Patients' attitude towards travelling for breast services versus waiting longer for local services

Geographical access is a cornerstone of health care provision. However, prolonged waiting for breast clinic appointments in local services results in delayed diagnosis and excessive anxiety for patients. In this study, we present a patient satisfaction survey results of an initiative to offer out-patient clinic appointments for non-urgent patients referred to the breast unit in Letterkenny General Hospital (LGH), Ireland, and exceeded the recommended waiting period of 12 weeks. These patients were offered appointment in University Hospital Galway (UCHG), which is an average travel time of about 3.5-4.5 hours away from LGH. 163 patients out of 336 (48.5%) patients actively waiting more than 12 weeks for appointments in LGH accepted alternative appointments in UCHG. Despite the long travel distance for these patients, 100% of them reported high satisfaction and 97.3% said they would accept further UCHG appointments if a similar situation of prolonged waiting in LGH arises. None of these patients were diagnosed with cancer, and only one had a benign lumpectomy. This study showed that if offered alternative appointments, just under half of the patients would accept. The initiative provides a feasible solution for long waiters, and the survey shows that patients' satisfaction remains high despite long travel.

Coma in fulminant pneumococcal meningitis: new MRI observations.

We report a 45-year-old man with fulminant pneumococcal meningitis. Fluid attenuated inverse ratio MR images showed the ravaging consequences of occlusive vasculopathy and a transient purulent basal exudate. Bilateral thalamic lesions may have explained the failure to awaken despite appropriate antibiotic therapy.

Use of magnetic resonance imaging and magnetic resonance angiography in diagnosis of sigmoid sinus thrombosis.

Magnetic resonance angiography is an established radiologic technique which is rapidly becoming useful in imaging the head and neck. Currently, this imaging modality is important in the diagnosis of sigmoid sinus thrombosis caused by otologic disease. Since the introduction of antibiotic therapy, the percentage of deaths attributed to intracranial complications from otitic disease has decreased from 2.5 to approximately 0.25% of documented deaths. Also, the incidence of sinus thrombosis within this group has decreased, but it is still a serious and potentially lethal condition. Sinus thrombosis is suspected clinically when mastoid disease progresses, with picket fence fever pattern, chills, headaches and signs of papilledema. Definitive diagnosis is necessary before surgical treatment. The Queckenstedt test is unreliable, computed tomography is better suited for demonstrating thrombosis of the sagittal sinus rather than the sigmoid sinus, and conventional angiography (although it provides excellent visualization) has the hazard of ionizing radiation and requires vessel puncture and the use of intraarterial contrast agents. We present two cases of thrombosis of the sigmoid sinus as an intracranial otologic complication which were diagnosed definitively with magnetic resonance imaging and magnetic resonance angiography. The combination of magnetic resonance imaging, which showed the thrombosis displaying abnormal signal intensity, and magnetic resonance angiography, which demonstrated the absence of flow in the sinus, was an ideal diagnostic tool. For both patients, treatment consisted of mastoidectomy, sigmoid sinus decompression and antibiotics.

Physician-assisted suicide. Finding common ground.

In Washington state, practicing physicians have been forced to confront the emotional, complex issue of physician-assisted suicide sooner than physicians elsewhere in the US. The Washington State Medical Association has struggled at length with the issue and ultimately delineated a policy on safeguards for physician-assisted suicide. The Washington experience may prove instructive to other professional physician organizations even before the US Supreme Court rules on the issue.

Effects of ischemia on cerebrovascular responses to N-methyl-D-aspartate in piglets.

