The relationship between patients' perception of the effects of neurofibromatosis type 2 and the domains of the Short Form-36.

OBJECTIVES: To investigate the relationship between those issues concerning quality of life in patients with neurofibromatosis type 2 (NF2) as identified by the closed set NF2 questionnaire and the eight norm-based measures and the physical component summary (PCS) and mental component summary (MCS) scores of the Short Form-36 (SF-36) Questionnaire. DESIGN: Postal questionnaire study. SETTING: Questionnaires sent to subjects' home addresses. PARTICIPANTS: Eighty-seven adult subjects under the care of the Manchester Multidisciplinary NF2 Clinic were invited to participate. MAIN OUTCOME MEASURES: Sixty-two (71%) completed sets of closed set NF2 questionnaires and SF-36 questionnaires were returned. RESULTS: Subjects with NF2 scored less than the norm of 50 on both the physical component summary and mental component summary scores and the eight individual norm-based measures of the Short Form-36 questionnaire. Correlations (using Kendall's tau) were examined between patients' perceptions of their severity of difficulty with the following activities and the eight norm-based measures and the physical component summary and mental component summary scores of the Short Form-36 questionnaire: Communicating with spouse/significant other (N = 61). The correlation coefficients were significant at the 0.01 level for the mental component summary score, together with three of the norm-based scores [vitality (VT), social functioning and role emotional]. Social communication (N = 62). All 10 correlations were significant at the 0.01 or 0.001 level. Balance (N = 59). All 10 correlations were highly significant at the P < 0.001 level. Hearing difficulties (N = 61). All correlations were significant at either the 0.01 level or less apart from the mental component summary score and three of the norm-based scores (role physical, VT and mental health). Mood change (N = 61). All correlations were significant at the 0.01 level or less, apart from one norm-based score (role physical). CONCLUSIONS: The Short Form-36 questionnaire has allowed us to relate patients' perceptions of their difficulties, as identified by the closed set NF2 questionnaire, to the physical and mental domains measured by this validated and widely used scale, and has provided further insight into areas of functioning affected by NF2.

Use of a closed set questionnaire to measure primary and secondary effects of neurofibromatosis type 2.

OBJECTIVES: To identify the greatest difficulties reported by people affected by neurofibromatosis type 2, and to determine the relationship between the primary and secondary effects of the disease. DESIGN: Postal questionnaire study. SETTING: Questionnaire sent to subjects' home addresses. PARTICIPANTS: Eighty-seven adult patients under the care of the Manchester multidisciplinary neurofibromatosis type 2 team were invited to take part. MAIN OUTCOME MEASURE: The response rate was 62 out of 87 (71 per cent). RESULTS: Respondents' answers emphasised that their greatest problem was deafness, which resulted in communication difficulties with social contacts, close partners, family and friends. Correlation coefficients indicated a relationship between general mood changes and hearing difficulties, social communication problems, balance difficulties and mobility problems. Self-confidence was significantly related only to social communication problems. CONCLUSIONS: The use of a closed set neurofibromatosis type 2 questionnaire identified hearing problems and subsequent communication difficulties as the main problems faced by people with this condition.

Improving cancer patients' pain: the impact of the hospital specialist palliative care team.

Pain is reported to occur in the majority of patients with advanced cancer and is one of the main reasons for referral to a hospital specialist palliative care team. Yet despite this, there is a paucity of research into the impact the hospital specialist palliative care team has on pain control in patients. A non-equivalent control group design using a quota sample investigated 100 cancer patients who had been admitted to hospital for symptom control. Fifty patients received specialist hospital palliative care team intervention compared with 50 patients receiving traditional care. Outcome was assessed using the Palliative Care Assessment (PACA) tool on three occasions. There was no difference between the groups on the initial assessment and the results indicated that all cancer patients admitted to hospital had a significant improvement in their pain control. However, the patients who had the additional input of the palliative care team demonstrated a statistically significant greater improvement than the control group (P<0.001). Potential explanations are made for the results including the enhanced knowledge and skills of the hospital specialist palliative care team.

The distribution of cardiac macrophages in myocardial ischaemia and cardiomyopathy.

