What do specialist registrars know about clinical governance?

Clinical governance is an essential part of quality assurance for everyday clinical practice. It is part of the generic curriculum for all specialist registrars (SpRs) training in medical specialities. The authors of this update undertook a survey of SpRs training in geriatric medicine to determine their perceived knowledge of clinical governance and whether they had received training in this area.

Type 2 diabetes mellitus and thyrotoxicosis presenting concurrently.

The symptoms of thyrotoxicosis and diabetes mellitus can be quite similar, and in patients presenting with diabetes, thyrotoxicosis could be missed unless specifically tested for. There are few reports of the two conditions presenting at the same time. We report on two such cases. In a patient who is diagnosed as having both conditions concurrently, an oral glucose tolerance test should be repeated after successful treatment of thyrotoxicosis before a diagnosis of diabetes mellitus is made.

Breastfeeding--a gradual return to mother's autonomy.

The aim of this study, the final in a series, was to assess mothers' perceptions of some aspects of midwifery care in relation to breastfeeding. These included conflicting advice and its possible effect on breastfeeding outcomes; whether information considered crucial to the maintenance of breastfeeding was provided by health professionals; and whether mother's autonomy was encouraged following the implementation of antenatal breastfeeding workshops. A structured, self-administered questionnaire was mailed to 550 women who delivered in 1994 approximately one year after the birth of their child. The results obtained were compared to those achieved in a 1991 survey of a similar population. Of the 247 respondents, 33.5% considered they had received conflicting advice, with 18.6% commenting they felt this had negatively influenced how successfully they had breastfed. Three quarters of the women surveyed indicated they received information on the factors considered crucial for the maintenance of lactation. Seventy-eight percent (78%) said they usually or always attached the baby for themselves. Fifty-three percent (53%) of the mothers breastfed for more than six months, and 37.7% were still breastfeeding at 12 months.

Understanding memory for faces in Parkinson's disease: the role of configural processing.

It has previously been reported that unfamiliar face recognition memory is impaired in Parkinson's disease (PD) [(Dewick, H. C., Hanley, J. R., Davies, A. D. M., Playfer, J. R. & Turnbull, C. J., Perception and memory for faces in Parkinson's disease. Neuropsychologia, 1991, 29, 785-802), (Haeske-Dewick, H. C., Are perception and memory for faces influenced by a specific age at onset factor in Parkinson's disease? Neuropsychologia, 1996, 34, 315-320), (Levin, B. E., Llabre, M. M. & Weiner, W. J., Cognitive impairments associated with early Parkinson's disease. Neurology, 1989, 39, 557-561)]. In the work reported here, we consider the possible mechanisms that might underlie this impairment. 28 PD patients and 28 controls were given a two-part test of recognition memory for words and faces, and two perceptual tests to measure their configural and componential processing ability. We found that PD patients were significantly worse than controls on the recognition memory test for faces, but not when the stimuli were words. In addition, PD patients were significantly impaired relative to controls on the closure test (FCT) used to measure configural processing, but there was no difference between the two groups on a test of componential processing ability. Multiple regression analyses revealed that even after accounting for the influence of age, intelligence and level of depression, configural processing ability was the important predictor of unfamiliar face recognition memory in Parkinson's disease. There was no effect of Parkinson's disease specific variables on either face recognition or FCT performance. In addition, some recently diagnosed patients were poor at face recognition. It is suggested that face configuration skills may be affected very early in the course of Parkinson's disease, and that this may be connected to the fact that considerable nigrostriatal degeneration and alteration in brain neurotransmitter levels occur before the clinical symptoms of PD appear.

The impact of hearing on communication.

The study was designed to assess the impact of hearing impairment on communication between older hospital patients and medical staff and to see whether intervention to improve hearing influences perceived communication. Structured interviews were held with 200 mentally alert elderly hospital in-patients before and after the introduction of voice amplifiers and acetate cards depicting a hearing problem. Prior to intervention 22% of patients rated communication with their doctor as poor or unsatisfactory. Following intervention there was a significant improvement (Chi-square p=0.006), with only 6% of patients reporting communication with their doctor as poor or unsatisfactory. Most of the patients who felt communication was unsatisfactory could not hear what was being said. We conclude that simple measures can improve the number of older patients hearing what their doctor says and improve their perception of communication with the hospital doctor.

Developing effective interactions to improve breastfeeding outcomes.

The objective of this replicated research was to assess the effectiveness of antenatal Breastfeeding Workshops (Jamieson 1990) in improving breastfeeding outcomes. It was a longitudinal study using a pre-test/post-test design to evaluate any increase in the confidence, skill and knowledge of women and midwives. The research was carried out in the maternity section of a large Tasmanian teaching hospital. Fifty-six midwives who attended the workshops became the research group with 49 non-attendees as the control. Of the 159 women who indicated an interest in attending, 107 who attended formed the research group, and the remaining 52 were used as the control. The paper is in two parts. The first describes responses from midwives. The results show those midwives who attended a workshop perceived an increase in their confidence level in supporting mothers to breastfeed, altered their perception of those factors most important in successful breastfeeding, and acknowledged that updating of breastfeeding knowledge is necessary on an annual basis. The second part analyses breastfeeding outcomes in respondent women. The results show that women who attended the workshops had a significant increase in confidence levels associated with breastfeeding, and were more likely (p < 0.01) to breastfeed for an extended time even though they experienced difficulties.

