Surgical treatment of drooling by bilateral parotid duct ligation and submandibular gland resection.

We have followed 14 patients for up to 6 years after they had submaxillary gland resections and parotid duct ligations for drooling. Good to excellent results were found in more than 85 percent of them in the control saliva, and there have been no recurrences or fistulae. This procedure is technically simple to do, and it is associated with less morbidity than surgical relocation of the parotid ducts.

Radiographic examination of the lumbar spine in a community hospital: an audit of current practice.

OBJECTIVE: To assess general practitioners' decisions to request lumbar spine radiographs according to the guidelines of the Royal College of Radiologists. DESIGN: Prospective questionnaire survey of outpatients attending for lumbar spine radiography. SETTING: London community hospital. SUBJECTS: 100 consecutive adult outpatients attending for lumbar spine radiography at their general practitioner's request. MAIN OUTCOME MEASURES: Patient's history and clinical signs; radiological diagnosis; change in management of patients with significant radiological abnormality in response to the radiologist's report. RESULTS: 60 patients were aged between 18 and 45, 27 (45%) of whom were women. Five patients were fully examined by their doctor before radiographs were requested, 76 were partially examined, and 19 were not examined. In 37 patients the examinations showed radiologically normal findings; 30 had radiologically significant disc or degenerative disease. Pain score and radiological diagnosis was not correlated (6.43 (range 1-10) for patients with significant disease v 6.14 (range 1-10) for those without, p greater than 0.05). There were no cases of malignancy or infection. One patient with radiologically significant disease was referred to a hospital specialist, and the management of only two such patients was altered by the report. 52 of the examinations should not have been requested if the guidelines had been strictly applied. CONCLUSIONS: There is a need to inform doctors of the efficacy of radiological examinations. An awareness of the college's guidelines among general practitioners should be actively promoted by radiologists.

Picture archiving and communication systems lead to sustained improvements in reporting times and productivity: results of a 5-year audit.

AIM: To evaluate the impact of picture archiving and communications systems (PACS) on reporting times and productivity in a large teaching hospital. MATERIALS AND METHODS: Reporting time, defined as the time taken from patient registration to report availability, and productivity, defined as the number of reports issued per whole time equivalent (WTE) radiologist per month, were studied for 2 years pre- and 3 years post-PACS installation. Mean reporting time was calculated for plain radiographs and specialist radiology techniques [computed tomography (CT), magnetic resonance imaging (MRI), ultrasound, and nuclear medicine]. Productivity, total department workload, and unreported film rates were also assessed. Pre- and post-PACS findings were compared. RESULTS: Between 2002-2006 the number of radiological patient episodes increased by 30% from 11,531/month to 15,057/month. This was accompanied by a smaller increase in WTE reporting radiologists, from 32 to 37 (15%). Mean reporting times have improved substantially post-PACS, plain radiograph reporting time decreased by 26% (from 6.8 to 5 days; p=0.002) and specialty modalities by 24% (4.1 to 3.1 days; p<0.001). Radiologist productivity has increased by 18% (337 films to 407 films/WTE radiologist/month). Unreported films have decreased from 5 to 4% for plain radiographs and are steady for specialty modalities (< 1%). In most areas improvements have been sustained over a 3-year period. CONCLUSION: Since the introduction of PACS, reporting times have decreased by 25% and the productivity improved by 18%. Sustained improvements are felt to reflect the efficiencies and cultural change that accompanied the introduction of PACS and digital dictation.

Randomized trial of lidocaine vs lidocaine/bupivacaine periprostatic injection on longitudinal pain scores after prostate biopsy.