AIMS: Recent evidence has implicated the macrophage as an effector cell in the inflammatory processes in transplant rejection, as well as cardiac disease, including coronary atherosclerosis. Although the latter is a vascular disease, the entire myocardium is affected. We have previously demonstrated the presence and distribution of macrophages in the 'normal' human heart. In this paper the distribution of myocardial macrophages, in the various chambers of the failing human heart, from cases of coronary atheroma and cardiomyopathy undergoing heart transplantation is documented. METHODS AND RESULTS: Tissue blocks were removed at specific sites taken from six cases with ischaemic heart disease (IHD) (four males, two females, age range 54-62 years), and four cases with idiopathic dilated cardiomyopathy (IDCM) (three males, one female, age range 18-49 years). These were compared with hearts from five cases of sudden death, unrelated to heart disease. Sections were stained with a CD68 pan macrophage marker. Positive cells were enumerated in 20 random fields. Results were analysed using a generalized linear modelling method using a Poisson distribution. Macrophages were identified within the interstitium and often close to blood vessels in all hearts. Macrophages from IHD hearts demonstrated the most intense staining and were often larger and more elongated than those found in 'normal' control hearts. Macrophages were also often degranulated and staining was diffuse in the interstitium. Overall, there were significantly more macrophages in most areas from IHD hearts than from IDCM hearts or control hearts (P < 0.001). CONCLUSIONS: Significantly more macrophages were found in all four chambers in diseased hearts compared with controls. Macrophage numbers were higher in the atria than in ventricles in the diseased myocardium. This study suggests selective recruitment of macrophages into the atria in the disease states studied.

Patient communication during cataract surgery.

PURPOSE: Most cataract surgery is now performed under local anaesthesia on a day-case basis. As patients are fully conscious during the procedure, it is important that they remain still. There are a variety of reasons why patients may need to move, and it is important that the surgeon is made aware that this may happen. Some centres offer a nurse's hand as a means of perioperative patient communication. We sought to study the safety and efficacy of using an electronic patient-controlled alert device. METHOD: We compared hand-holding with the use of a patient alert device, and with both communication methods at the same time, on 150 subjects undergoing cataract surgery under local anaesthesia. Assessment of pre- and postoperative state anxiety was undertaken and patients' satisfaction with the communication strategies was assessed. RESULTS: There was a significant difference between pre- and postoperative state anxiety for each group (P<0.001) but no significant differences in pre-, peri-, or postoperative state anxiety between groups. There were no significant differences in confidence, pain, understanding, satisfaction, memory, and reassurance between the three groups. A total of 46% of all patients reported experiencing one or more of the potential problems enquired about, during the operation. Significant correlations were also identified between some of the psychological variables investigated. CONCLUSIONS: An electronic patient alert device is as effective a means of perioperative patient communication as holding a nurse's hand, during cataract surgery under local anaesthesia. It is safe, reassuring and it allows patients to communicate directly with the surgeon.

Simultaneous mapping of blood volume and endothelial permeability surface area product in gliomas using iterative analysis of first-pass dynamic contrast enhanced MRI data.

We describe a novel method for the calculation of endothelial permeability surface area product from dynamic contrast enhanced MRI. The technique uses iterative estimation to automatically decompose tissue residue function into intravascular and extravascular components, which are subsequently used to generate tumour blood volume, which is equal to relative cerebral blood volume calculated from T(1) weighted images and corrected for contamination by contrast agent leakage (rCBV(T1)(corrected), and endothelial permeability (k(fp)) maps. The technique was assessed in patients with cerebral glioma (n=5) by examining the reproducibility of endothelial permeability and rCBV(T1)(corrected) between two separate examinations conducted with a 2-day interval. The technique produces maps of endothelial permeability that appear to be free of any contribution from intravascular contrast agent. Maps of rCBV(T1)(corrected) show close correlation with maps of blood volume calculated from independently acquired dynamic susceptibility weighted MRI examinations, with no evidence of residual permeability effects. The results were highly reproducible with strong intra-class correlation between the two examinations for mean values and for 97.5 percentiles of endothelial permeability and rCBV(T1)(corrected). The excellent reproducibility of this technique and the ability to calculate endothelial permeability and rCBV(T1)(corrected) values from rapidly acquired data sets offer considerable advantages over conventional approaches and support the use of this methodology for therapeutic monitoring or trials of novel therapeutic agents.

