The effect of short messaging service text on non-attendance in a general ophthalmology clinic.

To our knowledge there have been no previous studies that have examined the effect of short messaging service (SMS) text messaging reminders to both mobile and landlines on the 'did not attend' (DNA) rate in adult hospital clinic attendees. Our aim was to determine the effectiveness of a text messaging reminder in improving attendance in return general ophthalmology clinic patients. Ophthalmology clinic patients requiring a follow-up appointment were invited to enter the study. An information leaflet was provided and patients were contacted two weeks before their scheduled appointment by way of a customized text message to either the mobile phone or landline. The non-attendance rate compared with historic non-attendance rate was recorded. Two hundred and one patients were recruited. The historic DNA rate was 12%. The DNA rate in the SMS text reminder group was reduced to 5.5% (11 patients). The historic 'Could not attend' (CNA) rate of 6% had been reduced to 2% (4 patients). Forty-seven percent of patients used mobile phone technology with text messaging capability and 69% responded to the text reminder. In conclusion, routine SMS texting is a cost-effective means of reducing DNAs and should become standard practice. In addition, two-way messaging could allow for further efficiency as advance notification of patient cancellations facilitates re-scheduling of alternative patients.

Incidence of deep vein thrombosis in patients diagnosed with superficial thrombophlebitis after presenting to an emergency department outpatient deep vein thrombosis service.

OBJECTIVE: To determine the incidence of deep vein thrombosis (DVT) in patients diagnosed with superficial thrombophlebitis (STP) after presenting to an outpatient DVT service. METHOD: Six month prospective follow-up by telephone of patients diagnosed with STP after presenting to an outpatient DVT service. All patients who returned during follow-up with clinically suspected venous thrombosis underwent diagnostic testing (compression ultrasound). RESULTS: A total of 79 patients was diagnosed with STP after the exclusion of DVT with the diagnostic protocol. The incidence of a subsequent diagnosis of DVT on 6-month follow-up was three out of 79 patients (4%, 95% CI 0.8% to 11%). CONCLUSION: Although STP is generally considered benign, there is a risk that it may coexist or develop into DVT. The underlying cause of STP should be considered and patients with significant risk factors should be advised to monitor their symptoms closely with regard to potential DVT formation.

Interrater reliability of the Wells score as part of the assessment of DVT in the emergency department: agreement between consultant and nurse practitioner.

OBJECTIVES: To determine interobserver variability between an emergency medicine consultant and nurse practitioners for the use of the Wells score in the assessment of deep vein thrombosis (DVT) in the emergency department. METHODS: A prospective cohort study was undertaken in a population of 100 cases of suspected DVT. The Wells score reading from the consultant was compared with the reading of the nurse practitioners. Consultant and nurses were blinded to each other's assessments. The nurse practitioners were trained in interpreting the Wells score by assessing 100 patients together with the consultant before the start of the study. RESULTS: Consultant and nurse practitioner assessments resulted in the same final Wells score in 81% of cases (simple agreement), with a kappa score of 0.74 (95% CI 0.63 to 0.84). If the nurse practitioner score had been followed in preference to the consultant assessment, this would have resulted in eight patients being assessed in a lower risk algorithm (8%). CONCLUSION: There is good interobserver agreement between consultant and nurse practitioners for the use of the Wells score as part of a DVT assessment service within the emergency department. Pretest scoring is pivotal to integrated strategies for the exclusion of DVT. The Wells score is a robust and reliable tool for pretest scoring in the emergency department regardless of the grade of the assessor, provided there is adequate training in its use.

Emergency department nurse-based outpatient diagnosis of DVT using an evidence-based protocol.

OBJECTIVES: To investigate the clinical validity of a nurse practitioner emergency department-based service for investigating outpatients with suspected deep vein thrombosis. METHODS: A prospective management study was undertaken to investigate the safety of withholding anticoagulant treatment in patients who were negative for testing after application of an evidence-based protocol. The protocol involved a nurse assessment using the Wells pretest score followed by investigations tailored to the risk category (variable combinations of strain gauge plethysmography, D-dimer and ultrasound). The main outcome assessed was the venothromboembolic complication rate in patients deemed to have deep vein thrombosis excluded by the protocol. RESULTS: A total of 625 consecutive patients were evaluated between March 2003 and January 2007. Of these, 435 were eligible and 190 were ineligible. Four patients in the negative cohort were confirmed to have venous thromboembolism on follow-up. The incidence of venous thromboembolism in the 6-month follow-up period was therefore 1.04% (95% CI 0.41% to 2.65%). CONCLUSION: The evidence-based protocol used in this study can reliably exclude deep vein thrombosis in an outpatient population when applied as part of a nurse-based evaluation.

