A local diagnostic reference level for velopharyngeal investigations.

The purpose of this study was to derive an initial local diagnostic reference level for velopharyngeal investigations carried out as standard radiological practice in the Medical Imaging Department, Queen Victoria Hospital, East Grinstead. This is a specialist video-fluoroscopic radiological technique used to evaluate velopharyngeal dysfunction, especially for paediatric patients. A retrospective analysis over a period of 7 months involving 50 examinations yielded dose-area product values ranging from 0.04 Gy cm(2) (minimum) to 0.37 Gy cm(2) (maximum) with a mean value of 0.11 Gy cm(2) and 3rd quartile value of 0.12 Gy cm(2). The maximum effective dose was estimated as 0.016 mGy. An initial local diagnostic reference level of 0.12 Gy cm(2) has been levied.

Urinary flow rates in hypospadias.

Uroflowmetry has been performed on 140 occasions in 90 patients with hypospadias before and after reconstructive surgery. Children with hypospadias tend to have a lower maximum urinary flow rate for volume voided than the general population, lying around the population 5th centile. This is observed before any surgery is performed, and appears from our cross-sectional data to be unaffected by surgery. Uroflowmetry has proved a useful and economical means of gaining an objective assessment of urinary function in this group of patients. Further longitudinal studies to confirm this cross-sectional study would be useful.

Test-retest performance of a mailed version of the Medical Outcomes Study 36-Item Short-Form Health Survey among older adults.

OBJECTIVES: This study reports the reliability, internal consistency, and response patterns for a mailed version of the Medical Outcomes Study 36-item Short-Form Health Survey (SF-36) among older adults. METHODS: The SF-36 surveys were mailed to patients living in the community aged 65 years and older who were enrolled in two primary care practice clinics. Comorbidity scores also were assigned to patients based on their diagnoses from computerized clinic encounter forms using Deyo et al's modification of the Charlson Index. Subjects repeated the SF-36 by mail after 1 months. RESULTS: Four-hundred twenty-two subjects were mailed surveys and 253 returned them (60.0%). Missing items further reduced the number of subjects with scores on all SF-36 scales. A total of 186 subjects completed both base-line and retest SF-36 surveys. Intraclass correlation coefficients generally were high and ranged from 0.648 to 0.868. Internal consistency of scales also was high (0.802 to 0.924). Mean SF-36 scale scores decreased significantly with increasing comorbidity levels. CONCLUSIONS: The SF-36 demonstrated good retest reliability and internal consistency among these older adults and also showed a strong relationship to an external measure of comorbidity/health status. Mailed surveys pose a problem of response among older adults, a problem not unique to the SF-36, and methods for increasing response are needed when personal interviews are not feasible.

Hyperplasia of the mandibular coronoid process: an analysis of 31 cases and a review of the literature.

PURPOSE: This study was undertaken to investigate the demographic and clinical features of mandibular coronoid hyperplasia and to assess the response to current treatments. PATIENTS AND METHOD: Case notes were studied and records made of age, sex, duration of symptoms, operative procedures, and response to treatment in all patients presenting at the Queen Victoria Hospital, East Grinstead, over a 20-year period from 1970 to 1990 with a confirmed diagnosis of mandibular coronoid hyperplasia. RESULTS: Thirty-one cases were recorded, 23 bilateral and 8 unilateral. The average age on presentation was 27.8 years for bilateral and 23.6 years for unilateral cases, with symptoms predating presentation by an average of 9 years and 6.75 years, respectively. Surgery was disappointing in terms of improving mouth opening. CONCLUSION: The results of this large series are supported by meta-analysis of the previous literature. They suggest that surgical management may be improved by a greater understanding of the pathogenesis of this condition.

Secretory otitis media and mastoid air cell development.

Controversy continues over the factors involved in the development of the mastoid air cell system (MACS). This study examines the effect of persistent secretory otitis media with effusion (SOME) on the development of the MACS. Thirty-one children, aged 4, were drawn from a cohort of cleft palate children in a multi-centre, prospective otological study set up in 1984. The initial presence of SOME was assessed by otoscopy, tympanometry and bilateral myringotomy, performed under the same anaesthetic as surgical repair of the cleft lip or palate. Only one ear in each child was ventilated with a tube and the other, the control ear, was assessed by regular follow-up otoscopy and tympanometry. The persistence of SOME after palate repair in over 70% of the non-ventilated ears in 4 years olds and the presence of a contralateral ventilated middle ear provides the perfect model for assessing the effect of SOME on MACS development. Plain, lateral mastoid X-rays were assessed by planimetry to give a well accepted measurement of mastoid pneumatization. Nine children were excluded from analysis as they did not meet the strict criteria of one persistently ventilated middle ear and one with persistent SOME. 22 children (44 ears) were available for analysis, 9 children were tubed at 3 months and 13 were tubed at 12 to 16 months. In 19 of the 22 ears the mastoid air cell system was larger on the tubed side.(ABSTRACT TRUNCATED AT 250 WORDS)

Blood cholesterol concentration: fingerstick plasma vs venous serum sampling.