Borderline nuclear change; can a subgroup be identified which is suspicious of high-grade cervical intraepithelial neoplasia, i e CIN 2 or worse?

Borderline nuclear change; can a subgroup be identified which is suspicious of high-grade cervical intraepithelial neoplasia, i.e. CIN 2 or worse? Only 10% of first borderline smears are associated with a histological high-grade (HG) abnormality, i.e. CIN 2,3, invasive malignancy or glandular neoplasia on subsequent investigation. The advantages of highlighting this subgroup are obvious but is this possible? From 1996 and 1997, 242 borderline smears with histological follow-up were examined by two independent experienced observers (observer 1 and 2) without prior knowledge of further investigation results. For each smear a profile of nuclear details was produced, also noting the type of cell mainly affected by the process; then the observers were asked to assess the degree of worry of HG disease for each smear i.e. whether the smear fell into group 1 borderline changes indicative of low-grade (normal, inflammatory, CIN1/HPV) disease (BL/LG) or group 2 difficult borderline smear, HG disease (CIN 2,3, invasive neoplasia or glandular neoplasia) cannot be excluded (BL/HG). Observer 1 selected a group of BL/HG with a PPV for HG disease of 38%, with observer 2 having a PPV of 50%; this compared with the overall laboratory HG disease PPV for borderline smears of 14%. Both observers found the most useful criterion to be the increase in nuclear:cytoplasmic ratio. Our results show that it is possible to separate a small group of borderline smears which should be classified as 'borderline/high grade lesion difficult to exclude' (BL/HG). Both observers had some success in arriving at this classification although their method of selecting out this group was quite different.

Identification of inguinal lymph node metastases from vulval carcinoma by magnetic resonance imaging: an initial report.

AIM: Magnetic Resonance Imaging (MRI) has the potential to assess inguinal lymph nodes more accurately than palpation and less invasively than surgical exploration. The objective of this study was to measure the accuracy of MRI in identifying inguinal metastases by demonstrating abnormal lymph node morphology. MATERIALS AND METHODS: 10 women with vulval malignancy underwent T1- and fat-suppressed T2-weighted surface coil MRI of both groins before surgery. Each groin was prospectively categorised as normal or as having metastatic lymphadenopathy using criteria established in normal volunteers. Histopathological findings in patients undergoing groin dissection for invasive vulval carcinoma were used as validation. RESULTS: MRI had a positive predictive value of 89%, negative predictive value of 91%, sensitivity of 89%, specificity of 91% and accuracy of 90%. The most useful observations on MRI to identify metastatic lymphadenopathy were those of lymph node contour irregularity, cystic change in a lymph node, short axis diameter exceeding 10mm and abnormal long: short axis diameter ratio. CONCLUSION: High resolution MRI of the inguinal regions has potential to screen for lymph node metastases in patients with vulval cancer, with the aim of reducing the number of women who have to undergo groin dissection.

Review of safety in endoscopic laser foraminoplasty for the management of back pain.

