Showing papers in "Journal of the Royal Society of Medicine in 2001"

Exploring the causes of adverse events in NHS hospital practice.

Abstract: In a previous paper we reported that 10.8% of patients admitted to two large hospitals in Greater London experienced one or more adverse events, of which half were deemed preventable. Here we examine the underlying causes of errors in clinical practice. Rather than identifying specific errors made by individuals, we have looked at possible faults in the organization of care. Adverse events were grouped according to stages in the care process: diagnosis, preoperative assessment and care, operative or invasive procedure (including anaesthesia), ward management, use of drugs and intravenous fluids and discharge from hospital. Less than 20% of preventable adverse events were directly related to surgical operations or invasive procedures and less than 10% to misdiagnoses. 53% of preventable adverse events occurred in general ward care (including initial assessment and the use of drugs and intravenous fluids) and 18% in care at the time of discharge. Probable contributory factors in these errors included dependence on diagnoses made by inexperienced clinicians, poor records, poor communication between professional carers, inadequate input by consultants into day-to-day care, and lack of detailed assessment of patients before discharge.

The Mozart Effect

Abstract: In 1993 Rauscher et al.1 made the surprising claim that, after listening to Mozart's sonata for two pianos (K448) for 10 minutes, normal subjects showed significantly better spatial reasoning skills than after periods of listening to relaxation instructions designed to lower blood pressure or silence. The mean spatial IQ scores were 8 and 9 points higher after listening to the music than in the other two conditions. The enhancing effect did not extend beyond 10-15 minutes. These results proved controversial. Some investigators were unable to reproduce the findings2,3,4 but others confirmed that listening to Mozart's sonata K448 produced a small increase in spatial-temporal performance, as measured by various tests derived from the Stanford—Binet scale such as paper-cutting and folding procedures5,6,7 or pencil-and-paper maze tasks8. However, Rauscher has stressed that the Mozart effect is limited to spatial temporal reasoning and that there is no enhancement of general intelligence; some of the negative results, she thinks, may have been due to inappropriate test procedures9. So, does the Mozart effect exist? The generality of the original positive findings has been criticized on the grounds that any Mozart effect is due to `enjoyment arousal' occasioned by this particular music and would not take place in the absence of its appreciation. This interpretation is countered by animal experiments in which separate groups of rats were exposed, in utero followed by a postpartum period of 60 days, to Mozart's piano sonata K448, to minimalist music by the composer Philip Glass, to white noise or to silence and then tested for their ability to negotiate a maze. The Mozart group completed the maze test significantly more quickly and with fewer errors (P <0.01) than the other three groups; thus, enjoyment and musical appreciation is unlikely to have been the basis of the improvement10.

Carbon monoxide poisoning.

Abstract: The deadly effect of carbon monoxide was known as long ago as Greek and Roman times, when the gas was used for executions1. In 1857 Claude Bernard postulated that its noxious effect was caused by reversible displacement of oxygen from haemoglobin to form carboxyhaemoglobin2. In 1926 it became apparent that hypoxia was caused not only by deficient oxygen transport but also by poor tissue uptake. Warberg used yeast cultures to show that cellular uptake of oxygen was inhibited by exposure to a large amount of carbon monoxide3. Carbon monoxide is known as the silent killer since it has no colour or smell. Each year in Britain about 50 people die and 200 are severely injured by carbon monoxide poisoning4. Some poisonings are caused by self-harm but most are accidental5. It is the commonest cause of accidental poisoning and, according to one estimate, as many as 25000 people in the UK have symptoms due to faulty gas appliances4. In the 1960s and 1970s the conversion from coal gas to carbon-monoxide-free natural gas caused a dramatic reduction in poisoning6. In this review I discuss modern approaches to management and prevention.

