Large loop excision of the transformation zone (LLETZ) as an alternative to both local ablative and cone biopsy treatment: a series of 1000 patients.

One thousand patients, referred to the Oxford Colposcopy Clinic, were treated with either large loop excision of the transformation zone (LLETZ, 891 cases) or LLETZ cone (109 cases). Forty-five LLETZ cones were performed empirically, 64 under microcolposcopic guidance. Over 98% of patients were managed as outpatients under local anaesthesia, and 87% of new patients treated with LLETZ had treatment at their first visit. Ninety percent of patients had at least cervical intraepithelial neoplasia grade one (CIN I) and 73% had CIN II or worse. Seventeen cases of invasive or possibly invasive disease were detected, 6 of them unsuspected. The overall rate of complete excision of CIN or worse was 72%. Follow-up was cytologic with or without colposcopy depending on lesion severity. Ninety-one percent of 967 treated patients were free of dyskaryosis at a mean follow-up of 23 months, with complete excision of CIN or worse at LLETZ a significant predictive factor. No cases of invasive carcinoma have developed following treatment. Major morbidity was uncommon, with 3.8% severe hemorrhage. Stenosis was noted in 3.8% cases, mostly after LLETZ cone. One patient (0.1%) has reduced fertility possibly attributable to LLETZ. Questionnaire assessment revealed a very high degree of acceptability of the treatment to patients. LLETZ and LLETZ cone have proved highly acceptable and effective outpatient diagnostic and treatment alternatives to both local ablation and cone biopsy in the Oxford Colposcopy Clinic.

Auditing audits: the method of Oxfordshire Medical Audit Advisory Group.

OBJECTIVES: To develop a systematic method for both summative and formative audit of practice audits, and to use the method to review Oxfordshire practice audits and to plan improvement. DESIGN: Development of a coding system for the audit cycle subsequently used prospectively to assess audits reported to medical audit advisory group coordinators on practice visits. SETTING: All 85 general practices in Oxfordshire, of which 80 were visited by Oxfordshire Medical Audit Advisory Group coordinators. MAIN OUTCOME MEASURES: Satisfaction of criteria for different levels of audit (full, partial, potential, planning or no audit) according to coding scores for practice audits. RESULTS: 46 (58%) practices were classified as doing audit, the remainder doing no audit or only collecting data for family health services authority returns. Of audits being undertaken, 55/102 (54%) included planning care or the setting of targets. CONCLUSIONS: The coding system offers the prospect of formative assessment for practices to help them improve their audits, and summative assessment for the family health services authority to satisfy the needs for professional accountability. Its use in Oxfordshire disclosed considerable deficiencies in the process of practice audit. IMPLICATIONS AND ACTION: Practices in Oxfordshire should improve their audits. The advisory groups target to March 1992 is for 50% of practices to be doing full or partial and 25% potential audit and half of the remainder planning audit. Practices are encouraged to include in their audit implementing change, planning care, and agreeing criteria for further assessment.

Identification by combined gas chromatography-mass spectrometry of constituent long-chain fatty acids and alcohols from the meibomian glands of the rat and a comparison with human meibomian lipids.

Constituent long-chain fatty acids and alcohols from the meibomian secretions of the rat were examined as trimethylsilyl (TMS) and methyl ester-TMS derivatives by capillary gas chromatography and by combined gas chromatography-mass spectrometry. The positions of double bonds and methyl branch points were determined by the mass spectra of picolinyl esters and nicotinates for long-chain fatty acids and alcohols, respectively. Fatty acids had chain lengths from C12 to C34 and were of the straight-chain iso, anteiso and monounsaturated types. The unsaturated acids had double bonds in the omega-7 and omega-9 positions. The alcohols had corresponding structures. In common with the constituent acids and alcohols of other meibomian secretions, the chain lengths of the constituents showed a biphasic distribution with maxima around C16-C18 and C25-C27. The profile was qualitatively similar to that obtained from human meibomian secretion but with some differences in the relative proportions of certain acids and alcohols.

Non-invasive tear film break-up time: sensitivity and specificity.

The accuracy of a diagnostic technique; non-invasive tear film break-up time (NIBUT) was determined by calculating the sensitivity and specificity of the test. Thirty-three dry eye patients (65 eyes) of varying severity (mild, moderate and severe) and 66 age and sex matched normal subjects (132 eyes) were examined. The results indicate that the critical value of 10 seconds for the NIBUT provides sensitivity of 82% and specificity of 86%.

Effect of sodium hyaluronate (0.1%) on break-up time (NIBUT) in patients with dry eyes.

We evaluated the effect of 0.1% sodium hyaluronate (unpreserved) in 10 patients with dry eyes. The precorneal tear film break-up time was assessed by the non-invasive technique, and the severity of symptoms was recorded before and after treatment on a 0 to +3 scale. It was found that the tear film stability was significantly increased (p less than 0.05) in eyes treated with sodium hyaluronate. The symptoms of grittiness and burning were also significantly alleviated in the treated eyes.

Topical anaesthetic and tear film stability.

The effect of unpreserved topical anaesthetic on tear film stability (0.4% oxybuprocaine hydrochloride) was investigated in a double masked randomised study in 12 healthy volunteers, using a noninvasive tear film break up technique (NIBUT). It was found that the topical anaesthetic did not reduce the pre-corneal tear film stability, contrary to the electron microscopic evidence.

Effect of meibomian oils on Schirmer tear test.

The detrimental effect of meibomian oils expressed onto the lid margins on the value of the Schirmer test was investigated in two studies (N = 12 per study): without and with topical anaesthesia. In the 12 subjects studied there was no evidence of external ocular disease. The studies were conducted in a double masked randomised cross-over fashion. It was found that neither expression of meibomian oils nor topical anaesthesia showed any statistically significant (P greater than 0.05) reduction in final tear secretion rates. Thus, the notions that lid manipulation may impede tear flow into the Schirmer strip and that topical anaesthesia reduces apparent tear flow, are not supported.