bluuebunny/crossref_metadata_2025 huggingface dataset:
Can Hospital Transfusion Committees Change Transfusion Practice?
Authors: Torella Francesco , Haynes Sarah L , Bennett Joanne , Sewell Darreul , Mccollum Charles N
Published: November 2017

Blood and blood products are commonly over-used in hospital practice. We investigated whether the introduction of a red-cell transfusion trigger (haemoglobin <8 g dL–1) influenced transfusion practice in surgery. Coronary artery bypass grafts (CABGs, n=400), total hip replacements (n=107), colectomies (n=85) and transurethral prostatectomies (TURPs, n=158) were reviewed over two periods of six months, before and after the introduction of the policy by the local hospital transfusion committee.

After introduction of the policy, the proportion of patients transfused fell from 57% to 45% with CABGs (P=0.02) and from 52% to 26% with hip replacements (P=0.006); for colectomies and TURPs there was no change. Hospital stay did not increase in any of the groups. In the second period, haemoglobin concentration on discharge was lower after total hip replacement, by a mean (95% CI) of 0.7 (0.3–1.2) g dL–1 (P=0.002) and after colectomy, by a mean of 0.6 (0.1–1.1) g dL–1 (P=0.03).

Although other factors cannot be excluded, we suggest that the reductions in red-cell transfusion were in large part attributable to the new transfusion policy.
Health Status and Clinical Diagnoses of 3000 UK Gulf War Veterans
Authors: Lee Harry A , Gabriel Roger , Bolton J Philip G , Bale Amanda J , Jackson Mark
Published: November 2017

Up to June 2001, 3000 British veterans of the Gulf War had sought advice from a special medical assessment programme established because of an alleged Gulf War syndrome. After assessment those attending were classified as completely well, well with symptoms, well with incidental diagnoses treated or controlled, or unwell (physically or mentally). Mental illness was confirmed by a psychiatrist. The first 2000 attenders have been reported previously. The present paper summarizes findings in all 3000.

2252 (75%) of those attending were judged ‘well’, of whom 303 were symptom-free. Medical diagnoses were those to be expected in such an age-group (mean age 34 years, range 21–63). No novel or unusual condition was found. In 604 of the 748 unwell veterans, a substantial element of the illness was psychiatric, the most common condition being post-traumatic stress disorder.

The healthcare requirements of the Gulf veterans seen in this programme can therefore be met by standard National Health Service provision.
How Much do Doctors know about Consent and Capacity?
Authors: Jackson Elizabeth , Warner James
Published: November 2017

To assess knowledge of capacity issues across different medical specialties we conducted a cross-sectional survey with a structured questionnaire at academic meetings, lectures and conferences.

Of 190 individuals who received the questionnaire 129 (68%) responded-35 general practitioners, 31 psychiatrists, 29 old-age psychiatrists and 34 final year medical students. Correct answers on capacity to consent to or refuse medical treatment were given by 58% of the psychiatrists, 34% of the geriatricians, 20% of the general practitioners and 15% of the students. 15% of all respondents wrongly believed that a competent adult could lawfully be treated against his or her will, with no obvious differences by specialty.

As judged by this survey, issues of capacity and consent deserve more attention in both undergraduate and postgraduate medical education.
Symptom Severity in Advanced Cancer, Assessed in Two Ethnic Groups by Interviews with Bereaved Family Members and Friends
Authors: Koffman Jonathan , Higginson Irene J , Donaldson Nora
Published: November 2017

Little research has been reported on the experience of cancer among minority ethnic communities in the UK. As part of a wider survey in inner London we interviewed bereaved family members or close friends of 34 first-generation black Caribbeans and of 35 UK-born white patients about symptoms and symptom control in the year before death with cancer. They were drawn from population samples in which the response rates were equal at about 46%.

Symptoms in the two ethnic groups were similar. However, multivariate logistic regression indicated greater symptom-related distress in black Caribbeans for appetite loss, pain, dry mouth, vomiting and nausea, and mental confusion. Respondents were also more likely to say, in relation to black Caribbean patients, that general practitioners (though not hospital doctors) could have tried harder to manage symptoms.

The findings suggest a need for better assessment and management of cancer symptoms in first-generation Caribbean Londoners, guided by a deeper understanding of cultural influences on their responses to advanced illness.
Fast-Track Surgical Referral in a Population Displaced by War and Conflict
Authors: Ryan J M , Fleggson Matthew , Beavis John , Macnab Cara
Published: November 2017

After the 1988–1994 conflict between Armenia and Azerbaijan, fought over the territory of Nagorno-Karabakh, large numbers of people were resettled in camps in southern Azerbaijan. Healthcare in the camps was generally good but there was no access to hospitals. The Leonard Cheshire Centre of Conflict Recovery (LCC) organized a ‘fast-track’ system of surgical care in the southern camps by securing the help of still-functioning hospitals in the distant capital, Baku. Regular clinics were held in the camps for visiting specialists; and, by arrangement with the Government of Azerbaijan and various non-governmental organizations, treatment was offered to those who fell within strict selection criteria. After a pilot study yielded clear benefits, the scheme was transferred to a local nongovernmental organization, which successfully operated an expanded version.

