Analysis of NHSLA claims in hand and wrist surgery.

Claims for negligence are increasing in medical practice. We analysed data provided by the UK NHS Litigation Authority (NHSLA) on all hand and wrist surgery from 1995-2001. The numbers of claims increased from 13 to 40, but the number being successfully defended also increased from 2 to 13 during this period. Claims were most commonly attributed to errors at surgery (56%) or in outpatient clinics (24%). Strikingly the claims are clustered to a few common conditions, particularly the treatment of carpal tunnel syndrome (22%) and wrist fractures (48%). There were no claims related to complex hand surgery. We recommend better training for 'routine surgery', better description of distal radius fracture parameters at each clinic visit and better training in emergency departments (ED).

Proliferative glomerulonephritis with acute renal failure-a rare manifestation in seronegative rheumatoid arthritis.

A 55 years old lady with advanced rheumatoid arthritis (RA) presented with severe acute renal failure with significant proteinuria preceded by fever for 14 days. She had no history of taking drugs usually responsible for glomerulonephritis, neither had she any clinico-biochemical evidence of peri-infectious glomerulonephritis. Acute interstitial nephritis (AIN) was excluded by absence of eosinophilia and eosinophils in urine. Renal biopsy reveled absence of amyloidosis and showed Focal segmental proliferative glomerulonephritis (FSGN). Patient was successfully managed with methyl-prednisolone followed by steroid and immunosuppressive and patient came over renal failure. So FSGN should be considered as one of the causes of acute renal failure in a patient with seronegative RA which may respond to immune-therapy like rapidly progressive glomerulonephritis.

Use of genomic analysis of varicella-zoster virus to investigate suspected varicella-zoster transmission within a renal unit.

BACKGROUND: The source of hospital-acquired chickenpox infection may be presumed from a known exposure, but has not been previously proven using genomic analysis. OBJECTIVE: Investigation of suspected VZV transmission was done using single nucleotide polymorphism genomic analysis. STUDY DESIGN: Comparison was made of viral isolates from two patients with chickenpox on the same ward who were not known to have had direct contact. RESULTS: An identical genotype in the variable R1 region of the VZV was isolated from the two patients. CONCLUSION: Inapparent hospital-acquired transmission was the most likely route of infection.

Hospitalization in the first year of renal replacement therapy for end-stage renal disease.

BACKGROUND: The requirement for hospitalization of patients on dialysis is likely to be a surrogate marker of age and comorbid diseases. It may also reflect the level of care delivered, and substantially increases the cost of this expensive therapy. AIM: To identify the factors most strongly associated with hospitalization. DESIGN: Prospective population study. METHODS: Data were recorded for all patients starting RRT in Scotland over one year, including the reasons for and duration of, each hospital admission during the first year of RRT. Factors most strongly associated with hospitalization were determined by Poisson regression analysis. RESULTS: Overall, 526 patients were admitted to hospital on 1668 occasions (median 3, IQR 1-4) for 13384 days (median 13, IQR 4-35). Formation of vascular access for haemodialysis (HD) was the most frequent reason for admission, followed by infections. Age, comorbidity, mode of presentation for RRT and primary renal diagnosis were all significantly associated with prolonged hospitalization. Attainment of UK Renal Association standards for urea reduction ratio and serum albumin concentration, and vascular access in the form of arterio-venous fistulae were associated with less hospitalization in patients treated with HD by 90 days. DISCUSSION: Patients in their first year of RRT have a high requirement for in-patient care, 8.6% of patient treatment days being spent in hospital. Vascular access formation, failure and complications account for a large proportion of this. Age and comorbidity prolong the time spent in hospital. As the RRT population continues to increase, with older patients and those with greater comorbidity, in-patient facilities must also expand.

Interwell tracing by environmental isotopes at Fimkassar Oilfield, Pakistan.

Water flooding is an important operation to enhance oil recovery. Movement of injected water is traced to test the performance of the water flood and verify suspected geological barriers or flow channels, etc. This paper describes the application of environmental isotopes as interwell tracers at Fimkassar Oilfield in Chakwal District, Pakistan. Water flooding was started in March 1996 in the Sakessar formation (Eocene). When water appeared in the production well in June 1998, isotopes (18O, 2H and 3H) were used to determine the breakthrough/transit time of the water flood and the contribution of fresh injected water. Water samples were collected during June 1998-August 1999 from the injection well, the production well, and some other fields for reference indices of the Sakessar formation and analyzed for the 18O, 2H and 3H, and chloride contents. The isotopic results confirmed the breakthrough of injected water and indicated that the water in the production well was a mixture of the injected water and the formation water. The initial breakthrough time was 27 months. The contribution of injected water varied from 67% to 80%. This percentage did not change significantly from the time of breakthrough until the last sampling indicating good mixing in the reservoir and the absence of any high permeability channel. Chloride content did not give any information about the hydraulic connection between the injection well and the production well. The study proved the potential of environmental isotopes for interwell tracing.

