a questionnaire sent to relatives to seek their views on this telephone follow up. In a six-month period 98 families had relatives who died in A&E; 38 (39%) of them returned completed questionnaires. The telephone call was thought to be helpful by 37 (97%) of the respondents. The commonest reasons given were: 'It showed you cared' (95%) and 'It enabled me to ask questions' (46%). We have found that the experience and, more importantly, availability of the support workers allows a level of consistency and continuity in follow-up care which can otherwise be difficult to achieve.

Isolation and N-terminal sequence determination of a novel gamma/delta T cell surface antigen.

An antigen complex unique for porcine gamma/delta T cells has previously been identified using the monoclonal antibodies MAC319 and MAC320. Here we use digestion with the proteolytic enzyme bromelain to selectively release the MAC319 antigen as a soluble fragment, for further characterisation. A cytofluorometric inhibition assay was developed to follow the purification of this fragment, as the conformation sensitivity of the MAC319 epitope prevented the use of immunoblotting techniques. The antigen has been purified using a combination of anion-exchange and hydrophobic-interaction columns, followed by separation on a size-exclusion column. Fractions from the size-exclusion column containing the antigen consisted of one major band at Mr 95,000. This species was shown to be specifically absorbed onto MAC319-coupled Sepharose, thereby identifying the MAC319 antigen. N-terminal amino acid sequencing of this band has revealed a previously unidentified sequence. This fragment was also shown to be glycosylated, most likely with a single sugar moiety. Enzymatic removal of the sugars showed that they did not appear to be necessary for binding of the polypeptide to the MAC319 antibody.

The existence and composition of Trauma Teams in the UK.

To determine the existence and composition of Trauma Teams in UK hospitals postal and telephone enquiries were made to 185 Accident & Emergency (A&E) departments comprising all those in the UK with an annual attendance of over 30,000 patients per year. The existence of Trauma Teams was not influenced by the number of A&E attendances or the medical staffing composition in the A&E department. Of the hospitals surveyed, 113 (61 per cent) had either a Trauma Team or an adequate system for getting A&E staff or other specialists rapidly to injured patients. The most common reason (58/69) for not having Trauma Teams was an inability to get doctors to attend to an injured patient promptly. In 58 out of the 69 hospitals the difficulties in getting the appropriate doctors to respond quickly to multiply injured patients was the main reason for not making any arrangements for rapid multidisciplinary evaluation of them. Changing the medical profession's attitude to injury management is a hurdle that will need to be overcome.

Mechanisms for variability in a member of the scavenger-receptor cysteine-rich superfamily.

This study reports a molecular analysis of pig WC1, a new member of the scavenger-receptor cysteine-rich (SRCR) superfamily. The pig WC1 contains up to six extra-cellular SRCR domains, highly homologous to other members of the family. However, the striking feature of the WC1 gene, as for its cattle and sheep homologues, is that it is present as a multigene family showing extensive sequence diversity, for both DNA and predicted protein sequence. The basis of this diversity was examined and was shown to be attributable to several different causes. These included single base-pair changes within SRCR domains, the optional usage of whole domains or exons, including a SRCR domain and the proximal "hinge" region, and alternative isoforms of the putative cytoplasmic tail. These results suggest that WC1 may code for a new, though more primitive type of antigen recognition structure specific for gamma/delta T cells.

Outcome of Burch colposuspension in a district general hospital.

Genuine stress incontinence is a problem affecting women of all ages. There are several conservative means of alleviating the condition, but surgical intervention is an alternative when these fail. The Burch colposuspension has become a popular choice of procedure. In this report of 61 patients in a district general hospital, the success rate was high (84%, which compares favourably with the literature). There was a high rate of complications (55%), some of which have not commonly been reported. Burch colposuspension is a good operation for stress incontinence, although patients should be counselled about possible postoperative difficulties.

Adult asthma assessment in an accident & emergency department.

Poor initial assessment contributes to morbidity and mortality in acute severe asthma. We have audited this aspect of management in an A & E department over a single 6-month senior house officer employment cycle. The use of a cheap and simple stamp highlighting important clinical features of asthma was associated with a significant improvement in early assessment.

Quaternary structure of the native GABAA receptor determined by electron microscopic image analysis.

In the transmitter-gated ion channel class of receptors, the members of which are all believed to be heterooligomers, the number and arrangement of the subunits are only known with any certainty for the nicotinic acetylcholine receptor from Torpedo electric fish. That receptor has been shown to possess a pentameric rosette structure, with five homologous subunits (alpha 2, beta gamma delta) arranged to enclose the central ion channel. The data were obtained by electron image analysis of two-dimensional receptor arrays, which form as a consequence of that receptor's exceptionally high abundance in the Torpedo membranes and are therefore not attainable for other receptors. We have applied another direct approach to determine the quaternary structure of native ionotropic GABA receptors. We have purified those receptors from porcine brain cortex and analysed the rotational symmetry of isolated receptors visualized by electron microscopy. The results show the receptor to have a pentameric structure with a central water-filled pore, which can now be said to be characteristic of the entire superfamily.

Care of road traffic accident victims in a district general hospital.

It has been suggested that 20-33% of trauma related deaths are preventable. The Accident and Emergency Department of Luton and Dunstable Hospital, therefore, set out to examine its own performance and to attempt to highlight areas of possible improvement. The department sees 65,851 new patients per annum, 3936 of these were victims of road traffic accidents (RTA). There were 184 patients admitted and six died. One death was considered preventable; shortcomings were noted with delay in availability of services. It is recommended that early assessment by experienced clinicians and easy access to theatre facilities and diagnostic imaging be available in district general hospitals to improve the quality of care for trauma victims.

The role of extra-anatomic grafts for lower limb ischaemia.

Aorto-bifemoral graft is the conventional treatment for ischaemic lower limbs due to severe aorto-iliac disease. However, some patients are not fit to withstand this major procedure, and for them extra-anatomic grafts provide a method of improving the blood supply to the legs where the alternative may be amputation. The role of these grafts has still not been established because of variable results. We have used the femoro-femoral and the axillo-femoral routes for ten years. The patients were unfit for major surgery and had an overall mortality of 20% in two years. They all presented with critical lower limb ischaemia. Forty-three extra-anatomic grafts have been inserted. Perioperative mortality was less than 2%. None of those undergoing femoro-femoral grafting required subsequent amputation: four amputations were performed in those with axillo-femoral grafts. We conclude that extra-anatomic grafts should be considered before resorting to amputation in patients with critical lower limb ischaemia.

Cost of a roller skating rink to the local accident and emergency department.

A 14 month retrospective study was undertaken to determine the cost implications of the opening of a roller skating rink to the local hospital accident and emergency department (A and E). A total of 398 patients attended following injury at the roller skating rink, of whom 384 were included in the study. The estimated cost of their injuries was determined by the hospital accounts department. The average cost per patient attending the A and E department following roller skating injury was about 100 pounds. The total cost to the A and E department of all injuries sustained at the rink over this period was 38,412 pounds. The cost implications of opening a roller skating rink for the A and E department are considerable. If proposals for self-budgeting are applied, A and E departments will have to seek additional funding if such leisure facilities are opened in their vicinity.