A case of distal limb arterial tortuosity and dilation: observations and potential clinical significance.

Arterial tortuosity describes variation via bending of the arterial wall and has been noted in several arteries throughout the body. Tortuous blood vessels can cause nerve compression, as well as present difficulties to surgeons and radiologists. Here we present an unusual case of multi-vessel arterial tortuosity discovered in 78-year-old Hispanic male cadaver, independent of systemic pathology. The left ulnar and right tibial arteries were dissected, and using calibrated digital callipers, their external and internal diameters were measured both at the origin site and at the site of greatest dilation. Both wall thickness and the number of inflection points were also measured. Six bends were noticed in the ulnar artery and its diameter measured 8.11 mm at its widest, with a wall thickness of 0.88 mm. On the lower extremity, the right tibial artery had three bends and its diameter measured 4.86 mm at its widest, with a wall thickness of 1.32 mm. This uncommon tortuosity is not only more prone to laceration during surgery, but the bending and thickening can be mistaken for tumours. Finally, fluid dynamics can be altered, resulting in an impact on blood pressure in the extremities. Thus, raising awareness is crucial to prevent both symptoms and iatrogenic complications.

Lacunar-canalicular network in femoral cortical bone is reduced in aged women and is predominantly due to a loss of canalicular porosity.

The lacunar-canalicular network (LCN) of bone contains osteocytes and their dendritic extensions, which allow for intercellular communication, and are believed to serve as the mechanosensors that coordinate the processes of bone modeling and remodeling. Imbalances in remodeling, for example, are linked to bone disease, including fragility associated with aging. We have reported that there is a reduction in scale for one component of the LCN, osteocyte lacunar volume, across the human lifespan in females. In the present study, we explore the hypothesis that canalicular porosity also declines with age. To visualize the LCN and to determine how its components are altered with aging, we examined samples from young (age: 20-23 y; n = 5) and aged (age: 70-86 y; n = 6) healthy women donors utilizing a fluorescent labelling technique in combination with confocal laser scanning microscopy. A large cross-sectional area of cortical bone spanning the endosteal to periosteal surfaces from the anterior proximal femoral shaft was examined in order to account for potential trans-cortical variation in the LCN. Overall, we found that LCN areal fraction was reduced by 40.6% in the samples from aged women. This reduction was due, in part, to a reduction in lacunar density (21.4% decline in lacunae number per given area of bone), but much more so due to a 44.6% decline in canalicular areal fraction. While the areal fraction of larger vascular canals was higher in endosteal vs. periosteal regions for both age groups, no regional differences were observed in the areal fractions of the LCN and its components for either age group. Our data indicate that the LCN is diminished in aged women, and is largely due to a decline in the canalicular areal fraction, and that, unlike vascular canal porosity, this diminished LCN is uniform across the cortex.

Three dimensional mapping of strontium in bone by dual energy K-edge subtraction imaging.

The bones of many terrestrial vertebrates, including humans, are continually altered through an internal process of turnover known as remodeling. This process plays a central role in bone adaptation and disease. The uptake of fluorescent tetracyclines within bone mineral is widely exploited as a means of tracking new tissue formation. While investigation of bone microarchitecture has undergone a dimensional shift from 2D to 3D in recent years, we lack a 3D equivalent to fluorescent labeling. In the current study we demonstrate the ability of synchrotron radiation dual energy K-edge subtraction (KES) imaging to map the 3D distribution of elemental strontium within rat vertebral samples. This approach has great potential for ex vivo analysis of preclinical models and human tissue samples. KES also represents a powerful tool for investigating the pharmokinetics of strontium-based drugs recently approved in many countries around the globe for the treatment of osteoporosis.

Transition to adult services for children and young people with palliative care needs: a systematic review.