PURPOSE: Periprostatic lidocaine reduces immediate post-prostate biopsy pain but still many men will not consent to re-biopsy. We performed a randomized study to assess whether adding long acting local anesthesia to a short acting agent would further reduce pain. MATERIALS AND METHODS: A total of 300 men undergoing transrectal ultrasound guided prostate biopsy were sequentially randomized to receive either short acting local lidocaine (lid) or short and long acting lidocaine and bupivacaine (lid/bup). A 7-day questionnaire was used to study daily pain (10-point visual analog score), bleeding (hematuria, PR bleeding, hematospermia), visits to the family doctor and analgesic use, and whether they would agree to future re-biopsy. RESULTS: Of the 256 questionnaires returned 250 were suitable for analysis. Cross-sectional comparison showed no intergroup differences in mean pain scores immediately after biopsy (2.24, 95% CI 1.94-2.5 vs 2.61, 95% CI 2.3-2.9, p = 0.88 in lid and lid/bup groups, respectively). There was a significant rebound in visual analog scale at 1 hour in the lid group but not in the lid/bup group (+ 0.9 vs + 0.09, p = 0.0006). Longitudinal analysis showed the global pain experience after lid/bup was better compared to lidocaine alone, with significantly less pain every subsequent day (p = 0.0006 to 0.002). No difference was seen in morbidity, analgesia usage or number refusing future re-biopsy (9.6% vs 9.8%). CONCLUSIONS: Long and short acting local anesthetics together significantly attenuate the 1-hour rebound increase in pain scores seen after short acting anesthesia alone. Improved pain scores were sustained during the subsequent week and we advocate routine combination use for transrectal ultrasound guided prostate biopsy.

An outbreak of soft-tissue infections due to Mycobacterium fortuitum associated with electromyography.

An outbreak of infections due to Mycobacterium fortuitum associated with electromyography (EMG) is described. During a 6-week period, six patients who received EMG at one facility developed soft-tissue infections manifested by slowly expanding suppurative nodules at sites of needle electrode insertion. M. fortuitum was isolated from five patients; four isolates that were evaluated further were M. fortuitum biovariant fortuitum. EMG procedures were done in one laboratory by one physician and assistant. Standard procedures included use of reusable needle electrodes disinfected with 2% glutaraldehyde and then rinsed with tap water. On recognition of the outbreak, the procedure was changed to include autoclaving of needle electrodes. Active surveillance for 1 year revealed no further cases. M. fortuitum could not be isolated from the laboratory, EMG equipment and reagents, or skin of the medical personnel. The outbreak demonstrates that nontuberculous mycobacterial infection may be associated with EMG.

Influence of postal distribution of the Royal College of Radiologists' guidelines, together with feedback on radiological referral rates, on X-ray referrals from general practice: a randomized controlled trial.

BACKGROUND: The Royal College of Radiologists (RCR) have produced regularly updated guidelines on radiological referrals since 1990. A small study in 1992 showed postal distribution of guidelines reduced general practitioners' referrals over the subsequent 9 weeks. However there have been no randomized trials of the longer term effects of radiological guidelines and feedback on referral rates on X-ray requests from primary care. OBJECTIVES: To see if the introduction of radiological guidelines into general practices together with feedback on referral rates reduces the number of GP radiological requests over one year; and to explore GPs'attitudes to the guidelines. METHODS: Sixty-nine practices referring patients to St George's Healthcare Trust were randomly allocated to intervention or control groups. In February 1995 a GP version of the RCR guidelines was sent to each GP in the 33 practices in the intervention group. After 9 months intervention, practices were sent revised guidelines with individual feedback on the number of examinations requested in the past 6 months. The total number of requests per practice was compared for the year before and the year after the introduction of the guidelines. Control practices were sent the guidelines at the end of the study. All doctors were sent a questionnaire about the guidelines. RESULTS: A total of 43 778 radiological requests were made during the two years 1994-1996. In practices receiving the guidelines there was a 20% reduction in requests for spinal examinations compared with control practices (P < 0.05). This corresponded to the effect reported by GPs. There was also a 10% difference between the groups in the total number of requests made, but due to wide interpractice variation in referral rates this failed to reach statistical significance. CONCLUSIONS: Introduction of radiological guidelines together with feedback on referral rates was effective in reducing the number of requests for spinal examinations over one year. Wider use of GP-orientated guidelines with regular updating and feedback might save costs and reduce unnecessary irradiation of patients.

Ulcerogenic choledochoduodenal fistula.

Spontaneous choledochoduodenal fistula is a rare form of biliary enteric fistula which is usually related to peptic ulcer disease and therefore is seen more often in men. This is in contrast to the more common cholecystoduodenal fistula which is associated with calculous gall-bladder disease and occurs predominantly in women. We report two cases diagnosed by radiology following unhelpful laparotomy.

