A comparative study of postgraduate medical education in North East Thames Region.

As a prelude to more detailed formal contracting, North East Thames Region undertook a review to examine whether the content of postgraduate medical education (PGME) varies according to the type of hospital in which junior doctors are trained. The study covered a sample of 83 trainees at different grades in four types of hospital (postgraduate, university, district general hospital involved in off-site undergraduate medical education, and district general hospital with no formal involvement in undergraduate medical education) and was designed as a qualitative comparative study. The results of the study point to a perceived lack of structure in PGME and indicate that hospital type alone does not determine a trainees' PGME experience. Moreover, different training grades have different educational needs, which will need to be addressed under more formal contracting arrangements. The Region plans to take this work forward by convening one or more consensus conferences to examine how a more structured approach to PGME could be implemented.

Clinical comparison of extracorporeal shock wave lithotripsy and percutaneous nephrolithotomy in treating renal calculi.

STUDY OBJECTIVE: To compare extracorporeal shock wave lithotripsy and percutaneous nephrolithotomy for efficacy in treating renal calculi. DESIGN: Non-randomised multicentre cohort study with 3 month follow up and 13 month data collection period. SETTING: Lithotripter centre in London, tertiary referral hospital, and urological clinics in several secondary and tertiary care centres. PATIENTS: 933 of 1001 patients treated by lithotripsy at the lithotripter centre were compared with 195 treated by nephrolithotomy. Missing patients were due to incomplete collection of data. Age and sex distributions and characteristics of the stones were similar in the two treatment groups. Two patients died in the lithotripsy group. Three month follow up was achieved in about 84% of both groups (783/933 for lithotripsy; 163/195 for nephrolithotomy). INTERVENTIONS: The nephrolithotomy group had surgical nephrolithotomy alone. In the lithotripsy group 83% (774/933) had lithotripsy alone, 11% (103/933) had combined lithotripsy and nephrolithotomy, and 6% (56/933) had lithotripsy plus ureteroscopy. Single and combined lithotripter treatments were analysed as one group and compared with nephrolithotomy. END POINT: Presence of stones three months after treatment. MEASUREMENTS AND MAIN RESULTS: Presence of residual stones was assessed by plain radiography, ultrasonography, or intravenous urography. After adjustment for age and size and position of stone for patients with single stones the likelihood of being free of stones three months after treatment was significantly greater in the nephrolithotomy group than the lithotripsy group (odds ratio 6.6; 95% confidence interval 3.0 to 14.6) and the response was particularly pronounced with staghorn calculi (62% (8/13) v 15% (141/96) patients free of stones after nephrolithotomy and lithotripsy, respectively). OTHER FINDINGS: 19%(146/775) of patients who had had lithotripsy had to be readmitted within three months after treatment compared with 14%(23/162) who had nephrolithotomy; and 64%(94/146) of readmissions after lithotripsy were for complications compared with 30%(7/23) of readmissions after nephrolithotomy. CONCLUSIONS: Nephrolithotomy may be preferable to lithotripsy for treating renal stones and it may not be wise to invest heavily in lithotripsy facilities.

Case-control study to determine the cause of sclerosing peritoneal disease.

This paper presents the results of a case control study based on 55 patients identified with sclerosing peritoneal disease through the 1984 centre questionnaire. For each case with a confirmed finding of small bowel enclosed in a bag or 'cocoon' of thickened peritoneum, three controls were selected from the main EDTA Registry patient file. Questionnaires were sent out on cases and controls in order to compare exposure to a number of factors implicated in the aetiology of sclerosing peritoneal disease. These included a history of peritonitis, use of agents to sterilise the tubing connection, use of bacterial filters and buffers, drugs added to the dialysate, and history of medication with beta-blockers. Questionnaires were returned for 82% of cases and 74% of controls. Analysis of the returns using McNemar's test showed a significantly higher exposure to chlorhexidine in cases compared with controls. On the basis of this strong association, it seems advisable that the use of chlorhexidine to sterilise tubing connections for peritoneal dialysis patients should be halted.

Renal replacement therapy in patients with diabetic nephropathy, 1980-1985. Report from the European Dialysis and Transplant Association Registry.