OBJECTIVE: To evaluate the evidence on the transition process from child to adult services for young people with palliative care needs. DESIGN: Systematic review. SETTING: Child and adult services and interface between healthcare providers. PATIENTS: Young people aged 13-24 years with palliative care conditions in the process of transition. MAIN OUTCOME MEASURES: Young people and their families' experiences of transition, the process of transition between services and its impact on continuity of care and models of good practice. RESULTS: 92 studies included. Papers on transition services were of variable quality when applied to palliative care contexts. Most focussed on common life-threatening and life-limiting conditions. No standardised transition program identified and most guidelines used to develop transition services were not evidence-based. Most studies on transition programs were predominantly condition-specific (eg, cystic fibrosis (CF), cancer) services. CF services offered high-quality transition with the most robust empirical evaluation. There were differing condition-dependent viewpoints on when transition should occur but agreement on major principles guiding transition planning and probable barriers. There was evidence of poor continuity between child and adult providers with most originating from within child settings. CONCLUSIONS: Palliative care was not, in itself, a useful concept for locating transition-related evidence. It is not possible to evaluate the merits of the various transition models for palliative care contexts, or their effects on continuity of care, as there are no long-term outcome data to measure their effectiveness. Use of validated outcome measures would facilitate research and service development.

Transition to adult services for children and young people with palliative care needs: a systematic review.

OBJECTIVE: To evaluate the evidence on the transition process from child to adult services for young people with palliative care needs. DESIGN: Systematic review. SETTING: Child and adult services and interface between healthcare providers. PATIENTS: Young people aged 13-24 years with palliative care conditions in the process of transition. MAIN OUTCOME MEASURES: Young people and their families' experiences of transition, the process of transition between services and its impact on continuity of care and models of good practice. RESULTS: 92 studies included. Papers on transition services were of variable quality when applied to palliative care contexts. Most focussed on common life-threatening and life-limiting conditions. No standardised transition program identified and most guidelines used to develop transition services were not evidence-based. Most studies on transition programs were predominantly condition-specific (eg, cystic fibrosis (CF), cancer) services. CF services offered high-quality transition with the most robust empirical evaluation. There were differing condition-dependent viewpoints on when transition should occur but agreement on major principles guiding transition planning and probable barriers. There was evidence of poor continuity between child and adult providers with most originating from within child settings. CONCLUSIONS: Palliative care was not, in itself, a useful concept for locating transition-related evidence. It is not possible to evaluate the merits of the various transition models for palliative care contexts, or their effects on continuity of care, as there are no long-term outcome data to measure their effectiveness. Use of validated outcome measures would facilitate research and service development.

Multifactorial assessment and targeted intervention for preventing falls and injuries among older people in community and emergency care settings: systematic review and meta-analysis.

OBJECTIVE: To evaluate the effectiveness of multifactorial assessment and intervention programmes to prevent falls and injuries among older adults recruited to trials in primary care, community, or emergency care settings. DESIGN: Systematic review of randomised and quasi-randomised controlled trials, and meta-analysis. DATA SOURCES: Six electronic databases (Medline, Embase, CENTRAL, CINAHL, PsycINFO, Social Science Citation Index) to 22 March 2007, reference lists of included studies, and previous reviews. REVIEW METHODS: Eligible studies were randomised or quasi-randomised trials that evaluated interventions to prevent falls that were based in emergency departments, primary care, or the community that assessed multiple risk factors for falling and provided or arranged for treatments to address these risk factors. DATA EXTRACTION: Outcomes were number of fallers, fall related injuries, fall rate, death, admission to hospital, contacts with health services, move to institutional care, physical activity, and quality of life. Methodological quality assessment included allocation concealment, blinding, losses and exclusions, intention to treat analysis, and reliability of outcome measurement. RESULTS: 19 studies, of variable methodological quality, were included. The combined risk ratio for the number of fallers during follow-up among 18 trials was 0.91 (95% confidence interval 0.82 to 1.02) and for fall related injuries (eight trials) was 0.90 (0.68 to 1.20). No differences were found in admissions to hospital, emergency department attendance, death, or move to institutional care. Subgroup analyses found no evidence of different effects between interventions in different locations, populations selected for high risk of falls or unselected, and multidisciplinary teams including a doctor, but interventions that actively provide treatments may be more effective than those that provide only knowledge and referral. CONCLUSIONS: Evidence that multifactorial fall prevention programmes in primary care, community, or emergency care settings are effective in reducing the number of fallers or fall related injuries is limited. Data were insufficient to assess fall and injury rates.