OBJECTIVE: The purpose of this study was to analyze the incidence and gravity of reported complications that arise in spinal surgery and assess the comparative safety, or otherwise, of endoscopic laser foraminoplasty (ELF). BACKGROUND DATA: Chemonucleolysis, decompression, discectomy, and fusion have long been cited as treatments for chronic low back pain. Over recent years newer, less invasive surgical techniques have become available, one such being ELF. Although minimally invasive, the beneficial outcome must be interpreted in relation to concerns regarding the safety of the procedure and its risks relative to those of other forms of spinal surgery. The Spinal Foundation, Rochdale has performed 958 ELFs and has collated a comprehensive database of the results of all these operations. These prospective records provided the basis for a comparison of the safety of ELF to that reported with other spinal surgical techniques. METHODS: A total of 958 procedures have been performed on 716 patients. Complications that arose during the operation and the postoperative phase of 6 weeks following the procedure were elicited from patient records. These data were correlated and compared to a meta-analysis of randomized controlled clinical trial data of complications arising during and after conventional spinal surgery. The SPSS (statistical package for social sciences) and CIA (confidence interval analysis) statistical packages were used to draw conclusions regarding the safety of ELF. RESULTS: The cohort integrity of operation and outpatient review records at 6 weeks after surgery was 100%. In 958 ELFs performed, 24 complications occurred in 23 patients. There were 9 cases of discitis (1 infective, 8 aseptic) (0.9%), 1 dural tear (0.1%), 1 deep wound infection (0.1%), 2 patients suffered a foot drop (1 transient) (0.2%), 1 myocardial infarction (0.1%), 1 erectile dysfunction (0.1%), and 1 patient who developed panic attacks post-operatively (0.1%). This amounts to an overall surgical complication rate of 1.6%. Magnetic resonance imaging (MRI) follow up of clinically symptomatic patients highlighted 8 residual disc herniations (0.8%). Meta-analysis of randomized controlled trials of conventional spinal surgery for adult onset degenerative disc disease and/or sciatic pain reported overall complication rates for fusion (11.8%), decompression (7.6%), discectomy (6.0%), and chemonucleolysis (9.6%). CONCLUSIONS: The complication rate of ELF is shown to be significantly lower than that reported following conventional spinal surgery (p < 0.01). From these results, we conclude that ELF as a treatment for chronic low back pain and sciatica presents less risk to a patient than conventional methods of spinal surgery.

Ethnic variation in fluorescein angiography induced nausea and vomiting.

PURPOSE: A prospective survey was undertaken to investigate ethnic variations in the frequency of nausea and vomiting after fundus fluorescein angiography (FFA). METHOD: Between May and September 1998, 197 adult patients were recruited to the study. A questionnaire containing closed-ended questions was completed by nurses after each FFA and a questionnaire was given to patients to complete 5 hours after the procedure at home. Patients' anxiety level was measured before FFA using a 5-item ordinal response scale. RESULTS: Results indicate that patients from black, Asian, Chino-Asian and mixed ethnic origins are significantly more likely to vomit and feel nauseous immediately after the administration of fluorescein dye. Patients with a history of nausea after FFA are significantly more likely to feel nauseous again after repeat FFA. CONCLUSION: Ethnic origin and a previous history of nausea and vomiting appear to be important factors in FFA-induced nausea and vomiting. The results of this study have led the investigators to develop a protocol for the prophylactic treatment of nausea and vomiting following FFA.

Assessing the impact of a nurse-led health education intervention for people with peripheral vascular disease who smoke: the use of physiological markers, nicotine dependence and withdrawal.

This study evaluated the impact of a nurse-led health education programme on the behaviour, nicotine dependence and nicotine withdrawal in patients who smoke and suffer from peripheral vascular disease, based in a large teaching hospital in the north of England. Smoking behaviour was measured by self report, end-expired carbon monoxide and urinary cotinine. Nicotine dependence and withdrawal were measured using a nicotine dependence scale and a nicotine withdrawal scale. The findings demonstrated that the programme did have some impact on behaviour. The study raised issues concerning the measurement of physiological markers for smoking as nursing outcomes. Issues about the measurement of nicotine dependence and withdrawal are highlighted.

Attention to infants in the first year.

The time spent by 158 infants in contact with their carers at 6, 13, 26 and 52 weeks was reviewed prospectively. Periods of contact in the categories of (1) physical care, (2) holding the crying or sleeping infant, and (3) playing and interacting with the infant were recorded using 24-h log diaries completed by the mother. The mean total carer contact time over a 24-h day did not change significantly in the first year, varying between 6.5 and 73 h. Between 6 and 52 weeks, time spent by the mother in physical care declined significantly from 207 to 143 min and in holding the crying or sleeping infant from 61 to 17 min (P < 0.05 and 0.0001 respectively). There were no significant changes in the amount of time spent in playing and interacting with the infant over the first year by the mother and father, the time being on average 52.7 and 25.0 min respectively. Play and interaction with a non-parental carer increased significantly from 14 to 69 min (P < 0.0001). Relationships between infant size and holding became weaker as the infant became older. Infant gender, socioeconomic status and duration of breast-feeding did not influence infant contact time.