Disorders of Hemoglobin: Genetics, Pathophysiology, and Clinical Management

Abstract: The disciplines of molecular biology and haematology have been closely intertwined. Many of the initial insights into the general principles of protein structure and function were obtained during the course of work on the haemoglobin molecule performed by Perutz, Pauling and others. The subsequent realization that just a single aminoacid substitution in the β-chain of haemoglobin is responsible for sickle-cell disease, with its wide range of clinical manifestations, laid a basis for the revolution in understanding of human disease at the molecular level. Since then, research work on the organization and regulation of expression of the globin genes has continued to lead the way in providing understanding of wider principles of eukaryotic gene expression and its control. Disorders of Hemoglobin provides a comprehensive review of both the scientific and the clinical aspects of human erythropoiesis and its disorders. It offers a collection of well written chapters by leading international investigators, many of whom are able to refer to the contribution their own research work has made to the field. The chapters are grouped in eight sections covering the basic science of haemoglobin and red-cell physiology and the related clinical disorders—the thalassaemias, sickle-cell disease and other haemoglobinopathies. The chapters are detailed and succeed in providing state-of-the-art summaries of their topic area. All are extensively referenced and enable the reader to appreciate which original scientific papers have led to current models of thought. Furthermore, especially in the first basic science section, many of the chapters include detail of the history of the understanding of their topic areas, illustrating well the development of thinking over time on particular aspects of the field. A particular highlight is the chapter by Max Perutz on the molecular structure and function of haemoglobin. The sections focusing on the thalassaemias, sickle-cell disease, other sickle haemoglobinopathies and the rarer disorders of haemoglobin function and stability are again comprehensive, detailed and well written. These diseases are discussed very much from a scientific angle and the chapters emphasize molecular pathophysiology, together with physical chemistry and rheology where appropriate. The chapters on clinical management are strong and there is generally clear reference to the evidence base provided by experimental and clinical trial data. Of particular interest are the chapters summarizing the extensive role of malaria in defining the epidemiology of human red-cell disorders and the chapters updating the current thinking on treatment strategies, including iron chelation, hydroxyurea therapy, bone marrow transplantation and gene therapy. In summary, this is a fine and accessible text that can be recommended for students, scientists and clinicians who seek detailed reviews of red-cell disorders and their clinical management. For MRCPath haematology candidates who are daunted by the length of the whole book I would recommend selective reading of the chapters on clinical management (sections 2-4) and laboratory diagnosis (section 6). These chapters are as good as I have found anywhere. This text is not well suited to those preparing for MB or MRCP examinations, who can gain the information they require from much shorter works.

The evolution of palliative care.

Abstract: The development by the second half of the twentieth century of new technologies and effective specific treatments for disease still left much suffering unaddressed. As Professor Patrick Wall wrote in 1986, ‘Symptoms were placed on one side and therapy directed at [them] was denigrated’1. In the same vein, when Aneurin Bevan introduced the National Health Service Bill to Parliament, he stated that he would ‘rather be kept alive in the efficient if cold altruism of a large hospital than expire in a gush of sympathy in a small one’2. But what if no cure was possible and the end of life was inevitable? Referring particularly to the hospice movement, Wall added that ‘The old methods of care and caring had to be rediscovered and the best of modern medicine had to be turned to the task of new study and therapy specifically directed at pain’. Care, matched with an increasingly sound evidence base, was by then underpinned by the concept of ‘total pain’—defined in 1964 as including not only physical symptoms but also mental distress and social or spiritual problems3. This approach met ready audiences among nursing and medical students during lectures or in articles, as well as social workers and more gradually among senior members of the medical profession.

Quality of Life: Impact of Chronic Illness on the Partner:

Abstract: Patient quality of life is an increasingly important outcome measure in medicine and healthcare. It is now widely used in clinical trials and in patient management for assessing morbidity and the impact of treatment1. In the past, quality of life studies focused almost exclusively on changes in the quality of life of patients, but increasing attention is now being paid to the impact of chronic disease on carers. The ageing of the population and changes in medical practice resulting in shorter inpatient hospital stay and longer survival have substantially increased the burdens on carers, most of whom are partners2. In this paper, we examine research on partner quality of life and highlight some of the methodological challenges and the clinical implications. The background to this overview is collaborative research conducted in the Department of Urology in Taunton and the Department of Psychology at the Royal College of Surgeons in Ireland3,4,5,6. Further references were obtained by searching various databases (PubMed, CancerLit, PsycInfo, EMBASE and British Nursing Index) with the keywords ‘quality of life, burden, impact, partners, caregivers and carers’.

Neurological complications of cervical spine manipulation.

Abstract: To obtain preliminary data on neurological complications of spinal manipulation in the UK all members of the Association of British Neurologists were asked to report cases referred to them of neurological complications occurring within 24 hours of cervical spine manipulation over a 12-month period. The response rate was 74%. 24 respondents reported at least one case each, contributing to a total of about 35 cases. These included 7 cases of stroke in brainstem territory (4 with confirmation of vertebral artery dissection), 2 cases of stroke in carotid territory and 1 case of acute subdural haematoma. There were 3 cases of myelopathy and 3 of cervical radiculopathy. Concern about neurological complications following cervical spine manipulation appears to be justified. A large long-term prospective study is required to determine the scale of the hazard.