Successful use of feedback to improve antibiotic prescribing and reduce Clostridium difficile infection: a controlled interrupted time series.

OBJECTIVES: To investigate the effect of reinforcing a narrow-spectrum antibiotic policy on antibiotic prescription and Clostridium difficile infection (CDI) rates by feedback of antibiotic use to doctors, as part of a departmental audit and feedback programme. DESIGN: A prospective controlled interrupted time-series (ITS) study, with pre-defined pre- and post-intervention periods, each of 21 months. SETTING: Three acute medical wards for elderly people in a teaching hospital. PARTICIPANTS: Six thousand one hundred and twenty-nine consecutive unselected acute medical admissions aged >or=80 years. INTERVENTIONS: A 'narrow-spectrum' antibiotic policy (reinforced by an established programme of audit and feedback of antibiotic usage and CDI rates) was introduced, following an unplanned rise in amoxicillin/clavulanate (Augmentin) use. It targeted broad-spectrum antibiotics for reduction (cephalosporins and amoxicillin/clavulanate) and narrow-spectrum antibiotics for increase (benzyl penicillin, amoxicillin and trimethoprim). Changes in the use of targeted antibiotics (intervention group) were compared with those of untargeted antibiotics (control group) using segmented regression analysis. Changes in CDI rates were examined by the Poisson regression model. Methicillin-resistant Staphylococcus aureus (MRSA) acquisition rates acted as an additional control. RESULTS: There was a reduction in the use of all targeted broad-spectrum antibiotics and an increase in all targeted narrow-spectrum antibiotics, statistically significant for sudden change and/or linear trend. All other antibiotic use remained unchanged. CDI rates fell with incidence rate ratios of 0.35 (0.17, 0.73) (P=0.009). MRSA incidence did not change [0.79 (0.49, 1.28); P=0.32]. CONCLUSIONS: This is the first controlled prospective ITS study to use feedback to reinforce antibiotic policy and reduce CDI. Multicentre ITS or cluster randomized trials of this and other methods need to be undertaken to establish the most effective means of optimizing antibiotic use and reducing CDI.

Improving child protection: a systematic review of training and procedural interventions.

AIM: To synthesise published evidence regarding the effectiveness of training and procedural interventions aimed at improving the identification and management of child abuse and neglect by health professionals. METHODS: Systematic review for the period 1994 to 2005 of studies that evaluated child protection training and procedural interventions. Main outcome measures were learning achievement, attitudinal change, and clinical behaviour. RESULTS: Seven papers that examined the effectiveness of procedural interventions and 15 papers that evaluated training programmes met the inclusion criteria. Critical appraisal showed that evaluation of interventions was on the whole poor. It was found that certain procedural interventions (such as the use of checklists and structured forms) can result in improved recording of important clinical information and may also alert clinical staff to the possibility of abuse. While a variety of innovative training programmes were identified, there was an absence of rigorous evaluation of their impact. However a small number of one-group pre- and post-studies suggest improvements in a range of attitudes necessary for successful engagement in the child protection process. CONCLUSION: Current evidence supports the use of procedural changes that improve the documentation of suspected child maltreatment and that enhance professional awareness. The lack of an evidence based approach to the implementation of child protection training may restrict the ability of all health professionals to fulfil their role in the child protection process. Formal evaluation of a variety of models for the delivery of this training is urgently needed with subsequent dissemination of results that highlight those found to be most effective.

The geographical distribution of specialists in public health in the United Kingdom: is capacity related to need?

