Clinical utility of plain-film abdominal radiographs for inpatients outside standard working hours in a large university teaching hospital.

INTRODUCTION: Plain film abdominal radiographs (PFAs) are frequently the initial investigation ordered for patients with abdominal symptoms. However, increasing use of emergency ultrasound and availability of emergency CT raises the question of whether PFA remains an appropriate first line investigation. We investigated the impact of out of hours (OOH) PFAs on inpatient management. METHODS: All consecutive PFAs over an 8-week period were included to determine the impact on patient management. OOH was classified as from 5pm to 9am Monday to Friday, weekends and bank-holidays. PACS and hospital records were accessed to determine patient pathways. The institution is a tertiary referral centre with 850 acute beds and serves a population of 950,000. RESULTS: A total of 758 consecutive PFAs were performed in total (58.3% male, mean age 58.1 (range 0-93)). 310 (40.9%) were requested from the emergency department (ED) and 382 (50.4%) were requested from wards. 160 (21.1%) met the criteria of OOH, of these 120 (72.2%) were from ED and 28 were on adult inpatients. Of these 28, none had a change in management based on the PFA result. CONCLUSION: Our study suggests that OOH PFAs of inpatients are of limited clinical utility. These patients are exposed to extra radiation. IMPLICATIONS FOR PRACTICE: We propose that OOH PFAs of inpatients should be questioned as a viable investigation due to the limited contribution they offer in managing patients, the deleterious effects they confer on the patient and the associated economic cost. Further studies are needed to assess if these results are generalizable to other large hospitals.

Radiology trainees in the UK and Ireland: academic background, publication rates and research plans.

To assess the level of achievement of current trainees, we investigated the academic qualifications, publication rates and future research plans of 240 radiology trainees in the UK and Ireland. All radiology trainees in the UK and Ireland were surveyed by a questionnaire enquiring about academic record and career ambitions. Our study shows that the level of academic achievement of radiology trainees is high, and provides interesting information concerning the current group of radiology trainees in these regions. It will be of interest both to radiology trainers and to doctors hoping to pursue a career in radiology. It also demonstrates that a potential recruitment crisis in academic radiology exists.

Renal trauma in the west of Ireland--a regional review.

We herein present a regional review of the management of renal trauma in the west of Ireland. The majority of renal injuries occur as a result of blunt trauma and are amenable to conservative management. We sought to streamline the management of renal trauma in the west of Ireland. With the current restructuring of the Irish Health Service, it is important to acknowledge the role of the urologist in the management of trauma patients.

Sestamibi scan-directed, minimally invasive video-assisted parathyroidectomy: an effective treatment for solitary parathyroid adenoma.

BACKGROUND: Solitary adenomas have been shown to be responsible for almost 90% of cases of primary hyperparathyroidism. AIM: The purpose of this study was to determine the utility of sestamibi scanning pre-operatively to guide minimally invasive video-assisted (MIVA) parathyroidectomy. METHODS: We reviewed 40 patients who underwent parathyroidectomy between 2003 and 2004. All patients underwent a pre-operative sestamibi scan. RESULTS: Thirty-three (82%) patients had a localized solitary adenoma on sestamibi scan. Of these patients 29 underwent attempted MIVA parathyroidectomy. MIVA parathyroidectomy was successful in 22 patients. When pre-operative sestamibi scanning was correlated with pathological diagnosis it was shown to have a sensitivity of 82% and positive predictive value of 94%. CONCLUSION: Pre-operative sestamibi scan localization of a parathyroid adenoma offers a 94% positive predictive value for adenoma location. This facilitates MIVA parathyroidectomy to be used effectively to treat primary hyperparathyroidism in the majority of patients.

Polyethylene glycol solution as an oral contrast agent for MRI of the small bowel in a patient population.