Monitoring the circulatory responses of shocked patients during fluid resuscitation in the emergency department.

OBJECTIVES: To assess the feasibility of constructing left ventricular response curves non-invasively during the fluid resuscitation of critically ill patients in the emergency department (ED) using a portable suprasternal Doppler ultrasound (PSSDU) device. DESIGN: Prospective case series. SETTING: Emergency department, Catholic University of Leuven, Belgium. PATIENTS: Shocked patients in the ED were diagnosed by predefined criteria. Only those thought to require standardised intravenous colloid challenges were observed i. e., sequential boluses of 3.5 ml/kg/10 min titrated against changes in stroke distance (Doppler surrogate for left ventricular stroke volume). RESULTS: A total of 50 shocked patients were studied. Stroke distance was measurable in 45 patients. 35 patients were fluid responders in terms of stroke distance. Group mean stroke distance increased during resuscitation (8.6 +/- 4.1 cm to 19.5 +/- 4.6 cm, P < 0.001) and then reached a plateau value (19.6 +/- 4.6 cm, P = 0.488). No response to fluid was seen in nine patients of which eight had severe sepsis. Alternative therapeutic approaches increased stroke distance for all of these patients. Evidence for right ventricular dysfunction was found as a cause for fluid non-response in the majority of patients with sepsis. CONCLUSIONS: Previous experimental work has shown that changes in central blood flow can be derived using the PSSDU device. This clinical feasibility study suggests that the PSSDU can help tailor haemodynamic therapy for an individual patient and give an early indication of treatment failure in the ED.

Memory dysfunction in multiple sclerosis corresponds to juxtacortical lesion load on fast fluid-attenuated inversion-recovery MR images.

BACKGROUND AND PURPOSE: MR imaging is a sensitive diagnostic tool and paraclinical marker of disease activity and prognosis in multiple sclerosis (MS), yet the role of MR imaging of MS is controversial. The aim of this study was to describe the relationship between cognitive function and MS lesion size and position, as shown on comparative images from conventional spin-echo (CSE) and fast fluid-attenuated inversion-recovery (fast FLAIR) MR studies. METHODS: CSE and fast FLAIR sequences consisted of 40 noncontiguous, 3-mm-thick axial sections matched for geometric position in 18 patients with relapsing-remitting MS. Lesions were scored for size, anatomic position, and their comparative appearance on CSE and fast FLAIR images. The neuropsychological assessment tested general psychological performance, memory, and frontal lobe executive function. RESULTS: Fast FLAIR images showed significantly more small (146 versus six) and medium-sized (18 versus four) juxtacortical lesions than did CSE sequences. Small juxtacortical lesions displayed only on fast FLAIR images had a distinctive appearance, suggestive of small areas of perivascular inflammation. The number of these lesions corresponded to reduced performance on the fifth and delayed trials of the Rey Auditory Verbal Learning memory function test. CONCLUSION: Fast FLAIR images show small lesions at the juxtacortical boundary that are not seen on CSE studies. The presence of such lesions correlates with impaired retention of information in memory tasks, which is characteristic of cognitive problems in patients with MS.

Measurement of communication skills in cancer care: myth or reality?

Despite wide agreement about the importance of effective communication in cancer care there is continuing evidence of the need for nurses, doctors and colleagues to be helped to improve their communication skills. Consequently, there has been a growing demand for effective methods for evaluation of communication training programmes. This paper discusses theoretical perspectives in this field and describes the rationale underpinning the development of a detailed objective method of assessing interviews between health professionals and cancer patients. The method enables an utterance by utterance rating of transcribed interviews to be made which can be used to construct profiles of interviewer and patient behaviours and interactions. All categories were developed from interviews drawn from a large sample of participants (n=206) at counselling skills workshops. Six domains have been identified and these are: grammatical style; the purpose of each technique; what is being discussed, the degree of feeling expressed; explicit avoidance; and the use made of patients' cues. Each domain contains a mutually exclusive set of categories. In addition the method enables the sequence of events to be plotted. Using these methods, examples from published studies will be given to show how the processes of interaction within a health care interview can be better understood, thus enabling the most effective techniques to be taught, the effectiveness of different teaching methods to be assessed and how changes brought about by training have the potential to make a significant clinical difference to patients.