OBJECTIVES: Recent organizational changes reflect the need to be more responsive to local populations and have included fostering a closer structural relationship between primary care and public health. In light of this, we explore the distribution of the specialist public health workforce and the relationship with population deprivation and need. STUDY DESIGN: Questionnaire survey to all directors of public health working in primary care trusts (PCTs) and strategic health authorities (SHAs) in England to determine the number of specialists in public health working in either PCTs or SHAs. All identified specialists were given the opportunity to self-define in a further questionnaire survey. Whole-time-equivalent staffing, per head of population, was analysed against socio-economic deprivation, measured by the DETR 2000 Index of Multiple Deprivation. The analysis was conducted at the SHA level. RESULTS: The survey was undertaken whilst public health in the UK was undergoing immense change. This presented specific challenges in identifying specialists in public health working within PCTs and SHAs. Seven hundred and eighty-three specialists working in PCTs and SHAs were identified. On average, in England, there are 1.69 specialists in public health per 100,000 population, with some variability at SHA level (range = 0.8-2.89). Findings indicate an overall positive association between capacity at SHA level and socio-economic need, although some discrepancies between need and provision are apparent. CONCLUSIONS: The general positive association between capacity and deprivation should offer some reassurance to policy makers, researchers and patients alike. However, further efforts are needed to redistribute specialists in some areas to address organizational capacity and equity issues.

Developing a speciality: regearing the specialist public health workforce.

OBJECTIVES: To identify issues surrounding the future training needs of the specialist public health workforce following the most recent restructuring of the National Health Service (NHS) in England. METHODS: All directors of public health (DsPH) based in strategic health authorities and nine senior staff working in public health at the regional level were invited to participate in a semi-structured telephone interview. RESULTS: Twenty-six people were interviewed. Many interviewees expressed concern that because consultants and specialists in public health will be working in much smaller teams than hitherto, they will have to generalize their skills to cover a much wider range of functions (including board-level duties). This may result in a loss of specialist expertise. Successful public health practice in the new structures will require new ways of interorganizational working that will add an administrative burden to specialists in public health. Also, the creation of a board-level post in each primary care trust (PCT) has resulted in more time spent on corporate responsibilities and less on public health for DsPH, who are often the only fully trained specialist in public health in their PCT. Furthermore, interviewees expressed their anxiety about the lack of diversity in the posts available to specialists in public health and particularly to those newly completing their specialist training. Generally, interviewees felt that traditional public health roles and responsibilities were being eclipsed by corporate and managerial ones. Professional development activities were being carried out, but in a rather ad-hoc fashion. Interviewees were hopeful that public health networks would lead professional development initiatives once they were more established. CONCLUSIONS: It is important that excellence in public health is maintained through a set of accreditable standards, whilst corporate skills, essential to successful public health practice in the new UK NHS, are developed among specialists in public health.

Specialist public health capacity in England: working in the new primary care organizations.

OBJECTIVES: To determine the capacity and development needs, in relation to key areas of competency and skills, of the specialist public health workforce based in primary care organizations following the 2001 restructuring of the UK National Health Service. STUDY DESIGN: Questionnaire survey to all consultants and specialists in public health (including directors of public health) based in primary care trusts (PCTs) and strategic health authorities (SHAs) in England. RESULTS: Participants reported a high degree of competency. However, skill gaps were evident in some areas of public health practice, most notably "developing quality and risk management" and in relation to media communication, computing, management and leadership. In general, medically qualified individuals were weaker on community development than non-medically qualified specialists, and non-medically qualified specialists were less able to perform tasks that require epidemiological or clinical expertise than medically qualified specialists. Less than 50% of specialists felt that their links to external organizations, including public health networks, were strong. Twenty-nine percent of respondents felt professionally isolated and 22% reported inadequate team working within their PCT or SHA. Approximately 21% of respondents expressed concerns that they did not have access to enough expertise to fulfil their tasks and that their skills were not being adequately utilized. CONCLUSIONS: Some important skill gaps are evident among the specialist public health workforce although, in general, a high degree of competency was reported. This suggests that the capacity deficit is a problem of numbers of specialists rather than an overall lack of appropriate skills. Professional isolation must be addressed by encouraging greater partnership working across teams.

How is the high vaginal swab used to investigate vaginal discharge in primary care and how do GPs' expectations of the test match the tests performed by their microbiology services?

