Electrocardiography-gated CT for acute aortic syndrome: quantifying the potential impact of subspecialty national recommendations on emergency general radiology reporting.

AIM: To evaluate the detection of acute aortic syndrome (AAS) and the prevalence of alternative diagnoses that may explain the presentation or require follow-up. MATERIALS AND METHODS: This was a retrospective, blinded re-evaluation of consecutive electrocardiography (ECG)-gated computed tomography (CT) aortic studies by a cardiovascular radiologist performed between September 2019 and May 2020 in a tertiary-referral cardiothoracic centre. RESULTS: There were 118 identified examinations, six examinations were excluded leaving 112 (mean age = 61 ± 17; 56% male). Three cases of AAS were present (prevalence 2.7%); only one was reported on initial review. There were no false-positive diagnoses of AAS. The heart was mentioned in 79 (70.5%) reports and 73 (65.2%) of reviews revealed a total of 114 new observations; 111 (97.4%) of these were cardiovascular with 44/112 (39.3%) patients potentially having a significant previously unsuspected cardiovascular diagnosis. CONCLUSION: The implementation of national clinical guidance to increase testing and improve image quality led to a series of challenges. The real value of ECG-gated CT may lie in detecting other diseases that mimic AAS. With the additional workload, increased subspecialty expertise is required but there needs to be a willingness to learn with an adequate support infrastructure.

Identifying vulnerabilities in communication in the emergency department.

BACKGROUND: Communication in the emergency department (ED) is a complex process where failure can lead to poor patient care, loss of information, delays and inefficiency. AIM: To describe the investigation of the communication processes within the ED, identify points of vulnerability and guide improvement strategies. METHODS: The Failure Mode Effects Analysis (FMEA) technique was used to examine the process of communication between healthcare professionals involved in the care of individual patients during the time they spent in the ED. RESULTS: A minimum of 19 communication events occurred per patient; all of these events were found to have failure modes which could compromise patient safety. CONCLUSION: The communication process is unduly complex and the potential for breakdowns in communication is significant. There are multiple opportunities for error which may impact on patient care. Use of the FMEA allows members of the multidisciplinary team to uncover the problems within the system and to design countermeasures to improve safety and efficiency.

Improving communication in the emergency department.

BACKGROUND: A previous study examined the communication process within the emergency department (ED) and identified a complex process with many opportunities for breakdown and error. In this paper the first two interventions in a series of studies to improve this highly vulnerable communication process are described. AIM: To improve the reliability of two steps of the communication process identified as having a high probability of failure: (1) transfer of information between the ambulance crew and the emergency staff; and (2) preparation of written documentation following patient assessment. METHODS: Quantitative assessments of the reliability of communication were carried out to establish the extent of problems highlighted during the failures modes and effects analysis (FMEA) previously described. Improvements to the process were then introduced, and the process re-examined to assess the impact of the changes and reduction of the likelihood and severity of the failure mode. RESULTS: The studies demonstrated very high levels of communication failure, particularly in transfer of written information from the ambulance crew. Countermeasures were introduced which resulted in a substantial reduction in missing and incorrect information. In addition, there was a threefold improvement in the number of correct clinical documents used by doctors in the resuscitation room. CONCLUSION: Observational study and audit revealed the extent of process failures identified in the initial FMEA process. With the introduction of simple changes to the communication system, a marked improvement in the availability and quality of pertinent clinical information was achieved with considerable implications for the timeliness and quality of care provided to patients.

Influence of patient posture on oxygen saturation during fibre-optic bronchoscopy.

This study was designed to investigate the effect of posture on oxygen saturation during fibre-optic bronchoscopy (FOB). Thirty-eight consecutive patients requiring diagnostic FOB were randomized into two groups according to the initial posture in which the FOB was performed. In group 1 (20 patients), FOB was commenced supine, and in group 2 (18 patients) in a semi-recumbent position (45 degrees from horizontal). Sedation with midazolam was titrated according to clinical response. All patients received atropine 0.6 mg intravenously and topical lignocaine. Observations of peak, trough and plateau oxygen saturation and pulse rate were recorded during six study periods, each lasting 3 min. Periods 1 and 2 were pre- and post-sedation without supplemental oxygen, respectively. The bronchoscope was then inserted into the distal end of the trachea and observations taken during periods 3 and 4 (no supplemental oxygen) and periods 5 and 6 (2 l oxygen by nasal cannulae). In group 1, posture was changed from supine to semi-recumbent from periods 3-4 and reversed in periods 5 and 6. In group 2, posture changes were in reverse sequence. Patients with initial oxygen saturation of less than 90% or showing a fall below 85% during FOB were excluded. Five patients from each group were withdrawn because of hypoxia. In both groups, oxygen saturation fell significantly (P<0.001) following sedation. There was no significant change in saturation (peak, trough or plateau) with change in posture from supine to semi-recumbency (group 1) or the reverse (group 2). These correspond to periods 3-4 and 5 6 in both groups. Supplemental oxygen was associated with a significant rise in oxygen saturation in both postures, attaining levels close to presedation levels.

Plasma vasopressin and response to treatment in primary nocturnal enuresis.

