Showing papers by "Royal Devon and Exeter Hospital published in 1991"

Haemorrhagic disease of the newborn in the British Isles: two year prospective study.

Abstract: OBJECTIVE--To determine the incidence of haemorrhagic disease of the newborn in the British Isles, study risk factors, and examine the effect of vitamin K prophylaxis. DESIGN--Prospective survey of all possible cases of haemorrhagic disease of the newborn as reported by consultant paediatricians using the monthly notification cards of the British Paediatric Surveillance Unit and a follow up questionnaire for each case to validate the diagnosis and accrue further data. SETTING--Britain (England, Scotland, and Wales) and Ireland (Northern Ireland and the Irish Republic) during December 1987 to March 1990. PATIENTS--27 infants classified as having confirmed (n = 25) or probable (n = 2) haemorrhagic disease of the newborn. RESULTS--24 of the 27 infants were solely breast fed. 10 suffered intracranial haemorrhage; two of these died and there was clinical concern about the remainder. 20 infants had received no vitamin K prophylaxis, and seven had received oral prophylaxis. Relative risk ratios for these groups compared with babies who had received intramuscular vitamin K were 81:1 and 13:1 respectively. Six infants had hepatitis (alpha 1 antitrypsin deficiency in four), unsuspected until presentation with haemorrhagic disease of the newborn, of whom four had received oral prophylaxis. One other baby had prolonged jaundice. One mother had taken phenytoin during pregnancy. CONCLUSIONS--All newborn infants should receive vitamin K prophylaxis. Intramuscular vitamin K is more effective than oral prophylactic regimens currently used in the British Isles.

Screening for treatable diabetic retinopathy: a comparison of different methods.

Abstract: The results of the screening of 3318 diabetic patients for sight-threatening diabetic retinopathy in three UK centres are reported. The aims of the study were to determine the extent of diabetic retinopathy in the screened population and to assess the relative effectiveness of different screening methods in appropriately referring cases from a diabetic population, in a context very close to a routine clinical service. Patients were assessed by ophthalmoscopic examination by an ophthalmological clinical assistant. The clinical assistants' referral grades formed the reference standard against which to assess the effectiveness of other screening methods including ophthalmoscopy by primary screeners who were general practitioners (GPs), ophthalmic opticians and hospital physicians, and the assessment by consultant ophthalmologists of non-mydriatic Polaroid fundus photography. The performance of primary screeners based on ophthalmoscopy ranged from a sensitivity of 0.41, with a specificity of 0.89, for one of the GP groups, to a sensitivity of 0.67, with a specificity of 0.96, for the hospital physician group. The performance of the non-mydriatic camera ranged from a sensitivity of 0.35, with a specificity of 0.95, to a sensitivity of 0.67, with a specificity of 0.98.

Salivary duct adenocarcinoma

Abstract: Six cases of salivary duct adenocarcinoma are presented. All had a history of a rapidly enlarging mass in the parotid gland with involvement of the facial nerve. The histopathological appearance was distinctive, each case showing an invasive tumour resembling ductal carcinoma of the breast, often with areas of comedo necrosis. Five patients died within 26 months, and the one long-term survivor (68 months) has widespread metastatic disease. These findings are similar to cases which have previously been described, but the tumour has not been widely reported, particularly in Britain. We feel that salivary duct adenocarcinoma is a distinct clinicopathological entity and, as its histological appearance is usually unmistakable, we believe it deserves wider recognition.

Polymorphous low-grade adenocarcinoma of the salivary glands: a clinicopathological comparison with adenoid cystic carcinoma.