The hidden cost of war often includes the neglect of chronic medical conditions that require secondary and tertiary care. The ‘fast-track’ system illustrates the potential of existing facilities to meet these needs at modest cost, given sufficient support.
Homeopathic Arnica for Prevention of Pain and Bruising: Randomized Placebo-Controlled Trial in Hand Surgery
Authors: Stevinson C , Devaraj V S , Fountain-Barber A , Hawkins S , Ernst E
Published: November 2017

Homeopathic arnica is widely believed to control bruising, reduce swelling and promote recovery after local trauma; many patients therefore take it perioperatively. To determine whether this treatment has any effect, we conducted a double-blind, placebo-controlled, randomized trial with three parallel arms. 64 adults undergoing elective surgery for carpal tunnel syndrome were randomized to take three tablets daily of homeopathic arnica 30C or 6C or placebo for seven days before surgery and fourteen days after surgery. Primary outcome measures were pain (short form McGill Pain Questionnaire) and bruising (colour separation analysis) at four days after surgery. Secondary outcome measures were swelling (wrist circumference) and use of analgesic medication (patient diary).

62 patients could be included in the intention-to-treat analysis. There were no group differences on the primary outcome measures of pain ( P=0.79) and bruising ( P=0.45) at day four. Swelling and use of analgesic medication also did not differ between arnica and placebo groups. Adverse events were reported by 2 patients in the arnica 6C group, 3 in the placebo group and 4 in the arnica 30C group.

The results of this trial do not suggest that homeopathic arnica has an advantage over placebo in reducing postoperative pain, bruising and swelling in patients undergoing elective hand surgery.
Logistic Issues and Potential Prescribing Costs Associated with use of Neuraminidase Inhibitors for the Treatment of Influenza in Primary Care
Authors: Da Silva Philip R , Nguyen-Van-Tam Jonathan S , Hayward Andrew C
Published: November 2017

In the UK, the National Institute for Clinical Excellence has recommended the use of neuraminidase inhibitors for elderly and at-risk patients who present with influenza-like illness within 36 hours of symptom onset. However, few data exist to enable primary care trusts to evaluate the logistics and costs of prescribing. We sought to determine, during a confirmed influenza outbreak, the proportion of eligible patients who currently present in time to benefit from treatment with a neuraminidase inhibitor, and to develop the findings into a model for evaluating potential prescribing costs. Within a single primary care group, demographic and co-morbidity data were collected on all patients consulting their general practitioner or attending an out-of-hours centre with influenza-like illness during the outbreak period.

A typical primary care trust serving 100 000 patients might expect to prescribe a neuraminidase inhibitor to 140 eligible at-risk patients in a season of low influenza activity, rising to 300 in a large epidemic. At-risk patients were more likely than non-at-risk patients to consult within 36 hours of the onset of symptoms. However, only 20% of such patients, rising to 47% in out-of-hours centres, consulted in time to benefit from treatment.

The low proportion of elderly and at-risk patients who consult their general practitioner in time to benefit from treatment with a neuraminidase inhibitor emphasizes the overriding importance of annual vaccination in these groups. If the full benefits of neuraminidase inhibitors are to be realized, access to treatment for eligible patients must be improved.
A Hypothesis to Explain how the Sensory Cortices Respond in the Appropriate Sensory Mode
Authors: Hocker Geoffrey A
Published: November 2017

How does an area of sensory cortex recognize the specific nature of the sensory mode of the stimulus that arrives from the peripheral sensory receptor, when nerve impulses are only all-or-nothing action potentials? Work in animals has shown that an area of sensory cortex can learn in which mode to respond. A period of cortical learning is required for phantom limb phenomena to develop, and for the ocular blind to dream in the visual mode. Arguing from these facts I develop the hypothesis that within the sensory cortices there are neurons that learn by neurotropic factor transport from their sensory receptors to function as surrogates for those receptors, thus enabling sensory cortical response to be modally specific.
Cause and Outcome of Atypical Chest Pain in Patients Admitted to Hospital
Authors: Spalding Lynette , Reay Emma , Kelly Clive
Published: November 2017

In patients with acute chest pain the prime need, usually, is to diagnose and treat myocardial infarction or ischaemia. When a cardiac origin for the pain has been excluded, patients are commonly discharged without either a diagnosis or a plan for follow-up. We studied a group of such patients to see how far causation was pursued and how their mortality compared with that of patients with a proven cardiac cause for their symptoms. The study population was 250 patients admitted over five weeks with chest pain suspected of being cardiac in origin. Initial assessment included an electrocardiogram and measurement of troponin T. If neither of these indicated a cardiac event, the patient was deemed to have ‘atypical’ chest pain and the cause, where defined, was recorded. Outcomes at one year were determined by questionnaire and by assessment of medical notes.