The history of cryosurgery.

Abstract: The controlled destruction of tissue by freezing is today widely practised in medicine. Terms for it include cryotherapy, cryocautery, cryocongelation and cryogenic surgery, but cryosurgery (literally, cold handiwork) seems most appropriate. Cryosurgery is a cheap, easy, and safe treatment suitable for both hospital and office based practice. Its major advantage is excellent cosmetic results with minimal scarring. The benefits of cold have been appreciated for many thousands of years. The ancient Egyptians, and later Hippocrates, were aware of the analgesic and anti-inflammatory properties of cold. Over the past 200 years cold treatment has evolved from generalized application such as hydrotherapy (Figure 1) to specific, focal destruction of tissue—today's cryosurgery. Figure 1 A man self-administering hydrotherapy. Wellcome Library, London

Barriers and good practice in transition from paediatric to adult care.

Abstract: Arranging efficient and caring transfer for adolescents from paediatric to adult care is one of the great challenges facing paediatrics-and indeed the health services-in the coming century\". Many once 'paediatric' diseases, such as cystic fibrosis and metabolic conditions, are now increasingly being met by adult doctors, sometimes with poor results-. These conditions must now be thought of as diseases that begin in childhood but continue into adult life. Some ask what the fuss is all about? Transferring patients has been around as long as we have had paediatricians. But the simple transfer has been challenged in the last decade by the notion of 'transition', emphasizing the need for the change to adult care to be a gUided educational and therapeutic process rather than an administrative event.'. Indeed, this health transition is but one part of the wider transition from dependent child to independent adult. The American Society for Adolescent Medicine define good transition as 'the purposeful, planned movement of adolescents and young adults with chronic physical and medical conditions from child-centred to adult-oriented health care systems'\". Despite the well-developed services in some parts of America and Australia, little attention has been paid to the concept of transition in Britain. The House of Commons Select Committee on Health Fifth Report concluded in 1997 that 'Services for adolescents should be given greater focus and priority. The transfer of young people, particularly those with special health needs, from child to adult services requires specific attention' 5. It is telling that none of the medical Royal Colleges in Britain have developed policies on transition. Interest in transition has been driven by the increased survival of children with chronic illness into adolescence and adult life. The burden of chronic illness in adolescence is increasing in all developed countries as large numbers of chronically ill children survive into the second and third decades6 -s. The prevalence of cystic fibrosis in those over 15 years of age in the UK more than doubled between 1977 and 19859, and currently over 85% of children with chronic illness survive to adult life\".

Reducing Risk by Improving Standards of Intrapartum Fetal Care

Abstract: Confidential Enquiries into Stillbirths and Deaths in Infancy (CESDI) have pointed to a high frequency of suboptimal intrapartum fetal care of a kind that, in the event of an adverse outcome, is hard to defend in court. In an effort to minimize liability, various strategies were applied in a district hospital labour ward—guidelines, cyclical audit, monthly feedback meetings and training sessions in cardiotocography (CTG). The effects of these interventions on quality of care was assessed by use of the CESDI system in all babies born with an Apgar score of 4 or less at 1 min and/or 7 or less at 5 min. 540 babies (4.3%) had low Apgar scores, and neither the percentage nor gestational age differed significantly between audit periods. In the baseline audit, care was judged suboptimal (grade II/III) in 14 (74%) of 19 cases, and in the next four periods it was 23%, 27%, 27% and 32%. In the latest audit period, after further educational interventions, it was 9%. Many of the failures to recognize or act on abnormal events were related to CTG interpretation. After the interventions there was a significant increase in cord blood pH measurement. There were no differences between audit periods in the proportion of babies with cord pH <7.2. These results indicate that substantial improvements in quality of intrapartum care can be achieved by a programme of clinical risk management.

Students sitting medical finals--ready to be house officers?