Enhanced nutrition of offspring as a crucial factor for the evolution of intelligence on land.

Whilst life in the sea is undoubtedly an ancient process organisms with an exclusively marine lineage have not evolved the degree of intelligence demonstrated by the most advanced terrestrial species. Among the differences between terrestrial and marine environments which may begin to account for this is the instability of the terrestrial environment in comparison to the ocean. Unlike the ocean, terrestrial environments are not buffered against rapid changes in temperature, available water and other environmental extremes. This represents a challenge for the vulnerable offspring of terrestrial species. Evolutionary adaptation to this challenge has included greater transfer of resources from adult to offspring, as demonstrated by terrestrial vertebrates. However the evolution of mechanisms allowing enhanced transfer of resources between generations also creates conditions whereby offspring can be born with larger and more costly brains, developed and nourished from the outset even when they are not likely to prove useful until later life. As nutrition of offspring on land improved through natural selection better brains may thereby have been facilitated, with subsequent evolution driven by proximate selective pressures. The culmination of this process may be seen in the enormous transfer of resources from parents to offspring characteristic of humans and the advanced intelligence associated with them. Medical implications of this theory include the possible impact on the maternal brain of increased transfer of resources to the developing brain during pregnancy and lactation. This could help to account for the observed association between mental illness and the puerperium.

A prospective study of the rate of falls before and after cataract surgery.

BACKGROUND: There has been considerable interest in the development of intervention programmes aimed at reducing the risk of falls. The primary objective was to ascertain whether cataract surgery reduced the risk of falls in elderly patients with age related cataract. METHODS: 97 patients scheduled for cataract surgery were enrolled in this prospective clinical study. The patients were assessed for established risk factors for falls preoperatively and postoperatively. Patients were issued with a diary to record any falls and phoned at 2 monthly intervals during the 6 month preoperative and postoperative periods. RESULTS: Of the 84 patients who completed the study, 31 recorded falls during the preoperative period (37%). This group showed a statistically significant reduction in the number of fallers in the postoperative period (n = 6, p<0.001) CONCLUSION: These results suggest that cataract surgery is an effective intervention to reduce the risk of falls in elderly patients with cataract related visual impairment.

A little nightclub medicine: the healthcare implications of clubbing.

OBJECTIVE: To describe the scale and range of acute medical problems among patients who present to an inner city accident and emergency (A&E) department after attending nightclubs in Liverpool. METHODS: From April 1997 to April 1998, all patients identified as having attended a nightclub before their arrival at the department were included in the study. Information regarding their attendance was gathered retrospectively using a standard proforma. SETTING: A large, city centre, teaching hospital A&E department with an annual new patient attendance rate of over 95,000. RESULT: 777 such patients were enrolled in the study (0.81% of all new attendances during the same period). This was probably an underestimate, as some eligible patients were not identified during the study. Predictably, most presentations were at the weekend between midnight and 08.00. Surprisingly, the commonest mode of transport to the hospital was an ambulance (38%, 298 of the total). Assault accounted for most presentations (57%, 443 of the total) and lacerations were the commonest injury (the face being most frequently affected). Alcohol was the commonest intoxicant overtly associated with the A&E department attendance. CONCLUSIONS: Injury after assault is the commonest precipitant of hospital care among clubbers in Liverpool. Alcohol is the most important contributory factor, although illegal drug misuse is a considerable challenge in the clubs themselves. A number of measures such as (a) the introduction of unbreakable glass or plastic containers; (b) the elimination of glass from outside clubs; (c) the provision of high quality immediate medical care at larger venues; (d) the curbing of over crowding and cheap drinks promotions; (e) registration of doormen, and (f) targeted policing of the areas around nightclubs are urgently required to reduce the healthcare (and civic) burden of clubbing. The cost for these should be borne by the highly profitable clubbing and brewing industries. A national code of practice for clubs-already in existence voluntarily-should be made mandatory.

Disruption of the iliocolic artery after blunt trauma.

Injury to the superior mesenteric artery and branches is an uncommon event, which is typically associated with penetrating injury and high mortality. A case is presented of rupture of a branch of the superior mesenteric artery (iliocolic artery) after blunt trauma. The case illustrates the more occult presentation and better overall prognosis associated with this type of injury as compared with injury to the proximal superior mesenteric artery. In addition this case highlights the importance of vigilance in patients who deteriorate after initial resuscitation.

Pseudomyocardial infarction associated with a retrocaecal gangrenous appendix.