Of the 250 patients, 142 had cardiac pain (mean age 79 years, 58% male) and 108 atypical chest pain (mean age 60 years, 55% male). Of those with atypical pain, 40 were discharged without a diagnosis; in the remaining 68 the pain was thought to be musculoskeletal (25), cardiac (21), gastrointestinal (12) or respiratory (10) in origin. 41 patients were given a follow-up appointment on discharge. At one year, data were available on 103 (96%) patients. The mortality rate was 2.9% (3 patients) compared with 18.3% in those with an original cardiac event. Half of the patients with atypical pain had undergone further investigations and 14% had been readmitted. The yield of investigative procedures was generally low (20%) but at the end of the year only 27 patients remained undiagnosed.

Patients with atypical chest pain form a substantial proportion of emergency admissions. The symptoms often persist or recur. The commonest causation is musculoskeletal, but a sizeable minority remain undiagnosed even after follow-up.
Short-Term and Long-Term Physical Effects of Exposure to CS Spray
Authors: Karagama Y G , Newton J R , Newbegin C J R
Published: November 2017

CS gas (2-chlorobenzylidene malonitrile) is widely used in an incapacitant spray that causes intense lacrimation, blepharospasm and burning sensations in the throat and nose. Questions have been raised about its safety. We obtained information on short-term and long-term symptoms, and performed ear, nose and throat examinations and respirometry at 8–10 months, in 34 young adults who had been exposed to CS spray in a confined space during a confrontation with police. The group was subdivided into those who had been sprayed directly on the face ( n=10) and those exposed indirectly.

At one hour, all but 2 individuals still had symptoms; respiratory and oral symptoms were significantly more prevalent in the directly exposed group. At one month, only oral symptoms were significantly more prevalent. At 8–10 months, symptoms were still reported but there were no differences between the groups and clinical examinations revealed no specific abnormalities.

There was no convincing evidence of long-term physical sequelae from exposure to CS spray.
Hidden Diabetes in the UK: Use of Capture-Recapture Methods to Estimate total Prevalence of Diabetes Mellitus in an Urban Population
Authors: Gill Geoffrey V , Ismail Aziz A , Beeching Nicholas J , Macfarlane Sarah B J , Bellis Mark A
Published: November 2017

An early requirement of the UK's Diabetes National Service Framework is enumeration of the total affected population. Existing estimates tend to be based on incomplete lists. In a study conducted over one year in North Liverpool, we compared crude prevalence rates for type 1 and type 2 diabetes with estimates obtained by capture-recapture (CR) analysis of multiple incomplete patient lists, to assess the extent of unascertained but diagnosed cases. Patient databases were constructed from six sources—a hospital diabetes centre; general practitioner registers; hospital admissions with a diagnosis of diabetes; a hospital diabetic retinal clinic; a research list of patients with diabetes admitted with stroke; and a local children's hospital. Log linear modelling was used to estimate missing cases, hence total prevalence.

The crude prevalence of diabetes was 1.5% (95% confidence interval [CI] 1.41, 1.52), compared with a CR-adjusted rate of 3.1% (CI 3.03, 3.19). Age-banded CR-adjusted prevalence was always higher in males than in females and the difference became more pronounced with increasing age. Among males, CR-adjusted prevalence rose from 0.4% at age 10-19 years to 18.3% at 80+ years; in females the corresponding figures were 0.4% and 9.3%.

The gap between crude and CR-estimated prevalence points to a rate of ‘hidden diabetes’ that has substantial implications for future diabetes care.
Can we see more Outpatients without More Doctors?
Authors: Hughes Michelle L , Leslie Stephen J , Mclnnes Gordon K , Mccormac Kathleen , Peden Norman R
Published: November 2017

A reduction in the number of return patients attending general cardiology clinics, if achievable without harm, would improve access for newly referred patients. Outpatient clinic letters (525) sent to general practitioners over a threemonth period were reviewed. Simultaneously, physicians’ opinions were collected by questionnaire. A subset of 30 clinic patients who attended three local general practitioners were studied to identify how many were assessed in primary care, and how often, in a six-month period. The hospital records of these patients were reviewed to determine whether information about these visits to the general practitioner was documented in the hospital notes.

From the outpatient clinics the discharge rates were only 26% and the reason for further clinic review was often not clear. The fact that many patients had no intervention or treatment change performed at the clinic (42%) indicates that patients are reviewed to assess symptom change rather than to receive further interventions. The use of fixed times for review appointment (six months or 1 year) suggests that the intervals are determined by habit rather than clinical indication. A high proportion of patients (28/30) were reviewed at least once in primary care by general practitioners between hospital clinic visits and 20/30 were seen three or more times. There was poor documentation of these consultations in the hospital case notes, and so hospital physicians may be unaware that symptoms are under regular review in primary care.

This study suggests that a substantial proportion of current cardiology return outpatients do not require regular outpatient review. However, alternative management demands good communication and exchange of information between secondary and primary care, development of formal written discharge planning in outpatient letters and other forms of follow-up.
Public Views on Healthcare Performance Indicators and Patient Choice
Authors: Magee Helen , Davis Lucy-Jane , Coulter Angela
Published: November 2017

Patients on certain waiting lists in the UK National Health Service (NHS) are now offered the choice of persevering with their home hospital or switching to another hospital where they will be treated on a guaranteed date. Such decisions require knowledge of performance. We used facilitated focus groups to investigate the views of patients and members of the public on publication of information about the performance of healthcare providers. Six groups with a total of 50 participants met in six different locations in England.

