A practice pathway for the initial diagnostic evaluation of isolated sixth cranial nerve palsies.

PURPOSE: To define a practice pathway for the evaluation of sixth-nerve palsies (SNPs) and to determine its cost-effectiveness and validity in a retrospective chart review. METHODS: A Medline search of the English-language literature from 1966 to 1995 was performed to define the available clinical evidence and develop the practice pathway. The authors retrospectively reviewed 407 charts with the diagnosis of SNP seen at three centers. Information obtained included: etiologic diagnosis if known; development of new neurologic or ophthalmologic findings; and results and costs of neuroimaging studies, if performed. RESULTS: Of the 407 patients, 98 underwent computed tomography scans and 212 underwent magnetic resonance imaging of the head. Eighty cases were non-isolated, 317 were isolated SNP, and ten could not be classified from chart information. Of the 317 cases of isolated SNP, 49 were classified as traumatic; 5, congenital; 158, vasculopathic; 63, nonvasculopathic; and 42, progressive or unresolved. Following the recommendations of the practice pathway, the 158 patients classified as having vasculopathic SNP would not have undergone neuroimaging studies, realizing a savings of $100,000 in this study population of 407 patients. CONCLUSION: The recommendations of the practice pathway are supported by review of the literature and the retrospective review of these cases. However, a prospective study with a matched control group is needed to demonstrate regional and specialty-specific variations in care and to strengthen the clinical certainty of the pathway recommendations.

Training for visiting registrars: experience in East Anglia, UK.

A questionnaire was sent to 24 visiting registrars in East Anglia to obtain information on their perceptions of their training experiences. The results suggest that the needs of overseas doctors and the requirements of training authorities would benefit from organisational changes aimed at improving selection and training programmes. Formal training programmes are needed, tailored to an individual's requirement, with identification of educational supervisors for each trainee. An improved system of introduction to the National Health Service is also required.

A district confidential enquiry into deaths due to asthma.

BACKGROUND: The aim was to establish a continuing district based confidential enquiry into deaths from asthma. METHODS: A confidential enquiry was conducted in an English health district. Subjects comprised 24 residents of the Norwich health district aged between 16 and 65 years who had died between 1988 and 1991 with asthma as the principal cause of death. RESULTS: Twenty one of the patients (88%) died away from hospital. Overall the routine asthma management was appropriate in all respects in only four patients. In five cases the drug treatment was considered inappropriate, in 10 cases (42%) there was no written evidence that the patient had received advice and education, and only six cases had a written management plan. In 17 patients (71%) the fatal attack of asthma developed rapidly (in under three hours). The medical care during the final attack was found to have been inappropriate in six cases. Seventeen cases (71%) had psychological or social factors that were considered to have been of potential importance. CONCLUSIONS: This study has shown the feasibility of organising a confidential enquiry into asthma deaths within a health district. The distinguishing features of such an enquiry are that it is continuing, that the quality of care given to those patients who died is compared against a recognised standard, and that there is a structured system for feeding back the conclusions of the enquiry to the local medical community.

Bronchoscopic and bronchographic findings in 12 patients with sarcoidosis and severe or progressive airways obstruction.

Twelve patients (8 men), aged 33-67 (mean 49) years, with histologically proved sarcoidosis underwent bronchoscopy. All had symptoms, signs (wheeze in 11, high pitched inspiratory "squeaks" in six, stridor in three), and physiological abnormalities characteristic of severe or worsening airways obstruction. Eleven patients also underwent bronchography. At the time of bronchoscopy four patients had stage II, one stage III, and seven stage IV sarcoidosis. All patients had a peak expiratory flow (PEF) of 70% predicted or less and a maximum expiratory flow at 50% (MEF50) and 25% (MEF25) of vital capacity below 35% predicted. The ratio of their forced expiratory volume in one second to forced vital capacity (FEV1/FVC) ranged from 37% to 65%. Fibreoptic bronchoscopy showed single or multiple areas of segmental bronchial stenoses in 10 patients, two of whom had stenotic webs. Bronchography showed that the sites and severity of stenoses were more widespread than suspected from the bronchoscopic findings. Five of the 11 patients undergoing bronchography had bronchiectasis, which was restricted to the upper lobes in three and a lower lobe in one and affected both upper and lower lobes in one patient. The bronchiectasis had not been suspected or diagnosed from the chest radiography or the bronchoscopy.

The outcome of community acquired pneumonia treated on the intensive care unit.

Eighteen patients with community acquired pneumonia required intensive care for severe or progressive hypoxaemia, rising arterial carbon dioxide tension or respiratory arrest, and 17 received intermittent positive pressure ventilation. Thirteen survived to leave hospital and 12 are long term survivors. Ventilation was started within 4 days of admission in all cases and was continued for up to 34 days; six patients required ventilation for over 3 weeks. The most common medical complication was renal failure. The most common iatrogenic complication was pneumothorax. We believe that all the hypoxic patients would have died from their hypoxia had it not been corrected. We estimated that up to 5% of patients admitted with community acquired pneumonia need intensive care. This study demonstrates the effectiveness of such care, which is multidisciplinary, demanding, and may need to be prolonged.

The clinical spectrum and diagnosis of Mycoplasma pneumoniae infection.