Abstract: An initial survey of students approaching qualification and the preregistration house officer year revealed anxiety about competence in several important clinical skills. A questionnaire study was then undertaken to assess, first, the extent to which students had attained the skills required for the preregistration year and, second, the amount of training in these skills provided during the preregistration year. 122 medical students taking their final examinations were asked about training and practice in eight core clinical skills, and 84 graduates from the same school, approaching the end of their preregistration year, were asked about postgraduate training in these skills. The response rate of each group was 100%. Of the eight skills studied, most had been performed few times by the students at qualification. Less than half the current preregistration house officers could recall training being given in any of the skills studied. There were no significant differences in house-officer training between teaching hospitals and district general hospitals. Regarding needlestick injuries, nearly two-thirds of preregistration house officers were unable to recall any training at either undergraduate or postgraduate level. These results suggest that training in clinical skills can be improved. Training is already changing with use of clinical skills laboratories and logbooks. We also recommend mandatory needlestick training both in undergraduate programmes and in induction courses for preregistration house officers.

Aldosterone as a Determinant of Cardiovascular and Renal Dysfunction

Abstract: Aldosterone is a major regulator of extracellular fluid volume and the principal determinant of potassium metabolism 1,2,3,4,5. These effects are mediated by the binding of aldosterone to the mineralocorticoid receptor in target tissues, primarily the kidney. Volume is regulated through a direct effect on the collecting duct, where aldosterone promotes sodium retention and potassium excretion. The reabsorption of sodium ions produces a fall in the transmembrane potential, thus enhancing the flow of positive ions (such as potassium) out of the cell into the lumen. The reabsorbed sodium ions are transported out of the tubular epithellium into the renal interstitial fluid and from there into the renal capillary circulation. Three primary mechanisms control aldosterone release—the renin-angiotensin system, potassium, and adrenocorticotropic hormone. The renin-angiotensin system controls extracellular fluid volume via regulation of aldosterone secretion. In effect, the renin-angiotensin system keeps the circulating blood volume constant by causing aldosterone-induced sodium retention during volume deficiency and by decreasing aldosterone-dependent sodium retention when volume is ample. In recent years there has been a radical shift in our view of aldosterone's effects on the heart, the vasculature and the kidney6,7,8,9. Aldosterone's endocrine properties have taken on a broader perspective, involving non-classic actions in non-epithelial cells found in non-classic target tissues6, 10,11,12,13,14,15. The traditional concept, that aldosterone is synthesized only in the adrenal glomerulosa cell and acts almost exclusively on the kidney to modify sodium and potassium homoeostasis, needs to be expanded. There is increasing evidence that aldosterone can have an effect on vascular remodelling and collagen formation, and a non-genomic action to modify endothelial function. Among the most intriguing effects of aldosterone are its impact on fibrosis and activity associated with a cell surface receptor in certain target tissues, including endothelial cells 6, 7, 16,17,18,19. These actions contribute substantially to the pathophysiology of congestive heart failure (CHF), as well as progressive renal dysfunction. This new information has increased interest in the development of an antagonist to block aldosterone's effect, not just because of its diuretic action but primarily because of its potential cardiovascular and renal protective effects. In this review I consider the broad spectrum of non-genomic effects of aldosterone. It is becoming increasingly evident that these effects, occurring independently of haemodynamic factors, contribute to enhanced cardiovascular risk manifested by congestive heart failure and progressive renal disease. I also discuss the clinical trials with selective aldosterone receptor antagonists that are currently underway in patients with left ventricular hypertrophy, essential hypertension and systolic hypertension, and in those who have experienced myocardial infarction. Such trials will enhance our understanding of the role of aldosterone in the pathophysiology of cardiovascular disease. Also, selective aldosterone receptor antagonism holds promise for a reduction in cardiovascular and renal disease morbidity and mortality, and for enhancement of patient wellbeing.

Sleep problems in children with developmental disorders.