Participants felt that independent monitoring of healthcare performance is necessary, but they were ambivalent about the value of performance indicators and hospital rankings. They tended to distrust government information and preferred the presentational style of ‘Dr Foster’, a commercial information provider, because it gave more detailed locally relevant information. Many participants felt the NHS did not offer much scope for choice of provider.

If public access to performance information is to succeed in informing referral decisions and raising quality standards, the public and general practitioners will need education on how to interpret and use the data.
Identifying Neuropathic Pain in Patients with Head and Neck Cancer: Use of the Leeds Assessment of Neuropathic Symptoms and Signs Scale
Authors: Potter Jean , Higginson Irene J , Scadding John W , Quigley Columba
Published: November 2017

The Leeds Assessment of Neuropathic Symptoms and Signs Scale (LANSS) is a simple bedside test in two parts—a patient-completed questionnaire and a brief clinical assessment. Its diagnostic capabilities have never been tested in patients with cancer pain. To determine these we conducted a prospective study in outpatients with head and neck cancer. All patients with pain completed the LANSS and underwent a medical assessment with a palliative care physician, whose findings were then reviewed by a pain specialist blinded to the LANSS scores. We assessed acceptability and understanding of the LANSS by patients and calculated the sensitivity and specificity of total LANSS scores and subscores derived from the patient-completed section.

Of 130 patients approached, 125 took part. 25 (20%) of these had cancer related pain, mean score on an 11 point numerical rating scale 6.3 (median 6.0, range 3-10). Average age was 60 years (median 60, range 27-84); 56% were male. LANSS completion time was about five minutes, and the procedure was acceptable to all patients. The pain specialist diagnosed neuropathic pain in 14/25 patients, in 13 of whom the neuropathic pain was part of a mixed pain picture. The LANSS correctly identified 11 of these cases (sensitivity 79%; specificity 100%). The patient-completed section alone had a sensitivity of 86% and a specificity of 91%.

The LANSS is a simple and suitable screening test for neuropathic pain in patients with head and neck cancer related pain, although some modifications might improve it.
Association between Course of Study at University and Cause-Specific Mortality
Authors: McCarron Peter , Okasha Mona , McEwen James , Smith George Davey
Published: November 2017

Although socioeconomic position is clearly related to mortality and one measure of this is length of education, it is not known whether the choice of course at university determines future health. We therefore investigated the association between faculty of study and all-cause and cause-specific mortality in a prospective follow-up of male students who underwent health examinations while attending Glasgow University from 1948 to 1968.

Among the 9887 (84%) alumni traced by means of the NHS Central Register, 8367 (85%) had full data on important potential confounding variables; 939 of these men had died. Physiological variables differed little between students from the various faculties. Medical students were most likely to come from affluent social backgrounds and, after law students, were most likely to be smokers. Compared with former medical students, former arts and law students had excess all-cause and cardiovascular disease mortality, while science and engineering alumni had similar risks. Former medical students had lower lung cancer mortality than other alumni but higher mortality from alcohol-related causes including accidents, suicide and violence.

The lower mortality risks observed among former medical and engineering students may be due to their better employment prospects and healthier lifestyle behaviours, although the high mortality from alcohol-related causes among former medical students underscores the complexity of choice of health behaviour. The findings point to the potential for disease prevention among the large proportion of the population who now have third-level education.
Use of Information Technology in General Practice
Authors: Smith Jason J , Mallard-Smith Rebecca J , Beattie Victoria , Beattie David K
Published: November 2017

The internet and NHS Net are used increasingly in UK general practice. A questionnaire survey conducted in southern England examined these applications. 77 (55%) of 141 practices responded. Of these, 71 were connected to one or other service and 27 offered a practice website. Only a small minority used a website for direct patient booking or access to pathology results. Moreover, among those with a practice website, none paid the necessary attention to data security. The survey revealed some fundamental misunderstandings that may partly account for the slow uptake of these technologies in British general practice.
Troubles with the Foreskin: One Hundred Consecutive Referrals to Paediatric Surgeons
Authors: Huntley J S , Bourne M C , Munro F D , Wilson-Storey D
Published: November 2017

To assess the reasons for and outcomes of referrals concerning the foreskin, 100 consecutive patients seen in paediatric clinics were followed to discharge.

18 referrals were for circumcision on religious grounds. Of the other 82, the main reason for referral was non-retractability or phimosis. At clinic, 24 (29%) of these were deemed normal for age, 31 (38%) were treated with topical steroid (successfully in 25), 9 (11%) were listed for preputioplasty, 7 (9%) were listed for adhesiolysis, 7 (9%) were listed for circumcision, and 4 were listed for other forms of surgery. 6 patients were identified as having balanitis xerotica obliterans (BXO), a condition that had not been suggested on referral.

