Emergency head injury imaging: implementing NICE 2007 in a tertiary neurosciences centre and a busy district general hospital.

BACKGROUND: Head injuries are a common emergency department (ED) presentation. The National Institute for Health and Clinical Excellence (NICE) updated its guidance in September 2007 regarding imaging required for patients with head injuries. METHODS: A two-centre observational ED study was carried out, examining imaging practice in adults and children with head injuries attending pre-guideline and post-guideline implementation. Guideline implementation occurred through a formal implementation programme at the teaching hospital, and informally at the district general hospital (DGH). Retrospective extraction took place of prospectively recorded data case records and radiology department imaging registers. Pre-implementation data were collected from Salford Royal Foundation NHS Trust (SRFT) from January and February 2008 and post-implementation data in May 2008. Post-implementation data was collated from Royal Bolton Hospital Foundation NHS Trust (RBFT) from September to November 2007. Compliance with NICE 2007 was the primary outcome assessed. RESULTS: With the implementation of NICE 2007 guidelines at SRFT, a significant increase in compliance from 94.2% (92.9-95.5) to 98.8% (98.2-99.3) was observed for adults requiring head CTs, with an overall trend to improved clinical practice in the adult patient populations. However, a significant number of children (SRFT 68.7% and RBFT 77.1%) did not receive the indicated head CT scan following a head injury, after implementation of the guidelines. CONCLUSIONS: The SRFT implementation strategy employed was successful for adults, with the overall trend to increased clinical compliance post-guideline introduction. Evidence of a reluctance to adhere to the NICE recommendations for children indicated for CT head scan after a head injury was observed.

Emergency department follow-up of bereaved relatives: an audit of one particular service.

BACKGROUND: Although much has been written about the treatment of bereaved relatives in emergency departments, very little has been published about their follow-up after they have left the department. METHODS: One model of follow-up is described, in which relatives are invited to a meeting in the department 4-6 weeks after their loss. In this model, it is emphasised that the follow-up is not a counselling session but an opportunity to ask questions, and an audit of the service is presented. RESULTS AND CONCLUSION: It is suggested that the provision of information is theoretically beneficial to the bereavement process.

Core-peripheral temperature gradient as a diagnostic test in dyspnoea.

OBJECTIVES: To evaluate whether the core-peripheral temperature gradient could be used to distinguish between cardiac and respiratory causes of dyspnoea. METHODS: In total, 50 patients were enrolled in the study, based on the following inclusion criteria: (a) a primary presenting complaint of dyspnoea; (b) age > 40 years; (c) respiratory rate > 20 breaths/min; (d) hypoxia. The tympanic temperature and the temperature of the nasal tip were recorded, and the patient's discharge data and chest x ray results checked. Where there was discordance, arbitration was carried out by another researcher. RESULTS: Four patients were excluded, hence the final study sample was 46 patients. There was a statistically significant difference between the mean temperature gradients of the two study populations (p < 0.001). A gradient of > 8 degrees C was able to rule in a cardiovascular cause (92% specificity) whereas one of < 5 degrees C could rule it out (100% sensitivity). CONCLUSION: The test is safe, non-invasive and inexpensive. Although there were some limitations to the study, the test can still be commended as a useful adjunct to the emergency assessment of the acutely breathless patient.

Multiple aortic thrombi associated with protein C and S deficiency.

We describe a woman with an unusual case of thromboembolism of the mesenteric artery in whom multiple thrombi were subsequently found in the aorta and right heart chambers on transesophageal echocardiography. Further evaluation revealed a deficiency of protein C and S plasma proteins, inhibitors of the clotting system. The patient was treated successfully with systemic anticoagulation. Aortic thrombus is common in the setting of underlying atherosclerosis. However, the association of aortic thrombus with a deficiency of protein C and S is rare. To our knowledge, this is the first reported case of mural thrombus of the thoracic aorta associated with combined protein C and S deficiency. Our report underscores the important role of transesophageal echocardiography in the evaluation of patients with arterial thromboembolism.

Clinical and cost effectiveness of prophylactic parenteral penicillin in the care of simple wounds undergoing suture repair.