AIM: To assess the efficacy of polyethylene glycol solution as an oral contrast agent in a patient population. MATERIAL AND METHODS: Patients were fasted from 12.00 am. Administration of the oral contrast medium commenced 15 min before imaging and comprised one sachet of Norgine (Klean-prep, Middlesex, UK) reconstituted in 1 l water of which the patient took between 500-750 ml. Norgine is a balanced mixture of polyethylene glycol and electrolytes, which when added to water produces a clear colourless, iso-osmotic solution. RESULTS: In total 38 candidates were identified retrospectively covering a 2-year period. Visualization of the jejunum, ileal loops and ileocaecal region was excellent or sufficient in 87, 95 and 89%, respectively. The time taken to obtain complete visualization of the small bowel, from the jejunum to the ileocecal region varied from 15-240 min with an average time of 65 min and 73.7% of patients necessitating delayed imaging. CONCLUSIONS: Polyethylene glycol was demonstrated to be an excellent oral contrast medium in distending the small bowel. However, small bowel transit times were significantly delayed and problematic necessitating repeated imaging within the patient population. As result of theses findings longer examination time should be expected within a patient population and this should be borne in mind when scheduling patients.

Comparison of synthetic saponin cholesterol absorption inhibitors in rabbits: evidence for a non-stoichiometric, intestinal mechanism of action.

The hypocholesterolemic activities of pamaqueside and tiqueside, two structurally similar saponins, were evaluated in cholesterol-fed rabbits. The pharmacological profiles of the saponins were virtually identical: both dose-dependently decreased the intestinal absorption of labeled cholesterol 25-75%, increased fecal neutral sterol excretion up to 2.5-fold, and decreased hepatic cholesterol content 10-55%. High doses of pamaqueside (>5 mg/kg) or tiqueside (>125 mg/kg) completely prevented hypercholesterolemia. Decreases in plasma and hepatic cholesterol levels were strongly correlated with increased neutral sterol excretion. Ratios of neutral sterol excreted to pamaqueside administered were greater than 1:1 at all doses, in opposition to the formation of a stoichiometric complex previously suggested for tiqueside and other saponins. Ratios in tiqueside-treated rabbits were less than unity, a reflection of its lower potency. Pamaqueside-treated rabbits exhibited a more rapid decline in plasma cholesterol concentrations than control animals fed a cholesterol-free diet, indicating that the compound also inhibited the absorption of biliary cholesterol. Intravenous administration of pamaqueside had no effect on plasma cholesterol levels despite plasma levels twice those observed in rabbits given pamaqueside orally. These data indicate that pamaqueside and tiqueside induce hypocholesterolemia by blocking lumenal cholesterol absorption via a mechanism that apparently differs from the stoichiometric complexation of cholesterol hypothesized for other saponins.

Digitized mammograms: a preliminary clinical evaluation and the potential for telemammography.

We performed a preliminary clinical evaluation of digitized mammograms to assess whether digital images suitable for telemammography could be obtained. Thirty mammograms were digitized at a resolution of 4000 x 4000 pixels and 12 bit/pixel. The series contained 17 carcinomas in 16 patients. Five consultant radiologists reported both the original mammograms and the digitized images. There was agreement between the reports of the mammograms and the digitized images in relation to whether a suspicious lesion was present or not in 95% of cases. No study considered benign on viewing the film images was interpreted as malignant on reporting the digitized images. This suggests that film digitizers may allow a digital image of a mammogram of acceptable quality for telemammography to be obtained in the absence of a purpose-built digital mammography system.

Steroidal glycoside cholesterol absorption inhibitors.

We have explored the use of steroidal glycosides as cholesterol absorption inhibitors which act through an unknown mechanism. The lead for this program was tigogenin cellobioside (1, tiqueside) which is a weak inhibitor (ED50 = 60 mg/kg) as measured in an acute hamster cholesterol absorption assay. Modification of the steroid portion of the molecule led to the discovery of 11-ketotigogenin cellobioside (5, pamaqueside) which has an ED50 of 2 mg/kg. Replacement of the cellobiose with other sugars failed to provide more potent analogs. However, large improvements in potency were realized through modification of the hydroxyl groups on the cellobiose. This strategy ultimately led to the 4", 6"-bis[(2-fluorophenyl)carbamoyl]-beta-D-cellobiosyl derivative of 11-ketotigogenin (51) with an ED50 of 0.025 mg/kg in the hamster assay, as well as the corresponding hecogenin analog 64 (ED50 = 0.07 mg/kg).

Work load issues in clinical nursing education.