With the advent of new treatments for foreskin disorders, circumcision is decreasingly necessary. Knowledge of the natural history of the foreskin, and the use of topical steroids, could shift the management of paediatric foreskin problems from the hospital outpatient department to primary care. BXO is not sufficiently recognized as a form of phimosis that requires operation.
Is Preputioplasty Effective and Acceptable?
Authors: Barber N J , Chappell B , Carter P G , Britton J P
Published: November 2017

Foreskin complaints in childhood, if not manageable conservatively, are usually treated by circumcision. A less radical surgical option, when balanitis xerotica obliterans is absent, is preputioplasty. We sent questionnaires to the parents of 23 boys who had had this procedure and 22 replied.

Mean interval since operation was 20 months (range 3-36). The main indications for surgery had been irretractable foreskin in 9, recurrent balanoposthitis in 10 and ballooning on voiding in 3 and the operation had dealt successfully with these in 7, 7, and 3, respectively. In all but one case the parents were satisfied with the cosmetic result. However, in 8 cases (36%) the parents said they would have preferred circumcision and 3 of the boys had been listed for further surgery.

Preputioplasty is a satisfactory alternative to circumcision in selected cases.
Enteral Stenting in 21 Patients with Malignant Gastroduodenal Obstruction
Authors: Tang Tjun , Allison Mike , Irene Dunkley , Roberts Phil , Dickinson Richard
Published: November 2017

Placement of an enteral stent is emerging as an effective alternative to surgery for symptomatic relief in patients with malignant gastric outflow and duodenal obstruction. We report experience in a series of patients who had the Wallstent enteral prosthesis inserted.

21 consecutive patients with inoperable obstruction, median age 75 years, had twenty-three procedures for insertion of the Wallstent under fluoroscopic guidance. Stent implantation was successful in 18 patients (86%), all of whom gained relief from nausea and vomiting. There were no short-term complications. Median survival after the procedure was four months (longest ten months), and no deaths were related to insertion.

The efficacy and lack of complications in this series support use of the endoscopically placed stent for palliative management of malignant upper gastrointestinal obstruction.
The Accuracy of Guestimates
Authors: McLean Iain , Anderson C Mary , White Cath
Published: November 2017

At times a clinician must describe the size of a lesion when measurement presents difficulties. A ‘guestimate’ may then be recorded. We tested the accuracy of forensic clinicians (10 physicians and 1 nurse) in guestimating the sizes of ten test objects, comparing their performance with 13 individuals from other professions. The participants were permitted to handle the objects but not to use a measuring device.

For three of the objects (a balloon, a scratch and a coin) the entire sample of participants significantly overestimated size, by 13-22%. Both participant groups overestimated the size of a scratch, the clinicians being more accurate but not significantly so.

Guestimates should be avoided unless the use of a ruler or tape measure will be against the interests of the client.
Treatment for Newly Diagnosed Hypertension: Patterns of Prescribing and Antihypertensive Effectiveness in the UK
Authors: Walley Tom , Duggan Andy K , Haycox Alan R , Niziol Christie J
Published: November 2017

Improved practice in the management of hypertension depends on an understanding of existing patterns of treatment. To describe the management of newly diagnosed hypertension in British general practice and the effectiveness of current prescribing patterns we conducted a retrospective observational study using data from a computerized general practitioner record database (DIN-LINK).

21 024 patients were first treated for newly diagnosed hypertension between January 1993 and December 1997, and were followed for 4 years. Diuretics or beta-blockers were the most widely prescribed first-line treatments, used in 54% of patients. The mean continuation rate for first-line therapy was 69% at 12 months: the continuation rate was highest for angiotensin converting enzyme inhibitors/angiotensin II receptor antagonists. After 12 months of treatment the mean blood pressure reduction was 19/10 mmHg. Blood pressure targets were met in only 14% of patients. After 48 months of treatment 34% of patients had not improved in band of blood pressure severity. Many patients with severe hypertension at 12 months were still being prescribed only one drug.

The lack of aggression in antihypertensive treatment, indicated by the low number of agents prescribed and the failure to achieve targets, is disappointing. Prescribing patterns for first-line therapy corresponded to guidelines. Continuation rates on first-line therapy were higher than often reported. The choice of drug for additions to or switches from first-line therapy had no clear pattern. Routinely collected computerized data could be used to support clinical governance activities in primary care.
Diagnosis of Abdominal Tuberculosis: The Importance of Laparoscopy
Authors: Rai S , Thomas W M
Published: November 2017

Abdominal tuberculosis (TB) tends to present with non-specific features and can be hard to diagnose. In the University Hospitals of Leicester, which serve a large immigrant population, 36 patients had this diagnosis between 1995 and 2001. We examined their records to identify features, including history, clinical presentation, investigations and diagnostic procedures, that might help with diagnosis of future cases.