To assess whether venous and fingerstick blood samples yield similar cholesterol concentrations, we obtained both types of samples simultaneously in 108 volunteers participating in a cholesterol screening program. All samples were analyzed by the same enzymatic method in a standardized laboratory, and pairs of simultaneous samples were measured in the same laboratory run. Cholesterol concentrations in fingerstick-derived plasma were consistently higher than in the venous serum (P less than 0.0001), by a positive bias averaging 3.6%. Cholesterol values in fingerstick plasma also were higher than cholesterol results for venous serum placed in a capillary collection tube (average bias +2.4%). The positive bias of fingerstick plasma vs venous serum results appears to be at least partly due to specimen handling, although a true physiological difference between venous and fingerstick cholesterol concentrations is probably also involved. If a positive bias of this magnitude from fingerstick blood sampling is left unadjusted, substantial numbers of people will be labeled "at risk" and referred to physicians when their true values were actually within the acceptable range.

Precision and accuracy of a portable blood analyzer system during cholesterol screening.

The precision and accuracy of two Kodak Ektachem DT-60 portable blood analyzers were assessed in a model (research) cholesterol screening program in Rochester, New York. Between June and October 1987, a total of 8,573 people underwent a cholesterol screening held in a movable trailer. A wide variety of temperature, humidity, and other potentially adverse conditions were encountered during the screening period. Between-run coefficients of variation ranged from 1.9 percent to 4.8 percent per month; average bias compared to a Reference Laboratory method ranged between +0.2 percent and +2.0 percent. Both precision and accuracy met currently recommended standards for cholesterol testing in the United States.

Teaching risk-factor counseling skills: a comparison of two instructional methods.

The effectiveness of a class-wide lecture coupled with small group discussions was compared to the outcome of clinical instruction provided by patient instructors (PIs) who were specially trained to teach behavioral counseling skills for health promotion and lifestyle risk-factor modification. PIs are nonprofessionals trained to simulate a medical encounter in order to evaluate clinical competency and provide individual feedback. Each PI enacted the role of an ambulatory patient at high risk for coronary artery disease because of the presence of multiple risk factors. Two groups of medical students were studied using the entire second-year class in two consecutive academic years. In group 1 (n = 92), students received a lecture on risk-factor modification and attended a small group discussion. In group 2 (n = 91), students performed the PI exercise as their primary source of risk-factor counseling instruction. Six months after receiving the initial instruction (at time 2), all students completed the clinical exercise with the PI, who objectively rated each student's counseling skills using the University of Rochester Risk Factor Interview Scale (URRFIS). Differences between groups 1 and 2 at time 2 were significant for total URRFIS and all subscale scores, indicating that students who had received PI training as their form of instruction performed the risk-factor counseling more skillfully. For students in group 2, within-student performance from time 1 to time 2 also was significantly improved. This study demonstrates that instruction in risk-factor counseling for medical students who are early in their formal medical training may be taught more effectively by PIs; the learning appears durable when measured six months after instruction.

Using patient instructors to teach behavioral counseling skills.

The authors developed an exercise to teach medical students counseling skills for promoting change in health-related behaviors using trained patient instructors (PIs) who enact the patient role, perform a standardized evaluation of the interview, and provide instructional feedback. Third-year medical students in two consecutive academic years at the University of Rochester School of Medicine and Dentistry received either feedback from a faculty member on a videotaped interview between the students and a simulated patient (SP) or direct feedback from a PI immediately following the students' interview with the PI. The students in the PI group gave higher ratings to the realism and effectiveness of the interview session than did students in the SP group. Students in both groups rated PI feedback as more helpful than videotaped review, even though they had experienced only one of these two methods. This exercise represents a new use of patient instructors that may also be applicable to teaching counseling skills in other areas of behavioral medicine.

Feasibility of large-scale cholesterol screening: experience with a portable capillary-blood testing device.

We conducted a voluntary cholesterol screening in a medical/occupational setting using the Eastman Kodak Ektachem (desk top) blood analyzer. In 10 hours, five technicians performed a finger-stick puncture on 1,081 screenees, 17.7 per cent of whom were classified as moderate-to-high risk. The cost per screenee was under $3; cost per moderate-to-high risk case was under $16. Turn-around time from check-in to report of result was under one hour. This project suggests the feasibility and acceptability of large-scale cholesterol blood screening.

Pre-operative percutaneous transhepatic biliary drainage: the results of a controlled trial.

