Assessment of distance from skin surface to muscle for evaluation of the risk of inadvertent intramuscular insulin injection at potential injection sites among patients attending a tertiary care children's hospital in Sri Lanka-an observational study.

BACKGROUND: Insulin therapy is essential for type 1 diabetes. While a reasonable glycemic control prevents complications, inadvertent intramuscular (IM) insulin injection results in hypoglycemia and fluctuations of blood glucose levels. OBJECTIVE: To assess the subcutaneous thickness (SCt) at the potential insulin injection sites, in order to determine the suitable needle length. METHODS: Diabetic and non-diabetic children (n=125; aged 2-14 years) attending a tertiary care hospital were examined, after excluding those who had skin abnormality at the injection site, were hospitalized for>3 days, or had any other chronic illnesses. Dermal thickness (Dt) and SCt at the potential insulin injection sites were measured with ultrasonography. RESULTS: The mean age of the patients was 8 years and 57% were boys; mean Dt was 2.1±0.4 mm, SCt was 7.45.6±3.7 mm, and maximum SCt was 29.8 mm in the anterior abdominal wall. SCt increased with age and by raising a skin fold (sf). There was no difference (P>0.05) in Dt between genders, and limbs showed thinner Dt values than the abdomen. SCt changed with the injection site: it was the lowest in the thigh and the highest in the abdomen. SCt was thicker in females, with or without sf (P<0.001). For all sites, IM risk was high for 15-mm needles: it was highest in the thighs (98%) and reduced to 86% with sf. IM risk was low for 5-mm needles: it was highest in the thigh (38%), and reduced to 12% with sf. Compared with girls (up to 42%), IM risk was higher for boys (up to 54%), even for 5-mm needles with a sf. CONCLUSION: Using a short needle is recommended for children, particularly for boys. Regardless of the needle length, the raised sf technique is associated with reduced IM risk.

Prostatic pathology reporting in the UK: development of a national external quality assurance scheme.

AIMS: To develop a baseline picture of prostatic pathology reporting in the UK, identify areas of particular difficulty and assess the feasibility of a national external quality assurance scheme based on prostatic biopsy specimens using the same format as the National Health Service breast pathology scheme, as recommended by the National Institute for Clinical Excellence. METHODS AND RESULTS: Eight expert uropathologists and 32 randomly selected pathologists participated in four circulations each of 12 cases of prostatic biopsy specimens. A fixed text proforma was developed and responses were analysed for interobserver agreement using kappa statistics. Consistency of reporting the main diagnostic categories of benign and invasive carcinoma was good (kappa values 0.77 and 0.88, respectively), but only after excluding 19% of cases for which the experts did not reach 75% agreement. Areas of difficulty included the diagnosis of high-grade prostatic intraepithelial neoplasia and small foci of cancer. Prognostic factor reporting was more variable, with lower overall kappas for the assessment of Gleason grading (experts 0.55, others 0.50), perineural invasion (experts 0.64, others 0.50) and number of positive cores (experts 0.74, others 0.61). CONCLUSIONS: Given the difficulties in diagnosis of prostatic biopsy specimens and the assessment of prognostic factors, the expansion of the scheme could deliver important educational benefits.

A death due to concussive brain injury augmented by alcohol (case report).

We report here the case of a death following blunt trauma to the head in which the victim immediately became unconscious and remained unconscious until death. There were no associated intracranial bleeding or visible macroscopic/microscopic injuries to the brain. Additional injuries to other parts of the body included non-fatal contusions and abrasions. The victim was intoxicated, with a blood alcohol level of 168 mg/dl. Therefore, the conclusion was drawn that death in this case was due to the combination of the concussive effects of the head trauma and the central nervous system depressant effects of alcohol.

The NHS breast screening programme (pathology) EQA: experience in recent years relating to issues involved in individual performance appraisal.

BACKGROUND: The original role of the National Health Service breast screening programme (pathology) external quality assessment (EQA) scheme was educational; it aimed to raise standards, reinforce use of common terminology, and assess the consistency of pathology reporting of breast disease in the UK. AIMS/METHODS: To examine the performance (scores) of pathologists participating in the scheme in recent years. The scheme has evolved to help identify poor performers, reliant upon setting an acceptable cutpoint. Therefore, the effects of different cutpoint strategies were evaluated and implications discussed. RESULTS/CONCLUSIONS: Pathologists who joined the scheme improved over time, particularly those who did less well initially. There was no obvious association between performance and the number of breast cancer cases reported each year. This is not unexpected because the EQA does not measure expertise, but was established to demonstrate a common level of performance (conformity to consensus) for routine cases, rather than the ability to diagnose unusual/difficult cases. A new method of establishing cutpoints using interquartile ranges is proposed. The findings also suggest that EQA can alter a pathologist's practice: those who leave the scheme (for whatever reason) have, on average, marginally lower scores. Consequently, with the cutpoint methodology currently used (which is common to several EQA schemes) there is the potential for the cutpoint to drift upwards. In future, individuals previously deemed competent could subsequently be erroneously labelled as poor performers. Due consideration should be given to this issue with future development of schemes.

Impact of a national external quality assessment scheme for breast pathology in the UK.

BACKGROUND: This article presents the results and observed effects of the UK National Health Service Breast Screening Programme (NHSBSP) external quality assurance scheme in breast histopathology. AIMS/METHODS: The major objectives were to monitor and improve the consistency of diagnoses made by pathologists and the quality of prognostic information in pathology reports. The scheme is based on a twice yearly circulation of 12 cases to over 600 registered participants. The level of agreement was generally measured using kappa statistics. RESULTS: Four main situations were encountered with respect to diagnostic consistency, namely: (1) where consistency is naturally very high-this included diagnosing in situ and invasive carcinomas (and certain distinctive subtypes) and uncomplicated benign lesions; (2) where the level of consistency was low but could be improved by making guidelines more detailed and explicit-this included histological grading; (3) where consistency could be improved but only by changing the system of classification-this included classification of ductal carcinoma in situ; and (4) where no improvement in consistency could be achieved-this included diagnosing atypical hyperplasia and reporting vascular invasion. Size measurements were more consistent for invasive than in situ carcinomas. Even in cases where there is a high level of agreement on tumour size, a few widely outlying measurements were encountered, for which no explanation is readily forthcoming. CONCLUSIONS: These results broadly confirm the robustness of the systems of breast disease diagnosis and classification adopted by the NHSBSP, and also identify areas where improvement or new approaches are required.

Collaborative development of a new course and service in Sri Lanka.

Great Ormond Street Hospital (GOSH) has a long established service development and research programme with Sri Lankan colleagues. The Centre for International Child Health (CICH) is an academic unit with public health interests in the countries of the South. Together a group of collaborators at GOSH, CICH and in Sri Lanka worked together to plan how a cadre of health workers could be prepared to work with people with communication disabilities. This is not an uncommon aim in under-served countries and there is a small published literature about the courses which have been developed. Choices about models for training, service delivery and ensuring sustainability in emerging services for people with communication disabilities are complex. Links can be made with development work in other disciplines. The literature relating to these issues in countries such as Sri Lanka is examined.