32 of the patients were of Asian origin, predominantly from the Indian subcontinent. The most common presenting complaints were abdominal pain and weight loss. On clinical examination the findings were non-specific. Only 2 patients were found to have concurrent pulmonary TB. The most consistent laboratory finding (>90%) was a low haemoglobin with a raised C-reactive protein. The tuberculin test (Mantoux) was positive in only 7 patients (22%), and Ziehl-Neelsen staining of ascitic fluid was negative in all 11 patients in whom it was examined. An ultrasound scan of the abdomen revealed findings consistent with TB in 9/28 patients and a CT scan was helpful in 6/11. Laparoscopy, although usually performed as a last resort, proved the most effective investigation, yielding the diagnosis in 23 (92%) of the 25 patients in whom it was performed.

In patients with the relevant background and clinical history, laparoscopy is the investigation of choice.
Putrid Gums and ‘Dead Men's Cloaths’: James Lind aboard the Salisbury
Authors: Sutton Graham
Published: November 2017

18th century sailors often suffered from scurvy. In 1747 James Lind conducted his classic experiments aboard the Salisbury, in which he cured scurvy with oranges and lemons. The Royal Navy did not introduce citrus rations until 1795. The original ship's papers allow the circumstances of the experiment to be reconstructed. The relevant patrol began in March 1747, and Lind's experiment began after 8 weeks at sea. The muster roll records almost no sickness aboard until the ship returned to Plymouth in June. This is at odds with Lind's account and suggests an anti-sickness official culture, which may have contributed to the neglect of his work.
Smoking Rates in the Staff of a Military Field Hospital before and after Wartime Deployment
Authors: Boos C J , Croft A M
Published: November 2017

In the past, high rates of cigarette smoking have been reported in the British Armed Forces. We conducted an anonymous questionnaire survey in the 623 employees and attached staff of 34 Field Hospital on their sixth week of deployment to Iraq, in the course of Gulf War II. Information was sought on smoking status before and during the deployment, and self-declared reasons for smoking.

556 questionnaires were returned (response rate 89%). The median age of respondents was 33.3 SD 7.9 years (range 18-62) and 61% were male. Before deployment the number of regular smokers was 160 (29%) but it had now risen by 52 to 212 (38%). Of the extra smokers 33 were restarting an old habit but 19 were first-timers. Moreover, those who were regular smokers before deployment increased their daily consumption from a mean of 15 cigarettes to 21. Smoking rates did not differ between clinical and non-clinical staff or between men and women; the rates were lower in officers than in non-officers, and in reservists than in regular Army personnel. The reasons most commonly cited for starting smoking or increasing consumption were boredom, social factors and stress. Few respondents could recall having received smoking-related health education during previous service with the military.

Smoking rates in this medical unit increased substantially during the overseas deployment. There were no data on cigarette consumption after return to ordinary duties, so we cannot say whether these effects are short-term or long-term. However, even the pre-existing rate of 42% in regular army personnel is high enough to demand urgent action by an employer.
Waiting Times for Treatment of Rectal Cancer in North West England
Authors: Duff SE , Wood C , McCredie V , Levine E , Saunders MP , O'Dwyer ST
Published: November 2017

An interim goal of the NHS National Cancer Plan is that, by 2005, patients with cancer should be treated within one month of diagnosis and within two months from urgent general practitioner referral. Preoperative radiotherapy for rectal cancer reduces the risk of local recurrence and may translate into improved patient survival. We conducted a prospective audit of existing waiting times for preoperative radiotherapy experienced by 65 patients with rectal cancer referred to the Christie Cancer Centre, Manchester, UK, between May and November 2002.

The median time between referral from the surgeon to the start of radiotherapy was 40 days (range 11-85). Only 4 patients (6%) received radiotherapy within 28 days of referral by the surgeon. 62 patients (95%) underwent surgery within 14 days of completing radiotherapy.

Delays in the provision of preoperative radiotherapy were primarily due to shortages of radiography staff and equipment. Lack of such infrastructure will prove a major stumbling block to achieving the targets of the NHS Cancer Plan.
The State of Basic Surgical Training in the UK: Ophthalmology as a Case Example
Authors: Watson M P , Boulton M G , Gibson A , Murray P I , Moseley M J , Fielder A R
Published: November 2017

Concern is being expressed about the state of basic surgical training in the context of growing demands to improve service provision in the National Health Service. Taking ophthalmology as a case example, we sent questionnaires to all 466 senior house officers (SHOs) in recognized surgical training posts in England, Wales, Scotland and Northern Ireland. The main outcome measures were intraocular surgery performed in the previous two weeks and since starting as an SHO in ophthalmology; access to protected teaching time or cases on theatre lists; and supervision during surgery. Phakoemulsification, the most common type of cataract surgery, was used as a generic indicator of intraocular procedures. 314 (67%) of the SHOs responded.

Of those working in the hospital in the previous two weeks, 50% had performed at least one component part of a phakoemulsification (phako) operation and 44% had performed at least one full phako operation. The average number of full phako operations done per week was 0.741. 77% reported some protected surgical teaching time over the two weeks and those with protected teaching time reported more full phako operations per week. Of those who had performed at least one surgical procedure in the previous two weeks, 79% had been supervised by a consultant. Of those who had completed two or more years’ training as an SHO, only 42% met the Royal College of Ophthalmologists minimum requirement of 50 complete intraocular operations performed under supervision. Women were less likely than men, and SHOs in district general hospitals were less likely than those in teaching hospitals, to have achieved this target.