This survey of 22 baccalaureate (BSN) programs was undertaken to describe and analyze work load issues in BSN nursing education. Academic careers of nursing faculty may be at risk because clinical work load policies generally place less value on clinical teaching than on classroom teaching. Research question addressed teaching credit hours received for each clinical contact hour, remaining weekly hours available for clinical faculty to accomplish service and research activities, and student-to-faculty ratios in clinical settings. Seventy per cent of the programs surveyed allocated less than 1 teaching credit hour to 1 clinical contact hour. Nursing faculty who taught clinical courses with 5:1 to .25:1 work load credit for face-to-face contact hour ratios needed to work between 8 and 24 hours more in face-to-face teaching compared with colleagues teaching lecture courses, thus leaving less time for scholarship and service activities. Fifty per cent of the programs reported 10 or more students in some of the clinical courses. Faculty reported concerns about quality of learning experiences and supervisory difficulties as student numbers in clinical courses exceeded 8 students/faculty member.

Mammographic assessment of the symptomatic nonsuspicious breast.

BACKGROUND: Evidence from breast screening programs demonstrates the value of mammography in the detection of asymptomatic breast cancer. METHODS: This study prospectively assessed the role of mammography in the management of 585 patients presenting to a breast clinic, over a 1-year period, with symptomatic breast disease and without clinical or cytological evidence of malignancy. RESULTS: Eighteen (3%) of these patients had breast cancer. Eight patients presenting with nonspecific nodularity had carcinoma. All patients had relatively early disease. CONCLUSIONS: This study suggests that patients with symptomatic disease presenting to a breast clinic represent a group at higher risk of malignancy than screened asymptomatic patients, and that symptomatic women over 40 years of age should have bilateral mammography before being discharged from the breast clinic.

Colon cancer: morphology detected with barium enema examination versus histopathologic stage.

PURPOSE: To determine the relationship between the morphology of colon carcinomas detected with barium enema examination and the cancer stage. MATERIALS AND METHODS: Clinical, radiographic, endoscopic, surgical, and histopathologic findings were retrospectively reviewed in 152 patients with colon cancer detected with barium enema examination during a 2-year period. RESULTS: Eighty-six patients (57%) had lesions in the rectum and sigmoid and descending colon, and 66 (43%) patients had lesions more proximally in the colon. Lesions on the right side of the colon were less likely to cause symptoms than those on the left side. Eighty-one patients (53%) had annular or semiannular lesions, 57 (38%) had polypoid lesions, and 14 (9%) had plaquelike or carpet lesions. Six patients (4%) had Dukes stage A lesions; 84 (55%), Dukes stage B lesions; 42 (28%), Dukes stage C lesions; and 20 (13%), Dukes stage D lesions. CONCLUSION: Annular or semiannular carcinomas had higher rates of serosal invasion and lymph node metastasis than polypoid carcinomas, but the rates of liver metastases were comparable.

New approaches to atherosclerosis: an overview.

The mechanisms of action and selected agents for a variety of approaches to the treatment of atherosclerosis have been reviewed. In Table I, each approach is listed according to its primary physiological effect. This is a simplification, of course, and some agents, such as ACAT inhibitors, may have primary effects in all of these categories. As one goes from left to right, the benefit of each physiological effect becomes more speculative. There is no question of the benefit of LDL reduction, but less evidence exists for the clinical benefits of HDL elevation. With regard to direct anti-atherosclerotic effects, most approaches have yet to gather clinical data of any type. Perhaps as a result, the degree of medicinal chemistry effort in each area to date declines as one goes from left to right. This situation is changing rapidly, however. As evidence supporting the HDL hypothesis accumulates and knowledge of how to elevate HDL levels grows, very exciting opportunities for medical advances present themselves. Likewise, the knowledge base for nonlipid intervention is growing and very rapid advances are being achieved with the plaque-imaging techniques needed for evaluating such agents in man. Such results can only lead to greater opportunities for pharmacological intervention. Thus, in the future, much greater research effort will likely be dedicated to HDL elevation and nonlipid approaches. Through these efforts, physicians of the future should be armed with several complementary agents that can reduce the risk of cardiovascular disease in all patient populations.