Hospital doctors' assessment of baseline spirometry.

Baseline spirometry is useful in diagnosing and managing pulmonary disease. In a questionnaire survey of 100 hospital doctors in two hospitals in the Mersey region, their views and ability to interpret baseline spirometry was assessed. Of the 70 doctors who responded, 65% felt they could accurately interpret baseline spirometry. However, only 12% accurately interpreted all five vitalographs in the questionnaire. The majority (72%) felt they had not had adequate teaching in interpretation of spirometry, and 63% would prefer a report from a respiratory technician. These result suggest that improvement needs to be made in interpretation of baseline spirometry.

Local clinical guidelines: description and evaluation of a participative method for their development and implementation.

BACKGROUND: National guidelines are rarely followed by immediate change in clinical behaviour. We present our experience of an active educational method for local development and implementation of a guideline. OBJECTIVE: To evaluate the effectiveness of a participative method for developing local clinical guidelines. METHODS: A trial in a district of the effect of guideline development incorporating active participation of intended recipients on subsequent relevant prescribing. It was carried out in Wirral Family Health Services Authority district (the Wirral peninsula) comprising 69 general practices covering a population of 345,763. An exemplar guideline on 'hypertension in the elderly' was developed by the method described. The principal recommended drug was bendrofluazide 2.5 mg once daily. The differences in prescribed daily doses (PDD) of bendrofluazide 2.5 mg tablets per quarter per 1000 prescribing units (age-weighted population) between the intervention district and England as a whole was measured. RESULTS: Comparison of the intervention district with England data demonstrates a median difference of 122.49 PDD before and 206.34 PDD after guideline production, this change is statistically highly significant (Mann-Whitney two-tailed P < 0.0001; 95% CI = 36.51-104.77). Grouped regression analysis shows no significant difference (0.89) in slope gradients before guideline production (P = 0.35, 95% CI = -3.97-5.76), but the difference in slope gradients after (12.95) is statistically highly significant (P < 0.0001; 95% CI = 8.17-17.73). The data suggests that the change in clinical behaviour persisted for at least two years. CONCLUSION: Participation of intended recipient general practitioners and local specialists in the development of a guideline by an active educational method as described was followed by a favourable change in clinical behaviour which persisted for at least two years.

The prevalence of drivers in acute geriatric wards.

An audit of 150 patients on five acute geriatric wards found that 28 (19%) still drove. Forty-three (28%) used to drive but had given up, whilst 79 (53%) (76 of whom were female) had never driven. Former drivers gave the main reason for stopping as cost. No driver could recall being advised about driving by a doctor. Twenty-two drivers (79%) had a significant clinical condition that could affect driving, ranging from blackouts to arthritis. It is recommended that all elderly patients should be asked if they drive and any clinical conditions they might have that would adversely affect their driving be sought. Appropriate advice should be given by doctors to their elderly patients in order to safeguard them and the public from road traffic accidents.

Cardiopulmonary resuscitation in the elderly: patients' and relatives' views.

One hundred inpatients on an acute hospital elderly care unit and 43 of their relatives were interviewed shortly before hospital discharge. Eighty per cent of elderly patients and their relatives were aware of cardiopulmonary resuscitation (CPR). Television drama was their main source of information. Patients and relatives overestimated the effectiveness of CPR. Eighty-six per cent of patients were willing to be routinely consulted by doctors about their own CPR status, but relatives were less enthusiastic about routine consultation. Patients' and relatives' views about the appropriateness of CPR did not differ significantly. Seventeen percent of patients did not desire CPR. However, 64 per cent of patients were ultimately willing to follow their doctor's advice about the appropriateness of CPR. The conclusion reached is that mentally competent, elderly patients but not their relatives should be routinely consulted about their own desire for CPR in order to avoid resuscitating patients against their wishes. Further research is required to find out how patients would feel about resuscitation if they were terminally ill or chronically confused, and how carers would feel about resuscitating such patients.

Influenza vaccination: do the aged reap the benefit?

An audit of 100 elderly in-patients with appropriate medical conditions revealed that 63% had not been vaccinated this winter. 74% would have accepted vaccination if offered. A general practitioner questionnaire found that 42% relied on elderly patients coming forward and requesting vaccination. Unfortunately, many elderly patients are still missing out on influenza vaccination.

Diagnosis and management of parkinsonism in the elderly.

Of 123 patients with parkinsonism attending a department of medicine for the elderly who were assessed, 73% were thought to have idiopathic Parkinson's disease, and 91% of these cases and 52% of the remaining cases had a history of rest tremor; 34% of all cases were demented. The prevalence of dementia did not correlate with the duration of disease. Demented patients with presumed idiopathic Parkinson's disease were not distinguishable from non-demented by duration of disease, presence of a history of rest tremor or use of L-dopa. Eighty-eight per cent of non-demented patients but only 44% of demented patients were thought to have responded to L-dopa. Lower doses of L-dopa were used than are conventional with younger patients.