Abstract: Six cases of polymorphous low-grade adenocarcinoma (terminal duct adenocarcinoma) of the minor salivary glands are presented. In all but one there was a history of a painless intra-oral mass of fairly long duration. The histopathological appearances were characterized by cytological uniformity in a variety of morphological patterns, including tubular, solid, fascicular and cribriform areas. At a cellular level, the tumours possessed regular, often vesicular nuclei and generally eosinophilic cytoplasm. Five of the patients are still alive, although one had recurrent disease 16 years after her original operation: none died of their tumour. These findings are compared with those of six salivary adenoid cystic carcinomas, a neoplasm with many similar histological features, but with a much worse prognosis. The microscopic differences were mainly cytological and, to a lesser extent, morphological. The immunohistochemical reactions of the two tumours were not sufficiently dissimilar to be of practical value. Polymorphous low-grade adenocarcinoma has only rarely been reported in Britain, but we believe it deserves wider recognition as a distinct clinicopathological entity and, in particular, separation from adenoid cystic carcinoma.

A relative cost-effectiveness analysis of different methods of screening for diabetic retinopathy.

Abstract: The relative cost and cost-effectiveness of different methods of screening diabetic patients for sight-threatening retinopathy are assessed. The resource costs per screening visit, both to the health service and to patients, of ophthalmoscopic examination by primary screeners including general practitioners, hospital physicians, and ophthalmic opticians are estimated together with those of a similar screening test by ophthalmological clinical assistants. The total resource cost per screen of screening using non-mydriatic photography is also estimated. Using estimates of sensitivity, specificity, and prevalence generated in the screening of 3318 diabetic patients in three UK centres, the relative cost-effectiveness of screening methods is estimated in terms of their cost per true positive case detected. On the assumption that a patient makes a special trip for eye screening, the cost per true positive case detected for primary screeners ranges from 633 pounds for a GP-screened group in one centre to 1079 pounds for another GP-screened group in a second centre; the cost per true positive case detected of photography ranges from 497 pounds for a camera that is taken to general practices in one centre to 1546 pounds for a hospital-based camera. Relative cost-effectiveness changes if, in some contexts, the screening can take place without requiring an additional patient visit, and is strongly related to the relative sensitivity of the screening methods and to the prior probability (prevalence or incidence) of retinopathy in the diabetic population.

Flexible bronchoscopy via the laryngeal mask: a new technique.

Abstract: Malignant tracheal tumours often cause airway obstruction and this may be aggravated by vocal cord paralysis due to invasion of the recurrent laryngeal nerve. Conventional endoscopic techniques performed under general anaesthesia do not give a simultaneous view of vocal cord function and the distal airways. The technique of bronchoscopy via the laryngeal mask allowed full assessment of the cause of stridor in a patient with a malignant tracheal tumour that was causing airways obstruction and vocal cord paralysis.

Voltammetric behaviour of morphine at a glassy carbon electrode and its determination in human serum by liquid chromatography with electrochemical detection under basic conditions

Abstract: The electrochemical oxidation of morphine was studied at pH values of between 7.00 and 12.00 by cyclic voltammetry and chronoamperometry at a planar glassy carbon electrode. The peak potential was dependent on pH over the range 7.00–9.75; it was independent of pH above the latter value, indicating a pKa value of 9.75. The peak current was found to be independent of pH, ionic strength of phosphate buffer (0.02–0.1 mol dm–3) and percentage of acetonitrile (0–40% v/v). The oxidation was found to occur in three steps; these are considered to result from a one-electron oxidation of the phenoxide group, followed by a one-electron loss from the oxidation product, pseudomorphine, and finally a two-electron loss from a tertiary amine group. A simple method of analysis by high-performance liquid chromatography was developed which employed a column packed with a reversed-phase, pH-stable, octadecylsilane-modified silica. Separation was achieved with a mobile phase containing 20% v/v acetonitrile in 0.05 mol dm–3 phosphate buffer, pH 11.0. Amperometric detection was carried out with an applied potential of +0.45 V versus Ag–AgCl. The detection limit was 1.24 × 10–13 mol of morphine injected. The detector gave a linear response from 1.2 × 10–12 to 4.0 × 10–10 mol of morphine injected. The extraction method required 0.5 ml of serum, and no solvent evaporation was needed. The recovery of morphine was 80.9%. The method gave a linear response to at least 15.0 × 10–7 mol dm–3. The relative standard deviation was 4.95% at 0.75 × 10–7 mol dm–3 and 3.73% at 3.0 × 10–7 mol dm–3.