The case is presented of a 54 year old man who attended the emergency department with a history of central abdominal pain and electrocardiograpic changes consistent with an anteroseptal myocardial infarction. Myocardial infarction was not confirmed with serial cardiac enzymes and a subsequent laparotomy revealed a gangrenous retrocaecal appendix. This case highlights the rare but recognised association between an acute surgical abdomen and pseudomyocardial infarction. It is, to the authors' knowledge, the first reported case of pseudomyocardial infarction complicating a retrocaecal appendicitis.

Acute myelogenous leukaemia presenting with mid-foot pain after an inversion injury.

The case is presented of a 5 year old boy who attended after an inversion injury. He had persistent pain despite treatment and was subsequently diagnosed with acute myelogenous leukaemia. It is well recognised that acute leukaemia commonly presents as non-traumatic limb pain. This case highlights the need to consider acute leukaemia in the differential diagnosis of any persisting bone or joint pain, even in the context of recent injury.

Beaver fever--a rare cause of reactive arthritis.

Giardia lamblia infection is rarely associated with adult reactive arthritis. We report the first North American case and review the pediatric and adult literature to date. Antimicrobial treatment is essential to eradicate the parasite and control the arthritis.

The skeletonized body: suicidal inhalation of motorbike exhaust.

An adolescent boy who was being treated for psychiatric illness went missing. The body was discovered a year later, and he appeared to have committed suicide by inhaling the exhaust fumes from his motorbike. This report highlights the procedure used for the identification of his skeletonized body and the unusual nature of the source of exhaust fumes.

Cervical spine pseudogout with myelopathy and Charcot joints.

Myelopathy due to calcium pyrophosphate dihydrate (CPPD) crystals in the cervical spine is rare. Neuropathic-like joints are also uncommon manifestations of CPPD crystal disease. We describe a 79-year-old woman with multiple neuropathic joints containing CPPD crystals. She also had a large mass containing CPPD crystals impinging on the cervical spinal cord, causing a myelopathy. She appears to be the first patient with this combination of unusual clinical features with CPPD disease.

Reversible cardiogenic shock in an angry woman--case report and review of the literature.

A previously healthy woman presented with ischemic cardiac pain and ST elevation suggestive of acute myocardial infarction following a 45 min argument. Despite receiving tissue plasminogen activator, she developed cardiogenic shock and objective evidence of recurrent ischemia, with only a small creatine kinase rise. Angiography revealed the unexpected findings of normal coronary anatomy and akinesis of the distal two-thirds of the left ventricle. Apart from an iliac vein thrombosis, the remainder of her course was characterized by dramatic recovery of cardiac function. The differential diagnosis of myocardial infarction with angiographically normal coronary arteries is discussed, with emphasis on aspects relevant to this case. The presence of high titre anticentromere antibodies, anticardiolipin antibodies, protein S deficiency and supportive physical findings, suggested the diagnosis of concurrent antiphospholipid antibody syndrome (with secondary acquired protein S deficiency) and CREST syndrome. The pathogenesis likely involved an interaction between stress, vasospasm, and thrombosis.

Plus-maze retest profile in mice: importance of initial stages of trail 1 and response to post-trail cholinergic receptor blockade.

Recent research has shown that a single undrugged prior experience of the elevated plus-maze produces significant behavioural changes upon 24-h retest in rats and mice. Typically, when reexposed to the maze, animals display an increased avoidance of the open arms and a corresponding preference for the enclosed sections of the apparatus. Using ethological analyses, the present series of experiments sought to further characterize this phenomenon in mice and to determine whether or not it involves cholinergic receptor mechanisms. Results confirmed that behaviour during Trial 2 is markedly different to that seen on initial exposure, and that such changes are independent of the duration of Trial 1 (2 vs. 5 min). Retest behavioural changes included reduced entry latencies, reduced open arm entries, less time on the open arms and centre platform, lower levels of exploratory head-dipping, and increased entries into and time spent in the closed arms. The importance to the retest phenomenon of the first few minutes of initial exposure was further suggested by min-by-min analyses of the behaviour of animals naive to the maze. Results showed that behaviour during the first min is characterized by high levels of risk assessment from the centre platform and relatively low, but equal, levels of open- and closed-arm exploration. From min 2 onwards, however, behaviour showed a marked change with increasing open arm/centre platform avoidance, increasing closed-arm preference, and decreasing levels of risk assessment and exploratory head-dipping. Thus, it would appear that this within-session aversive learning transfers between sessions to account for behavioural profiles on retest. Irrespective of the duration of Trial 1 (2 or 5 min), posttrial administration of the muscarinic antagonist, scopolamine (0.1-1.0 mg/kg), failed to significantly alter the behavioural changes seen between trials. Data are discussed in relation to the apparent sensitization of fear produced by plus-maze exposure, its possible relation to phobia acquisition, and the need for further research on underlying mechanisms.