Abstract: In 1905 Clement Dukes, a school doctor, made the following observation about the effects of sleep loss upon the children in his care1: `...younger pupils are allotted the same number of hours as the seniors for sleep. What this means to the children is lowered vitality, apathy, bloodlessness, diminished growth of the body and brain. It renders the child an easy prey to disease [and] causes slight fainting attacks resembling these cases of epilepsy...' Although the tone of his remarks may seem over-dramatic it is now well recognized that impaired sleep quantity or quality can have profound effects on daytime mood, behaviour, cognition, general performance and physiology2. When sleep disturbance is present in children it impacts not only upon the child's daytime functioning but also on that of the parents and the family at large; associations between childhood sleep problems and maternal stress, depression, poor marital relationships and even child abuse have been reported3,4. The negative associations with childhood sleep problems are of particular concern in view of the high prevalence of sleep difficulties. Figures of about 25% of preschool children5, 43% of school-age prepubescent children6 and 33% of adolescents7 are given, and these are likely to be understimates. The reported rates of sleep disorders in children with developmental disorders are even higher. Rates vary depending upon the criteria used to define a `sleep problem' but examples reported are 49-89% of children with autistic spectrum disorders8, 25-50% of children with attention deficit hyperactivity disorder (ADHD)9 and 34-86% of children with intellectual disabilities10. The sleep problems of children with developmental disorders deserve particular attention not least because of their prevalence but also because of their persistence and severity, the additional stress that they place upon carers, the contribution that sleep disturbance might be making to daytime difficulties with behaviour and cognition and the parents' ability to cope with them and, fortunately, the improvements in child and parent functioning that can follow successful treatment11.

Chlamydial infection in sheep: immune control versus fetal pathology.

Abstract: Chlamydial abortion was first described by Greig1 in 1936 and named enzootic abortion of ewes (EAE). At that time he suggested that it was the result of environmental factors such as dietary deficiency. It was not until 1950 that Stamp and colleagues2 demonstrated that it was an infectious condition caused by an organism of the ‘psittacosis-lymphogranuloma venereum group’. In the mid 1960s specific phenotypic traits of the chlamydial strains were identified (sulphadiazine sensitivity and glycogen accumulation), which together with inclusion morphology became the basis by which the strains were differentiated into the two species Chlamydia trachomatis and C. psittaci3. The C. psittaci group consisted of strains from a wide variety of animal sources, including that responsible for EAE, while the C. trachomatis group consisted of strains from human sources. The development of DNA-based classification methods, particularly DNA—DNA reassociation studies4,5, in the 1980s led to the designation of two additional species, C. pneumoniae6 and C. pecorum7. These studies also supported the classification of chlamydial strains into eight species groups, with a ninth identified in 19938, highlighting the need for a revision of chlamydial taxonomy. In 1999 Everett and colleagues9 proposed a reclassification of the order Chlamydiales and its taxa based mainly on phylogenetic analyses of the 16S and 23S rRNA genes, but also on corroborating genetic and phenotypic information. A summary of this reclassification is shown in Table 1. The family Chlamydiaceae, which previously had only one genus Chlamydia, has been divided into two genera, Chlamydia and Chlamydophila. Within these genera five new species, in addition to the existing four, have been proposed. The organism responsible for ovine abortion, which was previously classified as serotype 1 C. psittaci, has been given species status and named Chlamydophila abortus. Table 1 Reclassification of the family