As many as half the SHOs in ophthalmology are not receiving an adequate basic surgical training. If this continues it may prove difficult to train sufficient new surgeons to an acceptable standard to meet the increasing demands of an ageing population. This is not an issue for ophthalmology alone but for all surgical specialties.
Clinical Management of Children and Young Adults with Heterozygous Familial Hypercholesterolaemia in the UK
Authors: Greene Owen , Durrington Paul
Published: November 2017

Life expectancy in familial hypercholesterolaemia (FH) has been greatly improved by the advent of statin therapy. In the UK, however, these agents are not licensed for use in children. We approached 169 physicians responsible for lipid clinics for information on their practice in young patients, and valid responses were received from 54%.

A typical lipid clinic has only 3.5 patients aged under 16 with FH. In boys aged 10-15 years 65% of physicians were prepared to treat with bile acid sequestrants but only 23% with statins. There was greater reluctance to treat in girls of the same age, corresponding figures being 52% and 12%.

Despite the efficacy of statins in reducing low-density-lipoprotein cholesterol, these agents are little used in children with FH. Their safety and clinical efficacy should be assessed by a randomized double-blind trial.
Prehospital Thrombolysis—Calculated Health Benefit for Catchment Population of One Hospital
Authors: Kroese Mark , Kanka David , Weissberg Peter , Arch Barbara , Scott John
Published: November 2017

The health benefit of thrombolysis in acute myocardial infarction is greatest when patients are treated soon after onset of symptoms. One approach to reducing treatment delay is to give thrombolysis before the patient reaches hospital. When an ambulance trust proposed a prehospital thrombolysis service, local commissioners requested an estimate of its possible health impact. Clinical audit and ambulance trust data were obtained for 165 patients who received thrombolysis for acute myocardial infarction in the coronary care unit of a local hospital in one year. This information was then used to estimate the health impact of prehospital thrombolysis in the local population in a mathematical model derived from the results of trials comparing prehospital and hospital thrombolysis.

The best predicted local health benefit from the proposed prehospital thrombolysis service is that, if 45 minutes can be cut off the call-to-needle time, 61 cases of acute myocardial infarction need to be treated to save one additional life at 35 days.

By use of published research data, the health benefits of prehospital thrombolysis can be estimated for a local population. Variables in the treatment population and ambulance service will influence the size of the health benefit that can be achieved.
Hospital Bathrooms and Showers: A Continuing Saga of Inadequacy
Authors: Monro Andy , Mulley Graham P
Published: November 2017

Previous surveys of UK hospitals have highlighted many deficiencies in the standards of hospital inpatient washing and bathing facilities–-especially inadequate access for wheelchair users, insufficient bathing equipment, and unsatisfactory cleanliness and privacy. We conducted a qualitative survey in three hospitals in the North of England to see whether these facilities have improved.

There have been some improvements, particularly in the provision of bath hoists, adapted taps, alarm call systems, shower seats and wheelchair access to bathrooms. But many basic problems remain–-absent locks and signs, inadequate heating, poor standards of privacy, insufficient bath aids, wet floors, and the inappropriate use of bathrooms as store rooms.

The overall condition of hospital bathrooms and showers remains unsatisfactory. Too many hospital bathrooms are austere, cold, smelly and poorly maintained.
Predictors for Falls among Hospital Inpatients with Impaired Mobility
Authors: Vassallo Michael , Vignaraja Raj , Sharma Jagdish C , Briggs Roger , Allen Stephen C
Published: November 2017

Gait and balance disturbances have been shown to predispose to falls in hospital. We aimed to investigate the patient characteristics associated with an unsafe gait and to determine what features predispose to falling in this group of hospital inpatients. In a prospective open observational study we studied 825 patients admitted for rehabilitation following acute medical illness or a surgical procedure. The patient's gait was assessed with the ‘get up and go’ test and classified into one of four categories—normal; abnormal but safe with or without mobility aids; unsafe; or unable.

72.6% of patients were assessed as having an unsafe gait. The factors independently associated with an unsafe gait were confusion, abnormal lower limbs, hearing defects and the use of tranquillizers. Patients with an unsafe gait who fell were more likely than the non-fallers within the group to have had falls in the past (85.3% versus 73.8%) and to be confused (66.2% versus 34.1%). Patients with both these characteristics had a 37.5% chance of falling compared with 15.4% in patients with one and 11.2% in patients with none of these characteristics.

The presence of confusion and a history of falls identifies those patients who are at greatest risk of falls. Such patients might be the focus of special efforts at falls prevention.
Needle-Stick Injuries in the National Health Service: A Culture of Silence
Authors: Elmiyeh B , Whitaker I S , James M J , Chahal C A A , Galea A , Alshafi K
Published: November 2017

Injury by contaminated sharp instruments and needles constitutes a major occupational hazard for healthcare workers. In a confidential survey at a district general hospital, 300 healthcare professionals were asked about their personal experience of needle-stick injury and their attitudes to reporting.