Diabetic nephropathy, a rarely listed cause of end-stage renal failure (ESRF) among patients starting renal replacement therapy (RRT) in the early seventies, has progressively gained in importance and become one of the major reasons for the continuous growth of the patient population on RRT in most European countries. Amongst new patients commencing RRT in 1985, the acceptance rate varied between 3 and 12 per million population for type I diabetes mellitus and between one and four per million population for type II diabetes mellitus. Nordic countries, particularly Sweden and Finland, had the highest acceptance rate of young patients with type I diabetes mellitus whose median ages were 38-42 years. In most central and southern European countries the median age of patients with type I diabetes mellitus varied between 50 and 58 years. The high number of young patients with type I diabetes mellitus and ESRF in Nordic countries point to a different natural history of this disease. It cannot be excluded, however, that the higher median age in other countries might result from doctors mistakenly diagnosing type I disease in patients with type II disease who need insulin treatment. Patients with type II diabetes mellitus had a similar age distribution at start of RRT throughout Europe and their median ages clustered around 60 years in most countries. The contribution of haemodialysis, peritoneal dialysis and renal transplantation was analysed for diabetic compared to non-diabetic ESRF. Despite large geographical differences in the proportional use of methods of treatment, a general trend to apply CAPD more frequently in diabetic as compared to non-diabetic patients was observed, and this was true for countries with both predominant haemodialysis and predominant transplant programmes. Transplantation without prior dialysis was performed in 17% of Swedish and 30% of Norwegian patients with type I diabetes mellitus. In order to better explain the mortality of patients with diabetic ESRF, the proportional distribution of causes of death was analysed. Myocardial ischaemia and infarction was confirmed to be the leading cause of death in patients with diabetes mellitus on RRT. The coronary death rate was estimated to be 10 times greater in young patients with type I diabetes mellitus as compared to their non-diabetic counterparts. Other cardiovascular as well as infectious causes were recorded in a similar proportion of deaths in diabetics as in non-diabetics. Cancer deaths, however, appeared to be definitely less frequent in patients on RRT due to diabetic nephropathy.

Survival on renal replacement therapy: data from the EDTA Registry.

Extensive survival data are presented from the EDTA Registry's files for patients who started renal replacement therapy in 1970-1974 compared to 1980-1984. The contribution of the different treatment modalities (haemodialysis, continuous peritoneal dialysis, and transplantation) to the survival of patients according to geographical region is also shown. Survival on renal replacement therapy, irrespective of treatment modality and of primary renal disease, was best in the 10-14-year-old patients, with 58% at 10 years and 52% at 15 years, and decreased with rising age to 28% at 10 years and 16% at 15 years in patients aged 45-54 when they commenced therapy in 1970-1974. When comparing the 0-4-year-old with the 10-14-year-old cohort of the paediatric patients, 5-year survival rates for patients starting renal replacement therapy in the early eighties declined from 85% to 70% with decreasing age. Treatment policy, as reflected by the proportion of patients on different modes of therapy, varied markedly between European regions but affected survival to a small extent only. The large population with diabetic nephropathy incurred annual mortality rates 2-3 times greater than those observed in patients with 'standard' primary renal diseases. Haemodialysis and continuous peritoneal dialysis, although not comparable because of important differences in selection policy, yielded similar survival rates. Patients and graft survival rates have improved markedly when comparing patients starting renal replacement therapy in the early seventies with the eighties; particularly for cadaveric transplantation. Patient survival after second grafting was similar to that after first grafting, with 83% at 5 years after second cadaveric grafting in the 15-44-year-old cohort, vs 85% after first cadaver transplantation in 1980-1984. Second cadaveric graft survival was superior to average first-graft survival for those recipients whose first graft had been functioning for more than 1 year. However, second-graft survival in rapid rejectors of a first graft as well as third cadaveric graft survival were curtailed by the large number of early losses, with only 52% of third grafts functioning at 1 year. For living related donor transplantation, parents were mostly used in children whilst identical siblings predominated in adults older than 45. In the early eighties, patient survival was 92% at 5 years for recipients younger than 15, 87% for the 15-45 year old cohort and 72% for those aged 45 or older.(ABSTRACT TRUNCATED AT 400 WORDS)

Impact of cuts in acute beds on services for patients.

The current redistribution of resources in the National Health Service will require a reduction in the number of acute beds in many district health authorities. The effect of such a reduction on services for patients was examined. Two hundred and two general medical admissions and 201 general surgical admissions to hospitals in West Lambeth District Health Authority were reviewed retrospectively. The elements considered were the severity of the patient's illness at admission, the scope for reducing the length of stay, the potential for other forms of care, and what types of patients would be denied access at different levels of reductions in the number of beds. Given the assumptions a considerable potential for maintaining levels of service with fewer beds was identified. The finding was, however, that even if all of this potential was realised the cuts in the number of beds that are planned by districts that are losing resources would force real reductions in patient services. This suggests a "trade off." To increase services in districts that are gaining resources, real unmet need may have to be created in districts that are losing resources.