AIMS: To examine the relation between nocturnal vasopressin release and response to treatment with the vasopressin analogue 1-desamino-8-D-arginine vasopressin (DDAVP) in children with primary monosymptomatic nocturnal enuresis. DESIGN: Children were recruited from a specific enuresis clinic and entered into a defined treatment programme. Nocturnal vasopressin concentrations were measured every 15 minutes over a four hour period during overnight admission. RESULTS: Sixty seven children were eligible for entry into the study, 35 of whom agreed to overnight sampling. There was a quadratic relation between mean plasma AVP and response to treatment with DDAVP, with very high or very low concentrations being unresponsive. Plasma AVP profiles ranged from low concentrations with little variability to high concentrations with wide variability. CONCLUSION: The ability to respond to DDAVP is related to endogenous AVP production and is influenced by neuronal patterning in early infancy. The best predictors of success with treatment were a past history of breast feeding, mean nocturnal AVP concentration, and the height of the child. The response was adversely affected by poor weight at birth and poor linear growth. The study suggests differing causes of nocturnal enuresis related to different patterns of AVP release.

The effectiveness of desmopressin in the treatment of childhood nocturnal enuresis: predicting response using pretreatment variables.

OBJECTIVE: To determine the factors that predict the effectiveness of desmopressin in the treatment of childhood nocturnal enuresis. PATIENTS AND METHOD: Sixty-six children with monosymptomatic nocturnal enuresis were treated with intranasal or oral desmopressin for a 4-week period. starting with a standard dose of 20 microg (0.2 mg oral) and increasing after 2 weeks where no progress was apparent to 40 microg (0.4 mg oral). Before treatment a range of variables (demographic, situational, enuretic history, physiological, parental attitude and child) were recorded. Three parameters of success acted as dependent variables, with stepwise linear regression models used to determine pretreatment predictors of success with desmopressin. RESULT: Each outcome variable produced a very similar model of predictors. Success, as assessed by the most dry nights over a 14-night period, was associated with less severe enuresis before treatment, a parental belief that the child's enuresis was unstable and higher birthweight. CONCLUSION: From the analysis, a model of arginine vasopressin release is proposed and the clinical implications of the findings addressed.

Children's notions about enuresis and the implications for treatment.

Children with nocturnal enuresis (n = 50) completed a range of measures designed to elicit their attitudes and perceptions regarding the problem prior to any treatment intervention. The measures included belief over aetiology, perceived impact on lifestyle, self image, estimates of parental tolerance and implications of becoming dry. Treatment consisted of the body worn enuresis alarm (9), with children followed up for 16 weeks. Child measures were related to outcome measures and a model linking presence of implications, negative self image and belief in incomplete learning of bladder control emerged as important predictors of treatment outcome. The implications of this result are discussed with reference to the clinical context.

Home exercises are as effective as outpatient hydrotherapy for osteoarthritis of the hip.

Hydrotherapy for OA of the hip has rarely been evaluated in controlled studies. Forty-seven patients with OA of the hip were followed for 18 weeks. Patients were randomly allocated either to a regimen of home exercises or to twice weekly hydrotherapy for 6 weeks in addition to home exercises. There was an improvement seen in both subjective and objective measures in both groups with treatment. There was no significant difference between the two groups. Response to treatment appeared independent of age, sex and radiological severity. We conclude that for most patients, a carefully graded and supervised regimen of home exercises is beneficial and there is little benefit in adding hydrotherapy to this regimen.

The Maternal Tolerance Scale and nocturnal enuresis.

The Maternal Tolerance Scale has consistently proved valuable in predicting those mothers who prematurely withdraw their children from treatment for nocturnal enuresis. This study sought to replicate the original work in examining the structure of the scale with an independent group of mothers. The results show the scale to have cross validity, although it appears weighted towards measuring intolerance rather than tolerance. A factor analysis produced 6 factors and these are discussed with regard to possible pathways leading to the development of intolerance.

In vitro microleakage associated with posterior composite restorations used with different base/bonding system combinations.

The study aimed to determine the base/restoration combination which allowed the least microleakage in Class II cavities. One hundred premolar teeth were prepared with a standardized, minimal two-surface cavity and randomly ascribed to ten equal groups. The cavities were restored by use of one of ten different material/technique combinations. Restored teeth were sealed to within 1 mm of the restoration margins with nail varnish prior to the immersion of the crowns in 5% (buffered) eosin for 48 h. The teeth were then hemisected longitudinally, in a mesio-distal plane, through the midline of the restoration by means of a diamond disc with water coolant, and one half of each tooth was then photographed. The transparencies were examined by image analysis programmed to facilitate calculation of the percentage of the tooth/restoration interface and of the crown dentin exhibiting dye penetration. Light- and chemically-cured glass-ionomer-based restorations showed similar amounts of leakage when expressed as a percentage area of crown dentin. This was significantly (p less than 0.05) less than that shown by cavities both etched and bonded. Cavities restored without enamel etching or involving the use of a bonding system exhibited significantly (p less than 0.05) greatest leakage.

The child's construing of nocturnal enuresis: a method of inquiry and prediction of outcome.

Fifty-five children with nocturnal enuresis were engaged in a structured interview prior to treatment with the body-worn alarm. The interview sought to understand how children make sense of the experience and examines the implications for becoming dry. Successful treatment outcome was found to be associated with the child both construing bedwetting psychologically, and indicating no resistance to change. The importance of establishing the child's attitude to bedwetting prior to treatment is stressed.

A simple instrument for the measurement of maximum occlusal force in human dentition.

A simple instrument for the measurement of maximum occlusal force has been developed and the results of an initial clinical trial have been reported. The maximum occlusal force in subjects with dentures was significantly lower than in a group of young male subjects with natural dentition. In the young males the bite force between the molars and premolars was significantly greater than between the incisors. The maximum bite force was not dependent on position for subjects with dentures.