Blood gas analysis: a study of blood loss in intensive care.

This paper describes a quantitative study conducted on an intensive care unit in the north of England. It involved the collection of data from the existing records of 65 patients consecutively sampled from a predetermined date provided that they stayed more than 24 hours and had an arterial line in situ. As patient records were used, ethical approval was not necessary. The objectives of the study were to quantify the mean number of blood gas samples taken per patient and estimate the mean blood loss resulting from this, including discard volume. Limitations include reliance on records and lack of an economic evaluation. The results show that blood loss in this study was greater than that reported elsewhere. Patients who were ventilated for 24 hours or more had a statistically significant greater blood loss when compared to those who were not (P < 0.001). A subgroup of patients undergoing renal replacement therapy had the greatest blood loss (mean 55.18 ml per day). This loss was statistically significant when compared to patients not in acute renal failure (P=0.007). When patients undergoing multiple therapies normally associated with increased sampling were compared to patients not receiving such therapies, there was no statistically significant difference in blood loss. The need to change current nursing practice to reduce iatrogenic anaemia is emphasized.

Assessment of the pain of blood-sugar testing: a randomised controlled trial.

Lancet puncture to the side of the thumb resulted in less pain than lancet puncture to the finger or venepuncture at the elbow. Success rates were the same.

The effect of foot massage on patients' perception of care following laparoscopic sterilization as day case patients.

This randomized-controlled study examined the effects of foot massage on patients' perception of care received following surgery. The sample of 59 women who underwent laparoscopic sterilization as day case patients were randomly allocated into two groups. The experimental group received a foot massage and analgesia post-operatively, whilst the control group received only analgesia post-operatively. Each participant was asked to complete a questionnaire on the day following surgery. This examined satisfaction, memory and analgesia taken. The 76% response rate was comparable with other patient satisfaction studies following day-case surgery. Statistical analysis showed no overall significant difference in the pain experienced by the two groups; however, the mean pain scores recorded following surgery showed a significantly different pattern over time, such that the experimental group consistently reported less pain following a foot massage than the control group. This study has attempted to explore the use of foot massage in a systematic way and is therefore a basis for further study.

Post-operative nausea and vomiting following orbital hydroxyapatite implant surgery.

Fifty-five consecutive patients undergoing a short-stay ophthalmic operation (orbital hydroxyapatite implantation) were recruited over 1 year to assess the frequency and duration of post-operative nausea and vomiting over 7 days. The incidence of nausea and vomiting in hospital was recorded. Patients scored their nausea and vomiting four times daily at home. By the end of the first day after surgery, 31 (75%) patients had experienced mild to severe nausea. Eighteen (38%) patients became nauseated on five or more occasions. Nineteen (35%) patients had vomited by the end of the first day after surgery and, over 7 days, 24 (43%) patients had vomited on one or more occasion. Three patients reported that they had vomited during the journey home. Vomiting was not correlated with pain or a past history of post-operative nausea and vomiting. However, there was a statistically significant correlation between nausea and pain. The high incidence of nausea and vomiting observed in this study appears to provide additional evidence of an oculo-emetic reflex. The timing of discharge and appropriate patient education are discussed.

Suprasternal Doppler ultrasound for assessment of stroke distance.

An assessment of a non-invasive technique for measurement of stroke distance was made using a portable Doppler ultrasound machine. The aim was to determine the measurement error of repeated stroke distance measurements (Within-observer variability) and to assess measurement agreement between two operators (between-observer variability). The measurement error (within-observer variability) for both operators was similar at approximately 2 cm. However, the measurements of the two operators (between-observer variability) did not agree well. Using the mean (SD) of three readings by each operator, the mean difference between the operators was -0.21 cm (1.96) giving a 95% confidence interval for the differences of -4.0 to +3.6 cm. There were significant positive and negative correlations between stroke distance and a variety of variables (age, height, weight, heart rate), but the relations were weak. The results indicate that the Doppler ultrasound technique for measurement of stroke distance would best be used to study trend changes in an individual patient, or subject, by a single operator.