The clinical, radiographic and microbiological data of 47 patients with Mycoplasma pneumoniae infection admitted to three Norfolk hospitals during a 20-month period between 1982 and 1983 have been reviewed. Thirty-nine presented with pneumonia and eight with non-pulmonary infection. The M. pneumoniae specific IgM test was positive in 42 of 45 patients tested (89 per cent); in 39 the levels were diagnostic on admission. Cold agglutinins were detected in 27 (57 per cent) and a fourfold rise in complement fixation titre was demonstrated in 13 (29 per cent). Sputum culture was positive in 12 (26 per cent). The extrapulmonary manifestations observed were haemolytic anaemia (17 per cent), Stevens Johnson syndrome (4.1 per cent), neurological abnormalities (4.1 per cent), arthritis (2.1 per cent), hepatitis (2.1 per cent) and pericarditis (2.1 per cent). One patient with multilobe pneumonia, pericardial effusion and haemolytic anaemia died. Six patients presented with a history of illness longer than a month; in three the clinical and radiographic picture suggested chronic disease (pulmonary tuberculosis, lymphoma and unresolving pneumonia). There were no distinctive clinical or radiographic features of M. pneumoniae infection. Diagnosis, therefore, relies on serological tests of which the most useful is the rapid, specific IgM test, positive in 86 per cent of the admission sera.

A controlled study of slow-release theophylline and aminophylline in patients with chronic bronchitis.

Twenty patients with chronic bronchitis who were also receiving beta-agonist inhalers entered a single-blind cross-over study comparing slow-release aminophylline (Phyllocontin) 325 mg twice daily and slow-release theophylline (Rona-slophyllin) 250 mg twice daily with placebo. 16 subjects who completed the study showed no objective or subjective benefit with either active preparation. Eight of the 16 patients achieved plasma theophylline levels of greater than 10 micrograms/ml on each of the drugs but no benefit was found when this group was analysed separately.

The possible role of aero-allergens in the epidemic of asthma deaths.

The 'epidemic' of asthma deaths observed in the mid 1960s remains unexplained; various aetiological factors having been suggested. We suggest that aero-allergenic factors may have been important based on an analysis of aero-allergens in Cardiff over a 17-year period: a striking temporal association exists between the concentration of hyaline ascospores and increased asthma deaths. These spores, which are particularly prevalent in the summer months, have been inadequately studied as a cause of severe asthma.

Predicting recovery from acute severe asthma.

Fifty-two patients admitted to hospital with acute severe asthma took part in a prospective study investigating the rate and pattern of their subsequent recovery. Clinical assessment of the severity of the acute attack on admission (according to pulse rate, degree of pulsus paradoxus, and peak expiratory flow rate) did not reliably predict the results of arterial blood gas analysis. Subjects were divided into three groups according to the speed of recovery of peak expiratory flow rate. Historical features associated with slow recovery were: age over 40 years, non-atopic asthma, a longer duration of the acute attack before hospital admission, poor long-term control of asthma, and the use of maintenance oral corticosteroids. The degree of pulsus paradoxus on admission and the improvement in PEFR at six hours and arterial oxygen tension (PaO2) at 48 hours were also useful in predicting speed of recovery. The severity of the attack, assessed on admission by arterial blood gas analysis and PEFR, did not differ between the three groups of recovering patients. Hyperinflation was still present in 15 out of 44 patients investigated five days after admission even though PEFR had returned to mre than 80% of predicted normal in seven of these 15 subjects. The recovery of hypoxia was also commonly delayed with 12 out of 52 patients having PaO2 values of less than 80 mmHg at five days. Persistent hypoxia was more common in those with delayed delayed recovery PEFR.

Non-Hodgkin's lymphoma, chronic lymphatic leukaemia and the lung.

In a retrospective study of 81 patients with non-Hodgkins's lymphoma and 35 patients with chronic lymphatic leukaemia, pulmonary involvement was found in 25% of cases and pleural effusion in 19%. Twenty-four patients (20%) had intrathoracic lymphadenopathy and 12 of these had associated pleural or lung involvement. Infiltration occurred almost exclusively in diffuse lymphocytic lymphoma and chronic lymphatic leukaemia, whereas round lesions were seen only in undifferentiated lymphomas. Pleural effusion complicated most histological types of non-Hodgkin's lymphoma but was uncommon in chronic lymphatic leukaemia. Pleural biopsy was successful in diagnosing lymphoma in nine of ten patients with an effusion in whom it was performed. Both pulmonary and pleural involvement responded poorly to treatment and had an adverse effect on prognosis. In contrast, intrathoracic lymphadenopathy responded well to radiotherapy and/or chemotherapy and did not affect prognosis adversely when it occurred in the absence of other intrathoracic manifestations of lymphoma.

The role of peritoneal biopsy in the diagnosis of ascites.

Percutaneous biopsies of the peritoneum were obtained in 23 patients with ascites of unknown cause. The only case of tuberculous peritonitis was correctly diagnosed. Peritoneal biopsy provided a diagnosis of malignancy in 6 patients (one lymphoma, one mesothelioma, 4 cases of disseminated carcinoma) but failed to recognize a further 13 cases of disseminated carcinoma. Previous literature is reviewed and the diagnostic usefulness of this procedure is discussed.