The Key to the Sanatoria

Abstract: The clinician in Britain in the 1890s knew that no effective treatment could be offered to a patient with tuberculosis. Even the diagnosis presented formidable difficulties. It had to be made on an evaluation of the patient's symptoms and on the findings of a physical examination of the chest. The pulse could be counted, the temperature taken and the patient weighed. Since Koch's discovery and demonstration of the tubercle bacillus in 1882 the sputum could be examined and, if positive, was an invaluable and decisive test. There were, however, no X-rays to show the extent of the disease or the presence of cavities in the lungs, nor even an erythrocyte sedimentation rate to reflect the degree of tissue damage, so it was difficult to categorize degrees of severity. From these uncertain foundations the clinician would have to make an attempt at prognosis, with little available guidance. He (it would nearly always be a he) could turn to Pollock's study of 3500 patients who, during the seven years before 1865, had attended the outpatients at Brompton Hospital; these were ‘patients of all classes below the wealthy’1. Pollock found that the survival time was longer than expected, probably exceeding four years. Another study looked at a different population; Williams reported 1000 patients ‘selected from private practice, the patients for the most part belonging to the upper and middle classes of society’ from 1842 to 1864, and found that at best a span of eight to ten years could be expected2. Then there was the awkward problem of when, or even whether, to tell the patient. Typically, he or she would be under forty years old, with family responsibilities. The prospect was a chronic illness with intermittent periods of increasingly debilitating ill-health, ultimately to be fatal, for which the clinician had little effective palliative treatment to offer. (This has been referred to as the ‘cod liver oil and mist.gent.alk’ era.) The only hope lay in the patient's bank balance; there was just the possibility, if the disease was caught early enough and if he or she could afford to travel, that a ‘cure’ might be achieved. Clearly this option excluded the vast majority of patients who were impoverished. Selecting a suitable climate was the proffered solution. Which climate was to be recommended was less clear; some experts were advocates of high altitude—the exhilarating Alpine winter made Davos very popular—but so was the seaside—Cannes and Menton had their attractions. Weber, in a detailed review, recommended matching the climate to the patient's constitution3. Such success as there was probably resulted from the patient spending long hours in the open air. On the Continent the ‘open-air treatment’ in sanatoria was also available. This was a much more systematic regimen with the patient under the direct, often daily, supervision of the doctor. The open-air treatment was not unknown in Britain, for George Bodington of Sutton Coldfield had been the first to describe and to practise it. His ideas were an abrupt change from the traditional teaching and when he published his theory and experience in 18404, The Lancet's reviewer dismissed its ‘very crude ideas and unsupported assertions’5. Bodington turned to other things. Henry MacCormac of Belfast had a similar experience and when his paper on the evils of rebreathed air (‘True Nature and Absolute Preventability of Tubercular Consumption’) was presented in 1861 to the Royal Medical and Chirurgical Society of London, they rejected it and scornfully refused him a vote of thanks6. Benjamin Ward Richardson in 18577 and John Henry Bennet in 18668 both described the hygienic treatment of pulmonary consumption but no one followed their advice in Britain. In 1885 Hermann Weber pleaded for open-air treatment in Britain in his Croonian Lectures to the Royal College of Physicians9; in 1889 the BMJ published a leading article describing Dettweiler's regimen in Falkenstein sanatorium in the Taunus Mountains near Frankfurt10, and Harris and Beale in their textbook11 gave a clear description of the open-air treatment in 1895. There were many other such publications and the subject was constantly before the profession. The first German sanatorium for the systematic open-air treatment had been started by Hermann Brehmer (1826-1889) at Gorbersdorf in Silesia in 1854. To start with it was a small group of cottages; ultimately it would grow to 300 beds. Brehmer advocated high altitude (it was at 518 m), abundant diet with some alcohol, and exercise in the open air under strict medical supervision. The results were regarded as highly successful, surpassing any previous treatment. Peter Dettweiler (1837-1904)—his patient who later became his assistant—opened Falkenstein sanatorium in 1876. He continued Brehmer's work but placed a greater emphasis on rest. His patients spent the day in Liegehallen, lying on chaises longues, sheltered by a roof but in the open air. When Dr Otto Walther's English wife, Hope Bridges Adams, developed tuberculosis Dettweiler recommended that they should go to the Black Forest, and it was at Nordrach that Walther (1853-1919) guided her back to health. In 1888 he started to accept other patients, expanding to about 50 beds at any one time. Nordrach was considered by some to be the finest development of the Continental sanatorium treatment.

Management of the difficult airway in children

Abstract: Airway management and endotracheal intubation in children usually present no difficulties for the experienced anaesthetist. In infants, access may be slightly more problematic because of certain anatomical variations: the tongue is large relative to the mandible and the larynx is more cephalad than in the older child. In infants below the age of four months the epiglottis is at the level of the first cervical vertebra; at six months it has moved down to the level of the third cervical vertebra. Unlike the epiglottis in adults, the epiglottis in infants is hard and narrow and is folded into an inverted U shape. These features together give rise to what many people refer to as the ‘anterior larynx’, but in fact are just due to the relative macroglossia and the higher placement of the larynx. The anatomical variations between infants, children and adults should be easily overcome by use of straight-bladed laryngoscopes which can pick up the epiglottis and reveal the larynx. The children who present major difficulties for the anaesthetist are not easily missed. In this paper I focus on congenital causes. Others are retropharyngeal abscess, burns, trauma and Still's disease.

Hand Hygiene—The Case for Evidence-Based Education

Abstract: Among the priorities identified for the National Health Service (NHS) are reductions in hospital-acquired infection and in antimicrobial resistance1. These are to be achieved by improved surveillance, optimal antibiotic prescribing and strengthening of basic infection control procedures such as handwashing. According to recent figures2,3, hospital acquired infection affects 1 in 11 inpatients, carries a 13% mortality and lengthens stay by a factor of 2.5. The extra cost to the NHS is nearly £3000 per patient, and the total annual cost is nearly £1 billion. Between 15% and 30% of hospital-acquired infection is considered preventable, but even a 10% reduction would improve bed management to the tune of 47ooo extra finished consultant episodes per year. The NHS's action plan to reduce hospital-acquired infection4 holds chief executives personally accountable, and requires handwashing to be implemented in line with Department of Health guidance5,6. Healthcare workers' compliance with handwashing is known to be poor, with doctors performing particularly badly7,8. When the Department of Health published its handwashing guidance a storm of correspondence in the BMJ excused low compliance on grounds of lack of time, poor availability of sinks and soaps, skin sensitivity and lack of evidence. This paper reviews the evidence that patient contact results in contamination of the hands by pathogens and that washing with liquid soap and water or, better, use of an alcohol handrub, greatly reduces hand contamination and infection rates, and presents the case for making hand hygiene a medical educational priority9.