279 individuals responded, of whom 38% had experienced at least one needle-stick (mean 1.8) in the past year and 74% had sustained such an injury during their careers (mean 3.0). Although 80% of respondents were aware that such incidents should be notified, only 51% of those affected had reported all needle-stick injuries. Doctors were less likely to report than nurses, despite a higher liability to injury.

This survey adds to evidence of a culture of silence pertaining to needle-stick injuries. The consequent risks to health, and the ethical and financial implications, remain uncertain.
Keep in a Cool Place: Exposure of Medicines to High Temperatures in General Practice during a British Heatwave
Authors: Crichton Brian
Published: November 2017

Exposure of medicines to high temperatures in storage or in transit could reduce their efficacy, and most licences specify storage at 25°C or less. To assess whether this criterion was being met, maximum temperatures in a general practice drug cupboard and in drug bags placed in car boots were recorded for two weeks during a British heatwave (average peak daily ambient temperature 26°C). Also, ten neighbouring dispensing pharmacies were questioned about their temperature-control policies.

On every day of the study, maximum temperatures in the drug cupboard and in the car boots exceeded 25°C. Mean daily maxima (range) were: drug cupboard 30.7 (27.5-37.0); silver car 37.5 (32.0-43.5); dark blue car 41.8 (35.0-49.5). None of the local dispensaries had air conditioning or kept a temperature log.

In the course of a British summer, medicines were exposed to temperatures that might in theory have reduced their efficacy. This aspect of quality control deserves more attention.
Cognitive Dysfunction in Homeless Adults: A Systematic Review
Authors: Spence Sean , Stevens Richard , Parks Randolph
Published: November 2017

Homelessness is associated with multiple adversities that might impact upon brain function. We performed a review of published work to assess evidence of cognitive dysfunction among adults who are homeless. Despite liberal inclusion criteria only seventeen publications were identified, these describing eighteen samples mainly from the USA. Although the total number of individuals studied is small (about 3300) and the samples are heterogeneous, most studies indicate a considerable burden of cognitive dysfunction among homeless people. Such dysfunction might be expected to impact upon their ability to reintegrate into society, thereby undermining policies of inclusiveness. In clinical practice, assessment of homeless adults should include their cognitive state.
Channelling the Emperor: What Really Killed Napoleon?
Authors: Mari Francesco , Bertol Elisabetta , Fineschi Vittorio , Karch Steven B
Published: November 2017

Arsenic was present in Napoleon's hair before he arrived on Saint Helena and the findings at necropsy are consistent only with the diagnosis of ulcerating, regionally invasive, gastric carcinoma. The question of whether Napoleon died of, or merely with, arsenic poisoning is illuminated by developments in the treatment of promyelocytic leukaemia. Arsenic trioxide induces remission in many, but treatment can be complicated by QT prolongation, torsades de pointes and sudden death. At clinically relevant concentrations, arsenic blocks both IKr and Iks channels and, at the same time, activates IK-ATP channels. The balance of these forces is easily disrupted, and QT prolongation is worsened by hypokalaemia. Napoleon was chronically treated with tartar emetic for gastrointestinal symptoms, and the day before he died he was given a huge dose of calomel (mercurous chloride) as a purgative. Both treatments would have caused potassium wastage. In addition, the Emperor was being treated with a decoction containing ‘bark’—presumably ‘Jesuit's bark’. The quinine in Jesuit's bark is another cause of QT prolongation. It is likely that the immediate cause of the Emperor's death was torsades de pointes, brought on by chronic exposure to arsenic and a medication error.
Mental Capacity, Legal Competence and Consent to Treatment
Authors: Buchanan Alec
Published: November 2017

Deciding whether someone is legally competent to make decisions regarding their own treatment requires an assessment of their mental capacity. The assessed capacity required for legal competence increases with the seriousness of what is at stake. The usual explanation is that patient autonomy is being balanced against best interests. An alternative explanation, that we require greater room for error when the consequences are serious, implies a change to clinical practice and in the evidence doctors offer in court.
Assessment of Patient Pain at Colonoscopy: Are Nurses Better than Endoscopists?
Authors: Ramakrishnan S , Yiannakou J Y , Ellis W R , Bain I
Published: November 2017

The pain that patients recollect having experienced at colonoscopy is likely to influence uptake of the procedure. We used visual analogue scales to assess recollected pain shortly before discharge, and compared these scores with assessments by the endoscopist and the attending nurse.

Data were complete for 426 procedures (90%). The mean perceived pain score for patients was 3.2, for endoscopists 2.8 and for nurses 3.1. On multivariate analysis, the endoscopists’ assessments of pain had little predictive value over and above those of nurses, whereas nurses’ assessments remained significant when adjusted for endoscopists’ assessments.

Nurses were more accurate than endoscopists in gauging the pain of colonoscopy. This may be because endoscopists are focused on the video monitor while nurses are focused on the patient. More active use of nurses’ assessments might help keep pain to a minimum.