We examined the effects of total global ischemia on cerebral arteriolar responses to N-methyl-D-aspartate (NMDA) in anesthetized newborn pigs. Arteriolar responses to 10(-4) M NMDA were determined before and after 10 to 20 min of ischemia caused by increasing intracranial pressure. Before ischemia, NMDA dilated arterioles by 30 +/- 5% (baseline = 88 +/- 2 microns; n = 6). However, after 10 min of ischemia, arteriolar dilation was reduced to 10 +/- 3% at 1 h (P < 0.05). At 2 and 4 h, NMDA-induced dilation was not different from preischemia values. Twenty minutes of ischemia had similar effects. Coadministration of 100 U/ml of superoxide dismutase did not restore arteriolar dilation to NMDA at 1 h after ischemia. Sodium nitroprusside dilated by 14 +/- 3 and 40 +/- 5% at 10(-6) and 10(-5) M before ischemia, respectively, and arteriolar responsiveness was not changed by ischemia (n = 6). Cortical nitric oxide synthase (NOS) activity, measured by the in vitro conversion of L-[14C]arginine to L-[14C]citrulline, was unaffected by ischemia (n = 12). We conclude that decreases in cerebral arteriolar responsiveness to NMDA are not due to impairment of NOS activity, enhanced degradation or chelation of nitric oxide (NO), or reduced vascular smooth muscle responsiveness to NO.

Shoulder arthrography for determination of size of rotator cuff tear.

One hundred eight shoulder arthrograms were performed in 105 patients who subsequently underwent surgical repair of a rotator cuff tear. Eighty-seven were single-contrast arthrograms and 21 were double-contrast studies; three or more views were used for all shoulders. Four readers independently evaluated the arthrograms (two orthopaedic surgeons and two radiologists). The size of the rotator cuff tear could be categorized into one of four groups with accuracy in only 56% of the cases; however, the fear size was identified with accuracy or within one size category in 96% of the shoulders studied.

Hand dose measurements in interventional radiology.

Measurements of radiation dose to the hand were conducted using TLD ring badges for individual interventional radiology cases. Results from over 30 examinations (including transhepatic cholangiograms and biliary and nephrostomy procedures) conducted by four radiologists using identical equipment show an average hand dose of 1.5 mGy (150 mrad) per procedure. Hand dose varied inversely with distance from the patient. Due to variable hand positions during clinical examinations, fluoroscopic time was not found to be a good indicator of hand dose.

Mediastinal duplication cyst. Percutaneous aspiration and cystography for diagnosis and treatment.

Needle aspiration and metrizamide cystography of a mediastinal duplication cyst is described. The technique is a reasonable alternative to surgery for both the diagnosis and the treatment of asymptomatic benign mediastinal cysts.

Percutaneous nephrostomy for stone removal.

Percutaneous nephrostomy placement was performed in 700 patients as the initial procedure in renal or ureteral calculus removal. The ease or complexity of the subsequent calculus removal procedure is directly dependent on precise nephrostomy placement. The most important technical factors in nephrostomy placement for calculus removal are selection of the nephrostomy track course, the track entry site into the renal collecting systems, intrarenal catheter and guidewire manipulations, and the final catheter positioning across the ureteropelvic junction and down the ureter.

Cystadenoma of the proximal common hepatic duct: the use of abdominal ultrasonography and transhepatic cholangiography in diagnosis.

Cystadenoma of the extrahepatic bile ducts is a rare cause of obstructive jaundice. In a case seen recently at our institution, the combined findings are abdominal ultrasonography and transhepatic cholangiography were diagnostic; such studies should provide evidence for preoperative recognition.

Rapid dilatation of percutaneous nephrostomy tracks.

Dilatation of a percutaneous nephrostomy track is essential for procedures such as stone or foreign-body removal and nephroscopy. In 140 patients, a technique was used of rapid dilatation to 24 French. It required only a few minutes. This procedure proved to be safe, easy to master, and the materials are readily available. Rapid track dilatation under general anesthesia, immediately followed by nephroscopy, has been a major contribution to success in renal calculus removal, resulting in considerably shortened patient and physician time.

Percutaneous removal of kidney stones. Preliminary report.

We have performed percutaneous extractions of renal pelvic stones in 15 patients with the use of the Wolf percutaneous universal nephroscope. At one session, with the patient under general anesthesia, a percutaneous tract is dilated to 24 F, and the stone is immediately removed. Fifteen stones have been removed successfully by ultrasonic lithotripsy, basket retrieval, use of a forceps, or a combination of these techniques. Average operating time has been 1 hour and the mean hospitalization time 4 days. The advantages of this technique are that a skin incision of only 1 to 2 cm is required to remove the stone, hospital days are fewer than with open procedures, and postoperative morbidity is minimal. In selected situations, this method represents a significant advance over standard open surgical procedures for removal of renal pelvic stones.