Efficacy, tissue distribution and biliary excretion of methyl (3R*,5S*)-(E)-3,5-dihydroxy-9,9-diphenyl-6,8-nonadienoate (CP-83101), a hepatoselective inhibitor of HMG-CoA reductase activity in the rat.

Methyl (3R*,5S*)-(E)-3,5-dihydroxy-9,9-diphenyl-6,8-nonadienoate, CP-83101, was identified as a potent competitive inhibitor of 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase activity, inhibiting enzyme activity in vitro with an IC50 of 8.5 +/- 0.7 microM and a Ki with respect to HMG-CoA of 2.6 microM. CP-83101 also inhibited rat hepatic sterol biosynthesis by 39 +/- 7% at a dose of 100 mg/kg. [3H]CP-83101, administered orally to rats, exhibited peak plasma levels at approximately 1 hr that declined thereafter with an apparent half-time of 2-3 hr. Peak tissue levels also occurred 1 hr following oral administration of [3H]CP-83101. The decline in radioactivity in the liver, however, was considerably slower than that noted in blood, whereas the half-life in non-hepatic tissues was approximately 1 hr. Liver/blood ratios of 14, and liver/lens ratios of greater than 3000, following oral administration of [3H]CP-83101, were similar to those previously reported for other HMG-CoA reductase inhibitors, suggesting a high degree of tissue selectivity. In addition, liver/adrenal and liver/ovary ratios were approximately 1000 at all time points examined between 30 min and 24 hr following oral [3H]CP-83101 administration, indicating a high specificity for hepatic versus other steroidogenic tissues. Evaluation of intravenous versus oral administration of the water-soluble, free acid, sodium salt of [3H]CP-83101 in bile duct canulated rats indicated that approximately 20% of orally administered CP-83101 is absorbed from the gastrointestinal tract, and that absorbed CP-83101 is cleared rapidly from the plasma via the liver and from the liver via the bile. In addition, several lines of evidence suggest that CP-83101 may undergo enterohepatic recirculation. Agents of this synthetic series may thus possess advantages over other HMG-CoA reductase inhibitors with respect to tissue kinetics and specificity.

Antiulcer agents. 4-substituted 2-guanidinothiazoles: reversible, competitive, and selective inhibitors of gastric H+,K(+)-ATPase.

A series of 4-substituted 2-guanidinothiazoles has been found to inhibit the gastric proton-pump enzyme H+,K(+)-ATPase. In general, these compounds were reversible inhibitors of canine gastric H+,K(+)-ATPase, competitive at the K+ site, and selective relative to canine renal Na+,K(+)-ATPase. Structure-activity relationship (SAR) studies on this series revealed no general replacement for the guanidinothiazole. On the other hand, use of pyrrolyl, phenyl, and indolyl groups as the C-4 substituent yielded active compounds. Extensive studies of substitution patterns on these 4-aryl groups led to more active compounds, but no consistent SAR became apparent. Monosubstitution of the guanidine and substitution of the thiazole at C-5 both often led to increased activity, but combining these changes generated compounds less active than the parents. Despite 100-fold improvement in in vitro inhibitory potency, only a 3-fold increase in gastric antisecretory activity in rats was observed for these agents.

Decision making in rehabilitative audiology.

With the emphasis on quality assurance and patient satisfaction in health care, decision making in rehabilitative audiology is a critical issue. Traditionally, rehabilitative decisions have been based on questionable assessment procedures and unproven treatment methods. In this paper, current strategies for decision making with hearing-impaired adults will be presented. Discussion will focus on nonacoustic factors influencing hearing aid fitting, the decision processes necessary for management of the hearing-impaired adult, and expanded uses of self-assessment inventories of hearing handicap.

Bronchial compression by an enlarged left atrium in infants; a cause of hypovascularity of the left lung.

In three infants seen recently at our institution we noted signs of compression of the left main bronchus associated with enlarged left atria. None of our cases demonstrated the more usual signs of hyperinflation which are a hyperlucent lung field, depressed hemidiaphragm and mediastinal shift away from the affected side. In addition, hypoperfusion of the left lung was noted in each case. We believe that bronchial compression due to an enlarged left atrium, with consequent hypoxic vasoconstriction as a clinically significant entity, which is not well described and may be unappreciated in infants in whom the typical signs of hyperinflation are absent.