OBJECTIVES: To describe the management of vaginal discharge in general practice, with particular regard to the use of the high vaginal swab (HVS), and to compare GPs' expectations of this test with the processing and reporting undertaken by different laboratories. METHODS: A postal questionnaire survey of 2146 GPs in the North Thames area and postal questionnaire study of the 22 laboratories serving the same GPs were carried out. GPs were asked how they would manage a young woman with vaginal discharge and what information they would like on an HVS report. Laboratories were asked how they would process and report on the HVS sample from the same patient. RESULTS: Response rate was 26%. 72% of GPs would take an HVS and 62% would refer on to a genitourinary medicine (GUM) clinic. 45% would offer empirical therapy and 47% of these would treat for candida initially. 75% of GPs routinely request "M,C&S" on HVS samples but 55% only want to be informed about specific pathogens. Routine processing of HVS samples varies widely between laboratories and 86% only report specific pathogens. 78% of GPs would like to be offered a suggested diagnosis on HVS reports, and 74% would like a suggested treatment. 43% of laboratories ever provide a diagnosis, and 14% provide a suggested treatment. CONCLUSIONS: GPs frequently manage vaginal discharge and most of them utilise the HVS. GPs' expectations of the test are not well matched to laboratory processing or reporting of the samples.

Anatomical considerations in the surgical management of blunt thoracic aortic injury.

PURPOSE: Blunt aortic injury (BAI) involving the thoracic aorta is usually described as occurring at the isthmus. We hypothesized that injuries 1 cm or less from the inferior border of the left subclavian artery (LSCA) are associated with an increased mortality rate compared with injuries that are more distal. METHODS: A retrospective review of patients admitted with the diagnosis of BAI was performed. Injuries were divided into two groups: group I, injuries that were 1 cm or less from the junction of the LSCA and the thoracic aorta; group II, injuries that were more than 1 cm from the LSCA. Primary outcome measures included cross-clamp time, rupture, and death. RESULTS: In a 14-year period, 122 patients were admitted with BAI. The anatomy relative to the LSCA could be determined in 91 patients who underwent operative repair. Forty-two injuries (46%) were classified as group I, and 49 injuries were classified as group II. Group I injuries were characterized by an increased mortality rate (18/42 or 43% in group I vs 11/49 or 22% in group II, P = .04), intraoperative rupture rate (7/42 or 17% in group I vs 1/49 or 2% in group II, P = .003), and cross-clamp time (39.5 +/- 21.9 minutes in group I vs 28.4 +/- 13 minutes in group II, P = .04). Three ruptures occurred while proximal control was being obtained. CONCLUSION: Increased technical difficulty and risk of rupture characterize injuries that occur proximally in the descending thoracic aorta, 1 cm from the LSCA. These injuries may be better managed by instituting bypass before attempting to obtain proximal control and by routinely clamping proximal to the LSCA.

Why don't low-income mothers worry about their preschoolers being overweight?

CONTEXT: Mothers are in an important position to prevent obesity in their children by shaping early diet and activity patterns. However, many mothers of overweight preschool children are not worried about their child's weight. OBJECTIVE: To explore mothers' perceptions about how they determine when a child is overweight, why children become overweight, and what barriers exist to preventing or managing childhood obesity. DESIGN: Three focus groups with 6 participants in each. Participant comments were transcribed and analyzed. Themes were coded independently by the 6 authors who then agreed on common themes. SETTING: A clinic of the Special Supplemental Nutrition Program for Women, Infants, and Children in Cincinnati, Ohio. PARTICIPANTS: Eighteen low-income mothers (13 black, 5 white) of preschool children (mean age of 44 months) who were at-risk for later obesity. All but 1 mother had a body mass index (BMI) >/=25 kg/m(2), and 12 mothers had a BMI >/=30 kg/m(2). All but 1 child had a BMI >/=85th percentile for age and sex, and 7 had a BMI >/=95th percentile. Results. Mothers did not define overweight or obese in their children according to how height and weight measurements were plotted on the standard growth charts used by health professionals. Instead, mothers were more likely to consider being teased about weight or developing limitations in physical activity as indicators of their child being overweight. Children were not believed to be overweight if they were active and had a healthy diet and/or a good appetite. Mothers described overweight children as thick or solid. Mothers believed that an inherited tendency to be overweight was likely to be expressed in the child regardless of environmental factors. In trying to shape their children's eating, mothers believed that their control over the child's diet was challenged by other family members. If a child was hungry, despite having just eaten, it was emotionally difficult for mothers to deny additional food. CONCLUSIONS: Health professionals should not assume that defining overweight according to the growth charts has meaning for all mothers. Despite differing perceptions between mothers and health professionals about the definition of overweight, both groups agree that children should be physically active and have healthy diets. Health professionals may be more effective in preventing childhood obesity by focusing on these goals that they share with mothers, rather than on labeling children as overweight.