Nephrotoxicity in the elderly due to co-prescription of angiotensin converting enzyme inhibitors and nonsteroidal anti-inflammatory drugs.

Abstract: Both angiotensin converting enzyme inhibitors and nonsteroidal anti-inflammatory drugs can lead to functional renal insufficiency. In an observational study we assessed the frequency of this adverse effect in patients aged over 75 years receiving these drugs in combination. In one year, out of 1500 patients whose records were screened, 12 were prescribed this combination. 2 developed acute renal failure, of whom one died and the other recovered after discontinuation of both drugs. 4 patients showed deterioration in renal function, which returned to normal after one of the drugs was stopped. Renal function remained stable in 6 patients: patients with deterioration in renal function were older and more likely to be on diuretics. This drug combination is commonly nephrotoxic in the elderly and should be avoided, especially in those taking diuretics.

Medicolegal consequences of postoperative intra-abdominal adhesions.

Abstract: Postoperative adhesions are an almost invariable consequence of abdominal and pelvic surgery. Their most important morbidity is small-bowel obstruction, but other sequelae include female infertility and dyspareunia and increased risk of visceral injury at subsequent laparotomy or laparoscopy. Whether chronic abdominal pain is truly a consequence of adhesions is debatable, although it is likely to be accepted as an entity by both patients and their legal advisors. Of 14 successful claims dealt with by a British medical defence organization, 5 were for perforations after laparoscopic division of adhesions, 2 for adhesions after laparoscopic surgery, 1 for infertility as a result of adhesions and 6 for delayed diagnosis of obstruction. General practitioners, surgeons and gynaecologists need to be aware of the increasing burden of medicolegal claims arising from these complications.

Robert Lee, The Uterine Nervous System and a Wrangle at the Royal Society 1839–1849:

Abstract: In the 1830s the obstetrician Robert Lee made a series of observations on the gravid uterus that ran counter to received wisdom. This paper recounts the way in which Lee's work was handled by the premier scientific institution of the day, the Royal Society.

Surgery for Intersex

Abstract: The physical features determining the sex of an individual are the karyotype, the internal and external sexual organs, the gonads and the secondary sexual characteristics which appear at puberty. Intersex conditions occur when there is a defect in the normal process of sexual maturation that results in abnormalities in any of these features. The management of these conditions is in the midst of great change. Every aspect is currently under review including diagnostic techniques, timing and nature of treatment including surgery, and information given to the patients. The true incidence of most of these conditions is unknown and great secrecy still surrounds them.

Cardiovascular manifestations of HIV infection.

Abstract: Studies published over the past three years have tracked the incidence and course of human immunodeficiency virus (HIV) infection in relation to cardiac illness in both children and adults1 (Table 1). This recent work shows that subclinical echocardiographic abnormalities independently predict adverse outcomes and identify high-risk groups who can then be targeted for early intervention and therapy2. Table 1 HIV-associated cardiovascular abnormalities The introduction of highly active antiretroviral therapy (HAART) regimens has greatly modified the course of HIV disease, with longer survival and better quality of life; however, early data from those treated raise concerns about a possible increase in both peripheral and coronary arterial diseases. In global terms HAART is available only to a minority of HIV-infected individuals, and studies before the advent of HAART remain applicable. UNAIDS estimates that 36.1 million people were living with HIV infection at the end of the year 20003. If 9-10% of patients develop symptomatic heart failure over 2-5 years4, then 3 million cases of HIV-related heart failure will present in that time period5. In this review article, I discuss the principal HIV-associated cardiovascular manifestations, with an emphasis on new knowledge about prevalence, pathogenesis and treatment.

An audit of audits: are we completing the cycle?