Report on the first 1000 patients treated at St Thomas' Hospital by extracorporeal shockwave lithotripsy.

Since March 1985, over 1000 patients have been treated on the lithotripter at St Thomas' Hospital. Since it is the only machine in the country offering treatment to National Health Service patients at no cost to the referring Health Authority, there has been a heavy demand for treatment and 97% of referrals have been accepted. Analysis of the first 1000 patients shows extracorporeal shockwave lithotripsy (ESWL) to be a safe procedure with a low morbidity rate and no mortality. The number of patients who were stone-free 3 months after treatment was low (44.1%) compared with the numbers reported in other series. The most likely reasons for this are the poor follow-up rate (48.9%), the stringent criteria for the diagnosis of "stone-free" and a possible skewed referral and follow-up pattern.

Treatment of end-stage renal failure due to diabetes in the United Kingdom, 1975-84.

In 1975-84 762 new patients with end-stage renal failure (ESRF) due to diabetes mellitus were accepted onto renal replacement programmes in the United Kingdom. They formed 5.7% of the total intake of ESRF patients. This proportion rose from 1.4% in 1975 to 11.1% in 1984. 4.1% of the patients on renal replacement therapy at the end of 1984 were reported as having ESRF due to diabetic nephropathy. During 1983-84, 272 patients taken on were type I (76%) and 87 (24%) were type II diabetics. Continuous ambulatory peritoneal dialysis (CAPD) was most popular as both initial (51%, plus 24% on intermittent peritoneal dialysis in 1983-84) and long-term treatment (48% of 446 under treatment at Dec 31, 1984); 163 patients (36.5%) had successful allografts, and only 14% of patients were on haemodialysis. Actuarial survival was 49% at 3 years, irrespective of type of treatment; the death rate for type II diabetics approached the intake rate in 1983-84. There was considerable regional variation in the numbers of diabetics on treatment. Even though the proportion of diabetics entering British end-stage renal failure programmes is rising, many patients who may benefit from treatment are probably not receiving it.

United Kingdom Heart Disease Prevention Project: 12-year follow-up of risk factors.

Ten of the original 24 factories from the United Kingdom Heart Disease Prevention Project were resurveyed in 1983 to assess the long-term (12-year) effects of an education program on diet, smoking, and exercise. These 10 factories had previously been grouped into five pairs matched for size, location, and nature of industry, with one of each pair randomly chosen for intervention. Men in intervention factories were given advice on reduction of cholesterol in diet, stopping smoking, weight reduction, and regular exercise. High-risk workers (13%) received personal counseling in addition to the factory-wide education program. A total of 1,204 workers randomly selected from those still employed in 1978 were surveyed. There were significant differences observed in cigarette consumption, butter use, and several other dietary behaviors; however, the differences were small and insignificant for the proportion smoking and leisure-time exercise. The largest effects were in the high-risk group who had received personal counseling. This education program appears to have some lasting effects on behavior associated with coronary disease risk factors. Similarly designed programs may serve as models for community-wide coronary disease prevention programs.

Negative selection of patients for dialysis and transplantation in the United Kingdom.

In order to understand why the United Kingdom ranks low in the treatment of end stage renal failure a questionnaire investigating knowledge of current acceptance practice for dialysis and transplantation was sent to various groups of doctors throughout the country. The questionnaire comprised 16 case histories of patients with established end stage renal failure and associated social and medical problems. In each case the responding doctor was asked to indicate whether the patient would be suitable for treatment by dialysis or transplantation or both. The questionnaire was sent to a randomly selected sample of general practitioners and non-renal consultant physicians and their responses compared with those of all the nephrologists identified in the United Kingdom. The mean number of cases rejected by both general practitioners and non-renal consultant physicians was significantly higher than the number rejected by nephrologists. The findings suggest that underreferral of patients to dialysis and transplant units contributes to the current low acceptance rate of new patients into treatment programmes in the United Kingdom.

KIE: A questionnaire, comprising 16 case histories of patients with end stage renal failure, was sent to all nephrologists in Great Britain and to a random sample of general practitioners and non-renal consultants. For each case, the physicians were asked to indicate the patient's suitability for dialysis and/or transplantation. Their responses revealed that the number of cases rejected by the general practitioners and consultants was significantly higher than the number rejected by the nephrologists. A small sample of North American and European nephrologists and general physicians indicated that they rejected far fewer cases. The authors conclude that underreferral of patients is one factor in the low rate of treatment for end stage renal failure in Britain as compared to other developed countries.