Characteristics of general practices involved in undergraduate medical teaching.

BACKGROUND: The movement of medical education into the community has accelerated the development of a new model of general practice in which core clinical services are complemented by educational and research activities involving the whole primary care team. AIM: To compare quality indicators, workload characteristics, and health authority income of general practices involved in undergraduate medical education in east London with those of other practices in the area and national figures where available. DESIGN OF STUDY: A comprehensive survey of undergraduate and postgraduate clinical placements and practice-based research activity within general practice. SETTING: One-hundred and sixty-one practices based in East London and the City Health Authority (ELCHA). METHOD: Cross-sectional survey comparing routinely-collected information on practice resources, workload, income, and performance between teaching and non-teaching practices. RESULTS: In east London, teaching practices are larger partnerships with smaller list sizes, higher staff costs, and better quality premises than non-teaching practices. Teaching practices demonstrate significantly better performance on quality indicators, such as cervical cytology coverage and prescribing indicators. Patient-related health authority income per whole time equivalent (WTE) general practitioner (GP) is significantly lower among teaching practices. A multiple regression analysis was used to explore the association between teaching status and income. Eighty-eight per cent of the variation in patient-related income could be explained by the combination of list size, list turnover, removals at doctor's request, quality of premises, and immunisation and cytology rates. CONCLUSION: This study demonstrates that practice involvement in undergraduate education in east London is associated with higher scores on a range of organisational and performance quality indicators. The lower patient-related income of teaching practices is associated with smaller list sizes and may only be partially replaced by teaching income. Lower vacancy rates suggest that teaching practices are more attractive to doctors seeking partnerships in east London.

Routine care of people with HIV infection and AIDS: should interested general practitioners take the lead?

People with HIV and AIDS in the developed world are living longer and healthier lives following the introduction of highly active antiretroviral therapy. The medical management of stable HIV infection could eventually fit into the more normal pattern of chronic disease management in the United Kingdom (UK). Routine monitoring of many chronic conditions is generally regarded as primary care business in partnership with secondary care. The latter service should be reserved for what it does best: periodic review, in-depth assessment, major changes in medication, management of complex or refractory cases, and inpatient care. We look at some of the issues and the arguments for and against any change from the current position in the UK, where almost all HIV infection is managed medically by specialist clinics in secondary and tertiary care.

Designing a community-based fourth-year obstetrics and gynaecology module: an example of innovative curriculum development.

INTRODUCTION: This paper describes the design and evaluation of the community-based obstetrics and gynaecology module at St Bartholomew's and the Royal London School of Medicine and Dentistry. This module sets out to comply with the General Medical Council's recommendations of encouraging students to consider the community perspective, and places less emphasis on a disease-orientated approach. OBJECTIVES: The development of the module, issues of improving student acceptance of the course, staff development and the benefits of community teaching in obstetrics and gynaecology are discussed. MODULE ORGANIZATION: The 2-week module precedes the 8-week hospital obstetrics and gynaecology firms that occur in the fourth undergraduate year. The course is organized into three components: general practice, departmental teaching, and self-directed learning. Students are allocated to general practices for their clinical teaching, for eight sessions. Seven departmental sessions are run by the Academic Department of General Practice and Primary Care. These include a review of the students' self-directed learning. EVALUATION AND CONCLUSION: Evaluation data are reported for the three components of the course. Overall the majority of students rated the module as useful, GP attachments being most favourably received. The majority of students have grasped the basic obstetric and gynaecological history and examination skills and found this useful before starting their hospital firms. Aspects of a specialist subject, such as, obstetrics and gynaecology, can be taught successfully in the community and GP tutors are, as yet, an untapped source of excellent obstetric and gynaecology teaching.