Physicians working in casualty and outpatient departments where adverse conditions prevail often prescribe antibiotic prophylaxis routinely at the time of suture repair of simple wounds. To evaluate this practice, we performed a randomized, controlled study of parenteral chemoprophylaxis of simple wounds undergoing suture repair. Uncomplicated wounds were randomized to either treatment with a combination of benzathine penicillin (2.4 million units) and procaine penicillin (2.0 million units) intramuscularly, or a control group. At the time of suture removal, seven days later, all wounds were reviewed for signs of infection. Of 320 patients enrolled in the study, 173 (54.1%) returned for review. Among treated wounds, 75 of 81 (92.6%) were healing, compared to 79 of 92 (85.9%) controls (p = 0.24). A significantly higher rate of healing was observed when wounds repaired nine or more hours after injury and involving the arms, legs, or trunk were treated (22 of 23, 95.7%) compared to those in whom prophylaxis was omitted (20 of 30, 66.7%) (p = 0.03). Wounds involving the head, and wounds repaired within nine hours after injury had a high rate of healing (greater than 90%), whether prophylaxed or not. Based on a 30% higher healing rate for the patients who benefited from treatment (arm, leg, trunk wounds repaired after nine or more hours), the drug cost of implementing prophylaxis for this group alone was more than five times that of an expectant, non-prophylactic strategy. These results serve to remind practitioners of the possibility that a clinically effective mode of therapy may not necessarily be cost-effective in the delivery of health care.

The endothelin system in cardiovascular physiology and pathophysiology.

Endothelin-1, a member of a novel family of regulatory peptides, is the most potent vasoconstrictor and pressor substance known. Endothelin-1 is a 21-amino-acid endothelium-derived peptide causing uniquely sustained vasoconstriction. In addition, endothelin-1 has pronounced effects on the coronary, renal and cerebral circulations, enhances responses to other vasoconstrictors, and is comitogenic. Recent studies have shown that the endothelins are essential for normal fetal development, and that endothelin-1 plays an important physiological role in the regulation of basal vascular tone and blood pressure in healthy humans. There is now also a wealth of evidence suggesting that endothelin-1 is a key mediator in a range of cardiovascular diseases associated with sustained vasoconstriction, such as chronic heart failure, and with vasospasm, such as subarachnoid haemorrhage. In addition, endothelin-1 appears to act in opposition to nitric oxide to promote the atherosclerotic process. There are a large number of oral and intravenously active endothelin antagonists entering clinical development and a number of clinical studies, particularly with endothelin receptor antagonists, are now under way. Such studies are beginning to define the role of the endothelins in cardiovascular disease and to confirm the potential of the endothelin system as an important new therapeutic target.

Migrant farm workers: social conditions, adaptive belief systems, and psychiatric care.

Two migrant farm labor camps were observed during two summer harvesting seasons. A part of the observations consisted of interviews with 104 farm laborers, with 16 of them being interviewed intensively. Migrant farm workers were exploited by the crew boss and the farm owner, and they in turn exploited each other. Consequently, many workers left farm work. Those who remained in the camps adapted their attitudes and their views to the conditions. Though they had a begrudging respect for the crew boss, they showed an overriding concern with exploitation. They conveyed a numbness about life, themselves, and their place in society; this numbness was combined with self criticism and an attempt to maintain some self-respect. They expressed distrust for and suspicion of others, and though they could not articulate it very well, they felt great fear and anxiety. In order to diagnose and treat disorder in migrant farm workers, psychiatrists must understand the exploitive social setting of migrant farm work and the adaptations of workers to that setting.

Effects of sera and liver extracts from partially hepatectomized rats on liver slice DNA synthesis.

Sera from partially hepatectomized rats (PH) compared to sera from control rats (C) enhance liver slice DNA synthesis but depress kidney slice DNA synthesis. Alone, liver extracts from PH do not affect DNA synthesis; but adding sera to PH extracts stimulates, suggesting that sera and liver factors from PH may participate in compensatory growth.