Abstract: Clinical audit plays an important part in the drive to improve quality of patient care and thus forms a cornerstone of clinical governance. We evaluated the standard of clinical audits conducted by all departments in a teaching hospital between 1996 and 1997. Of a total of 213 audits carried out, 102 (48%) were ‘partial’ and only 29 (14%) were ‘full’. Recommendations for improvement emerged from 134 (63%) of the audits performed. In only 51 audits (24%) was the cycle completed by re-auditing, during the subsequent 3 years. Most departments undertake clinical audits but failure to close the loop undermines their effectiveness and wastes resources.

Inappropriate admissions: thoughts of patients and referring doctors.

Abstract: Research on inappropriate hospital admissions has tended to neglect the views of the referring doctors and the patients. In this study, the Appropriateness Evaluation Protocol was applied to a random sample of 102 emergency medical admissions. The patients and doctors were then presented with a list of possible alternatives to admission that might have been used at the point of referral. Case notes were available for 88 patients. As judged by these, 28% of admissions were inappropriate, the commonest reason being the potential for treatment or tests to have been performed as outpatient procedures; next commonest was the possibility of lower level care. The response rate to the questionnaires was about two-thirds, for both doctors and patients. Of the general practitioners and casualty doctors who responded, 60% specified alternatives to admission that they would have considered, and the equivalent figure for patients was 70%. For both groups the major preferences were same-day outpatient assessment and admission to a community hospital. Referring doctors and patients, in this survey, favoured alternatives to acute medical care in proportions much higher than that of supposedly inappropriate admission.

To Improve the Evidence of Medicine: the 18th Century British Origins of a Critical Approach

Abstract: Ulrich Trohler's thesis is that a quantitative and critical approach to medicine did not originate in Paris in the first half of the nineteenth century, as is generally believed, but was first fostered in Britain in the second half of the eighteenth century. At this time several British doctors perceived the need for adequate empirical evaluation of existing and proposed treatments. They understood that the way forward was a rejection of the traditional dependence on dogma and complex pathophysiological theories of disease and instead a reliance on comparative trials with the results expressed as numbers—something they referred to as `medical arithmetic'. With its roots in a PhD written over twenty years ago the book finally brings Trohler's valuable and fascinating research to a wide audience. It is broadly divided into three parts. In the first there is an overview of the state of British medicine in the eighteenth century and an explanation of the intellectual and structural elements which allowed the new arithmetic approach to be applied. The intellectual basis was essentially the emergence of a climate of `rational empiricism', a general emphasis on observation rather than theory, and also the profusion of medical societies allowing these views to be propagated. The structural change was the increased dependence on institutionalized medical treatment in hospitals and dispensaries and in the armed forces which permitted adequate numbers of cases to be collected together to use the new methods. The second and largest part is the exploration of contemporary health issues to illustrate Trohler's theory. Trohler states that this presentation is for a general readership and undoubtedly it provides both a vivid insight into the medical practice of the period and a cogent argument for a British origin for quantitative evaluation. The subjects addressed are the management of fever (the `cancer' of the eighteenth century), surgery for bladder stones, the treatment and prevention of scurvy, digitalis in dropsy, the use of spa waters for rheumatic disorders, amputation for limb injuries in war and the control of syphilis and ophthalmia in the army. Even the very familiar, such as Lind's work in scurvy and Withering's in dropsy, are reinvigorated by Trohler's exhaustive research. In the third and final part the major findings are summarized. There is discussion of the type of men who invented this new medicine—often outside the mainstream, `dissenting' in nature, and from a military or provincial background with Scottish connections. The immediate impact of `medical arithmetic' on day-to-day practice and the ethical issues it raised about experimenting on patients are addressed. Most significantly, Trohler draws striking parallels between the eighteenth and early nineteenth century work of the `arithmetic observationists and experimentalists' and ongoing developments in the second half of the twentieth and early twenty-first centuries. One is repeatedly impressed by the apparent modernity of the methods used by these pioneers of evidence-based medicine. I have no serious criticisms. The title is a direct quote from the eighteenth century but perhaps the book deserved something more inspiring. On occasion Trohler's `rocky Swiss English' (his own words) has evaded the editors. This is a scholarly and entertaining work. The author argues his case lucidly with a profusion of historical detail which is thoroughly referenced. The Royal College of Physicians of Edinburgh have produced it very nicely in softback format with pleasing illustrations and at a surprisingly reasonable price. I strongly recommend it to all those with an interest in the history or future of British medicine.