Injection Sclerotherapy for Varicose Veins — A Comparison of Materials for Applying Local Compression:

Abstract: One-hundred-and-two patients undergoing sclerotherapy for varicose veins were randomized for the use of adhesive Molefoam (Scholl®) or traditional Sorbo pads (STD®) under the compression bandage. A...

Paranoid features in the elderly with dementia

Abstract: Ninety-two consecutive psychogeriatric day hospital referrals were assessed using the Camdex schedule. Sixty-six of the patients had a first-degree relative visiting more often than once per week and the data from the patient and informant sections of these schedules were analysed to assess the prevalence of paranoid features. Overall, 36.4% fulfilled the modified criteria for paranoid disorder. Significantly more patients with Alzheimer's disease fulfulled these criteria than did those with vascular dementia, and paranoid features were most common in patients with dementia of moderate severity.

Discipline strategies and parental perceptions of preschool children with asthma.

Abstract: Parents of 37 children with asthma (aged between three and five years) and of 37 healthy controls were interviewed about their involvement in everyday care, discipline practices, perceptions of their child and situations which were particularly stressful. There was little correlation between mothers' and fathers' preferences for different discipline practices. There was, however, greater agreement in their perceptions. Parents of children with asthma did not differ from those of healthy controls in discipline practices. However, children with asthma were perceived to be generally less healthy. Parents of those with asthma also reported a greater number of everyday situations to be stressful. These data do not support traditional assumptions that parents of children with asthma are more permissive or overindulgent. At least in this preschool sample, there was only limited indication of adverse effects of chronic disease on parenting practices.

A comparison of apache ii and a clinical sickness score : a study of 97 consecutive admissions to a district general hospital intensive care unit

Abstract: The aim of this study was to compare the predictive power of a simple illness severity score (Clinical Sickness Score) to that of APACHE II in a District General Hospital intensive therapy unit. A prospective comparison was carried out on 97 consecutive adult patients whose severity of illness was scored one hour after admission using both the Clinical Sickness Score and APACHE II. Intensive Therapy Unit and hospital outcomes were recorded for each patient. The Clinical Sickness Score and APACHE II identified survivors and nonsurvivors with similar power (p less than 0.001). There was a highly significant correlation between the two scoring systems for hospital survivors and nonsurvivors together (r = 0.5418, r2 = 0.28, p = less than 0.0001) and for hospital survivors alone (r = 0.6102, r2 = 0.37, p = 0.0001). Correlation for hospital nonsurvivors was not significant (r = 0.1629, r2 = 0.027, p = 0.3134). The positive predictive values of APACHE II were between 5% and 10% more sensitive than the Clinical Sickness Score for hospital outcome. Admission Clinical Sickness Score and APACHE II scores had similar predictive power in this study.

Juvenile spring eruption of the ears in four brothers: associated with polymorphic light eruption and hydroea vacciniforme in one.