Pain after transrectal ultrasonography-guided prostate biopsy: the advantages of periprostatic local anaesthesia.

OBJECTIVE: To prospectively evaluate the efficacy and safety of periprostatic local anaesthesia (LA) during prostatic biopsy guided by transrectal ultrasonography (TRUS), as 20-65% of men report moderate to severe pain, and there is anecdotal and published evidence that periprostatic anaesthesia improves patients' tolerance. PATIENTS AND METHODS: In all, 157 patients were prospectively recruited and sequentially randomized to receive either LA or no anaesthesia. Sextant biopsies were taken in all men but some had more than six biopsies. All were asked to complete questionnaires immediately after TRUS-guided biopsy and for the subsequent week, giving pain scores and recording any morbidity, including symptoms of infection; analgesic use was also surveyed. RESULTS: Patients given LA had significantly lower pain scores at the time of biopsy than those given no anaesthesia, with median (sd) pain scores of 1.53 (0.7) and 1.95 (0.65) (P < 0.001), respectively. In addition, there was a trend towards less analgesic use by those given LA, although this was not statistically significant. There was no difference in the amount of haematuria, haematochezia or haematospermia, or infection rate, between the groups. The additional cost and time of the procedure was minimal ( pound3.00 and 3 min/per patient, respectively). CONCLUSION: Periprostatic LA infiltration is a quick and simple procedure which significantly improves immediate pain with no added morbidity; we strongly advocate its use to improve patient tolerance of TRUS-guided prostate biopsy.

The diagnostic contribution of the frontal lumbar spine radiograph in community referred low back pain--a prospective study of 1030 patients.

AIM: The diagnostic contribution of the anteroposterior (AP) view was studied to assess whether this view could be omitted safely, thus reducing the radiation burden received by patients undergoing lumbar spine radiography. MATERIALS AND METHODS: Prospective analysis of 1030 consecutive referrals for lumbar spine radiography from general practice. RESULTS: In the majority of cases (90.5%) the AP view was non-contributory. In 4.2% the diagnosis was strengthened and it was altered in 4.6%. However, in the latter group only 1.3% of the total were considered significant alterations. These were cases of possible, but not definite, pars defects and sacroiliitis. Specific important conditions such as infection, malignancy and benign tumours were not missed on the lateral view alone, in our study population. The radiation burden is reduced by 75% by omitting the AP view. CONCLUSION: A single lateral view is an adequate examination, with the proviso that sacroiliac joint disease is not assessed on this view and some pars defects and facet joint degenerative changes may be overlooked. The radiation protection gains are considerable. A single lateral lumbar view is now our routine practice unless sacroiliitis is a specific clinical concern.

A study of hepatitis C prevalence in healthcare workers in the West of Scotland.

BACKGROUND AND AIMS: Whether healthcare workers have an increased prevalence of hepatitis C virus infection as a result of exposure to patient's blood and body fluids is controversial. This study assesses the prevalence of hepatitis C virus infection in healthcare workers, and its relation to the performance of exposure prone procedures and duration of occupational exposure, allowing an estimate to be made of the incidence of occupationally acquired hepatitis C infection among medical staff. METHODS: In this anonymous retrospective cohort study, we estimated the prevalence of hepatitis C infection in 10 654 healthcare workers. ELISA-3 testing was performed on pools of five sera collected during immunisation against hepatitis B. Healthcare workers were arranged into five occupational groups, according to the degree of patient exposure, and three age bands (<30 years, 30-39 years, >40 years). RESULTS: Prevalence of antibodies to hepatitis C was 0.28% (30/10 654), comparable in all occupational groups (p=0.34) and unrelated to duration of potential exposure. Assuming that all detected infections had been occupationally acquired, the maximum estimated risk of hepatitis C infection in exposure prone medical staff was low: 1.4% for surgeons and 1.0% for physicians over a 35 year professional career. CONCLUSIONS: Hepatitis C infection is infrequent in healthcare workers in Glasgow. Those conducting exposure prone procedures do not seem to be at higher risk than other healthcare staff.