Free concentrations of sodium, potassium and calcium in chromaffin granules.

We have measured the contents of Na+ and K+ in isolated chromaffin granules. Total contents varied between 227 and 283 nmol/mg of protein, equivalent to matrix concentrations of 53-66 mM. The value found depended on the isolation buffer used, and the ratio of the two ions reflected the composition of the buffer. We then measured the free concentration of each of these ions, and of Ca2+, in the matrix, by using a null-point method with acridine-fluorescence quenching. This monitored H+ fluxes induced by an ionophore in the presence of known concentrations of the ion in the supporting medium. In contrast with organic constituents of the matrix, which have low activity coefficients, Na+ and K+ were found to have activity coefficients around 0.8 Ca2+, however, was strongly bound: its free concentration was only 0.03% of the total.

Fast volatile organic compound recovery from soil standards for analysis by thermal desorption gas chromatography.

The development of high-throughput environmental screening assays are needed to meet high-specification data quality objectives (DQOs) that require large numbers of samples to be taken and analysed rapidly. The acquisition and stabilisation of the sample is a key technical and operational challenge in analytical sequences associated with the determination of volatile organic compound (VOC) contamination of soils. Further the development of miniaturised and embedded analytical systems for environmental conditioning monitoring requires the development of new sampling techniques. A proof-of-concept study is described that shows how pressurised gas, in this case carbon dioxide, may be used to recover reversibly-bound VOCs from soil into an adsorbent sampler, and then analysed by thermal desorption-gas chromatography. The effects of the volume of the pressurised gas, the gas flow rate and the mass of the soil sample on the recovery efficiency and breakthrough from the adsorbent trap were investigated in a preliminary characterisation study. Two distinct approaches were identified. The first involved ventilation of the voids within the soil matrix to displace the soil-gas headspace, a rapid screening approach. The second involved a more prolonged purge of the matrix to strip reversibly bound species into the gas phase and hence pass them into the adsorbent trap, a purge and trap approach. The shortest possible sample processing time required to yield analytically useful responses was 5 s with the use of the headspace approach. In this case n-octane, benzene and toluene were recovered from conditioned spiked soil samples at concentrations in the range 42 to 1690 mg kg(-1). The limit of detection for the system was estimated to be no greater than 1.2 mg kg(-1). Using the purge and trap variant enabled recovery efficiencies greater than 93% to be achieved with liquid spikes of n-octane onto soil samples. These preliminary studies showed that a system based on this approach would need to balance recovery efficiency, time and analyte breakthrough from the adsorbent trap.

Clinical and cost effectiveness of prophylactic parenteral penicillin in the care of simple wounds undergoing suture repair

Physicians working in casualty and outpatient departments where adverse conditions prevail often prescribe antibiotic prophylaxis routinely at the time of suture repair of simple wounds. To evaluate this practice, we performed a randomized, controlled study of parenteral chemoprophylaxis of simple wounds undergoing suture repair. Uncomplicated wounds were randomized to either treatment with a combination of benzathine penicillin (2.4 million units) and procaine penicillin (2.0 million units) intramuscularly, or a control group. At the time of suture removal, seven days later, all wounds were reviewed for signs of infection. Of 320 patients enrolled in the study, 173 (54.1%) returned for review. Among treated wounds, 75 of 81 (92.6%) were healing, compared to 79 of 92 (85.9%) controls (p=0.24). A significantly higher rate of healing was observed when wounds repaired nine or more hours after injury and involving the arms, legs, or trunk were treated (22 of 23, 95.7%) compared to those in whom prophylaxis was omitted (20 of 30, 66.7%) (p=0.03). Wounds involving the head, and wounds repaired within nine hours after injury had a high rate of healing (>90%), whether prophylaxed or not. Based on a 30% higher healing rate for the patients who benefitted from treatment (arm, leg, trunk wounds repaired after nine or more hours), the drug cost of implementing prophylaxis for this group alone was more than five times that of an expectant, non-prophylactic strategy. These results serve to remind practitioners of the possibility that a clinically effective mode of therapy may not necessarily be cost-effective in the delivery of health care.