Abstract: area in early 1982 showed the histological appearances of mycosis fungoides. In September 1982, the lesions were noted to be increasingly indurated and he subsequently underwent a course of PUVA treatment lasting 11 months. He remained clear for 6 months upon cessation of PUVA until January 1984, when there was a gradual recurrence of lesions, PUVA treatment was recommenced in September 1984 for a period of 3 months and following this he remained stable with minimal skin lesions for several years. There was subsequently a gradual worsening of his skin lesions, and a further course of PUVA was commenced in April 1989. In January 1990 he developed erythema with small scattered superficial pustular lesions on the legs and face. The eruption was most marked in the 24 h following PUVA treatment. Repeated skin swabs for bacteriology were negative, A biopsy of the pustular eruption on the right leg revealed subcorneal pustules with parakeratosis that was most marked over the pustules. The pustules predominantly consisted of neutrophils with an occasional eosinophil. Mild spongiosis was observed just deep to the pustules but no spongiotic vesicles were seen. There was an extensive polymorphonuclear cell infiltrate with nuclear fragmentation and some red cell extravasation in the dermis extending beyond the areas of pustulation. There was no evidence of vessel wall injury or follicular inflammation. The eruption persisted for 4 weeks and finally resolved when PUVA was discontinued. A number of adverse cutaneous reactions have been described during PUVA therapy^ including acneiform eruptions that have had pustular lesions at typical acne sites,''* The clinical and histological appearances of the eruption in our patient indicate a diagnosis of toxic pustuloderma. This eruption has not previously been described as a complication of PUVA, It has been suggested that toxic pustuloderma is a variant of severe toxic erythema characterized by a generalized erythroderma with sterile miliary pustulation,' often associated with fever and eosinophila. Our patient's eruption could be interpreted as a PUVA-induced toxic erythema in' which the accompanying infiammatory response was so intense that sterile pustulation developed. We conclude that PUVA therapy should be added to the list of causes of toxic pustuloderma.

The construction of biochemical reference ranges and the identification of possible adverse drug reactions in the elderly.

Abstract: In the assessment of adverse drug reactions (ADRs) it is important to establish what is a normal range of values for a given biochemical measurement. Furthermore, such ranges need to be specific to the study population, for example, the elderly. A mixture of Gaussian distributions has been used in the construction of the reference ranges with maximum likelihood used to obtain estimates of the unknown parameters. With this approach, well-defined reference ranges have been established. Brief details are given of the numbers of ADRs identified in the study population using these ranges.

Cyclical hypothermia: successful treatment with ephedrine.

Abstract: pulmonary embolism in 30%3. Mesenteric and portal vein thrombosis which both occurred in this case are less common'':\". It is well recognized that there is an association between tuberous sclerosis and retroperitoneal angioleiomyoma. There does not appear to be an established link between tuberous sclerosis and protein C deficiency. The former is linked to markers on chromosome 9, whereas the gene for protein C has been isolated and assigned to chromosome 2s. The clinical response chosen for the combination of bleeding oesophages varices and a hypercoagulable state was to aim to obliterate the varices by injection sclerotherapy and then to maintain anticoagulation with warfarin. The use of danazol as an interim measure until anticoagulation could be safely undertaken was based on the evidence that anabolic steroids increase protein C levels\". However, this treatment may not offer effective protection against thrombosis as illustrated by the development of further thrombotic problems in our case.

Ethical and Practical Problems of Setting Up a System of Elective Ventilation

Abstract: The Exeter Protocol of elective ventilation for the provision of organs for transplantation has been in operation for 2 years. Here we discuss the ethical and practical considerations met in devising and running the protocol.

What happens to patients with non-vascular leg pain?

Abstract: for 15 months and had a relatively low antibody titre, she may have had a subclinical parasitaemia with a chloroquine resistant strain (IC50 223 nmol/l). Although the organs were flushed out before transplantation, schizonts may have adhered to the vascular endothelium and multiplied when flushed with the recipient's blood. The lack of knowledge about the donor's origin combined with the many other possible causes of fever in the organ recipient led to a late diagnosis. A blood film is simple and cheap to perform and may be life saving. We therefore re-emphasise the need to screen all febrile patients who have recently had a transplant operation (or transfusion) for malaria. Pretransplantation evaluation of donors, especially a detailed travel history, is important but often difficult. An asymptomatic carrier from an area endemic for malaria may, however, be a high risk donor. We recommend systematic screening of donors, even after transplantation. A positive finding on malaria testing before transplantation need not prevent the transplantation but should protect both patients and clinicians against the hazards of diagnostic delay.