The operative mortality for biliary tract obstruction due to malignancy is high. In 1981 a controlled clinical trial of pre-operative percutaneous drainage was started at the Royal Postgraduate Medical School. At the time of percutaneous transhepatic cholangiography patients were randomized either to laparotomy or to pre-operative percutaneous transhepatic biliary drainage ( PTBD ) followed by laparotomy. Only patients with malignant biliary tract obstruction and serum bilirubin greater than 100 mumol/l were included. Seventy patients entered the trial, and five were withdrawn. Of the 65 remaining, 31 underwent laparotomy and 34 had pre-operative PTBD followed by laparotomy. The median duration of drainage was 18 days and during this time the median bilirubin fell from 305 to 115 mumol/l. Five patients required early surgery for complications of PTBD and two died within 30 days of surgery. The mortality for laparotomy was 19 per cent (6/31) compared with 32 per cent (11/34) for drainage plus laparotomy. This trial highlights the hazards of PTBD in high risk patients and has failed to demonstrate a reduction in mortality with the use of pre-operative PTBD .

Localized amyloidosis of the ureter.

We report a case of localized ureteral amyloidosis. This condition usually presents as hematuria and a ureteral stricture, and is clinically indistinguishable from a neoplasm. Treatment should consist of local resection if possible.

Combined bipedal lymphangiography, CT scanning and transabdominal lymph node aspiration cytology for node staging in carcinoma of the prostate.

Forty-two patients with carcinoma of the prostate have been studied by bipedal lymphangiography, abdominal CT scanning and percutaneous transabdominal lymph node aspiration cytology to try to increase the accuracy of lymph node staging. The use of two independent radiologists to report the lymphangiograms did not improve the accuracy of reporting. CT scanning was of value only in patients in whom the lymph nodes were not opacified on lymphangiography. Aspiration cytology was positive in 8 of the 40 patients who were studied. There was no morbidity. Six of these 8 patients had MO disease, three had TO tumours and were not on treatment. A poor correlation was found between the presence of lymph node metastases and the Gleason score. Percutaneous transabdominal lymph node aspiration cytology is a safe procedure. When positive, it avoids the need for a staging lymphadenectomy and so helps to identify those patients for whom local treatment is not applicable.

Idiopathic localized bile duct strictures: relationship to primary sclerosing cholangitis.

Two patients have been described who presented with localized hilar bile duct strictures initially diagnosed as cholangiocarcinoma. Resection of the strictures showed benign disease. The subsequent development of further independent benign strictures was consistent with sclerosing cholangitis. Problems in diagnosis and management of this form of primary sclerosing cholangitis have been discussed.

Carcinoma of the proximal extrahepatic biliary tree radiologic assessment and therapeutic alternatives.

Preoperative cholangiography and angiography have been used in a series of 37 patients with hilar cholangiocarcinoma investigated over a 17-month period in a single specialist unit. Twelve lesions were judged to be irresectable on the basis of the cholangiographic findings: this was confirmed at laparotomy in nine patients and at autopsy in one. Angiography was performed in 21 patients, and suggested irresectability in eight: this was confirmed by laparotomy in seven. The eighth patient had compression of the left portal vein which had been interpreted as tumor invasion on angiography, and it was possible to perform a curative extended right hepatic lobectomy. Of the 13 potentially resectable patients, three were unfit for major resectional surgery. Five were found to be irresectable at laparotomy because of vena cava involvement in two and distant metastases in three. Five patients underwent resection with histologically clear margins. The combined use of cholangiography and angiography is recommended as a means of selecting appropriate therapy for patients with hilar cholangiocarcinoma.

Massive retroperitoneal lymphadenopathy as a terminal event in hairy cell leukaemia.

A case of hairy cell leukaemia complicated as a terminal event by massive retroperitoneal lymphadenopathy is described. The patient had recently been treated with lithium carbonate and had previously been demonstrated to suffer from a systemic vasculitis, either or both of which may have contributed to the development of this rare complication.

Wegener's granulomatosis: observations on 18 patients with severe renal disease.

Eighteen patients with Wegener's granulomatosis with renal involvement have been studied. Their course before treatment has indicated how the disease may progress and has provided a framework for diagnosis based on clinical and radiological features combined with available histology. The need for such diagnostic criteria is emphasised by the fact that a firm histopathological diagnosis could only be made in nine patients. A strong association between Wegener's granulomatosis and previous suppurative or tuberculous respiratory infection has been noted as well as between intercurrent infection and relapse. Evidence that immune complexes play a pathogenetic role has come from the association between active disease and circulating immune complexes. The observation of a reversible abnormality of splenic clearance of altered red cells suggests that immune complex handling by the spleen is defective. Treatment of these patients has shown a surprising degree of reversibility in many manifestations, especially renal failure. Remissions occurring spontaneously or induced by steroids alone are temporary and steroids, if used alone, may adversely affect outcome. While confirming the central role of cyclophosphamide in the induction of remission, this study has indicated that its combination with steroids and/or plasma exchange may be valuable in initial control of fulminating disease. The fact that seven patients died during induction (as well as a further four in the succeeding five years) reflects the advanced disease at presentation and the infective problems associated with immunosuppressive therapy. This highlights the need for earlier diagnosis.