Acute renal failure requiring renal replacement therapy: incidence and outcome.

BACKGROUND: Renal replacement therapy (RRT) for acute renal failure (ARF) may be provided in many settings within the hospital. Such patients require a high level of care and often have a poor prognosis. No prospective studies have accurately defined this population, making the prediction of necessary resources and the planning of services difficult. AIM: To ascertain the incidence, causes and outcomes of acute renal failure requiring renal replacement therapy in Scotland. DESIGN: A prospective observational census of all clinical areas providing renal replacement therapy in three Scottish health boards (Grampian, Highland, Tayside). METHODS: Patients were identified by liaison with each unit providing RRT. Factors precipitating renal failure and reasons for RRT were recorded at the time of initiation. Comorbid disease burden was scored using the Charlson index. Patient status at 90 days was assessed from case-notes, contacting general practitioners where necessary. RESULTS: 375 patients per million population per year received RRT; 203 per million per year for either ARF or acute-on-chronic renal failure. 73.5% of patients receiving RRT for ARF died within 90 days, 23.5% became independent of RRT. The median duration of hospital admission was 19 days. DISCUSSION: The annual incidence of ARF requiring RRT is just over 200 per million population, almost twice that of end-stage renal disease requiring RRT. Such treatment places high demands upon health care resources.

Origin of whales from early artiodactyls: hands and feet of Eocene Protocetidae from Pakistan.

Partial skeletons of two new fossil whales, Artiocetus clavis and Rodhocetus balochistanensis, are among the oldest known protocetid archaeocetes. These came from early Lutetian age (47 million years ago) strata in eastern Balochistan Province, Pakistan. Both have an astragalus and cuboid in the ankle with characteristics diagnostic of artiodactyls; R. balochistanensis has virtually complete fore- and hind limbs. The new skeletons are important in augmenting the diversity of early Protocetidae, clarifying that Cetacea evolved from early Artiodactyla rather than Mesonychia and showing how early protocetids swam.

Do the Y-set and double-bag systems reduce the incidence of CAPD peritonitis? A systematic review of randomized controlled trials.

BACKGROUND: Peritonitis is the most frequent serious complication of continuous ambulatory peritoneal dialysis (CAPD). It has a major influence on the number of patients switching from CAPD to haemodialysis and has probably restricted the wider acceptance and uptake of CAPD as an alternative mode of dialysis. This systematic review sought to determine if modifications of the transfer set (Y-set or double-bag systems) used in CAPD exchanges are associated with a reduction in peritonitis and an improvement in other relevant outcomes. METHODS: Based on a comprehensive search strategy, we undertook a systematic review of randomized or quasi-randomized controlled trials comparing double-bag and/or Y-set CAPD exchange systems with standard systems, or comparing double-bag with Y-set systems, in patients with end-stage renal disease (ESRD) treated with CAPD. Only published data were used. Data were abstracted by a single investigator onto a standard form and subsequently entered into Review Manager 4.0.4. Its statistical package, Metaview 3.1, calculated an odds ratio (OR) for dichotomous data and a (weighted) mean difference for continuous data with 95% confidence intervals. RESULTS: Twelve eligible trials with a total of 991 randomized patients were identified. In trials comparing either the Y-set or double-bag systems with the standard systems, significantly fewer patients (133/363 vs 158/263; OR 0.33, 95% CI 0.24-0.46) experienced peritonitis and the number of patient-months on CAPD per episode of peritonitis was consistently greater. When the double-bag systems were compared with the Y-set systems significantly fewer patients experienced peritonitis (44/154 vs 66/138; OR 0.44, 95% CI 0.27-0.71) and the number of patient-months on CAPD per episode of peritonitis was also greater. CONCLUSIONS: Double-bag systems should be the preferred exchange systems in CAPD.

Performance of stochastic approaches for forecasting river water quality.

This study analysed water quality data collected from the river Ganges in India from 1981 to 1990 for forecasting using stochastic models. Initially the box and whisker plots and Kendall's tau test were used to identify the trends during the study period. For detecting the possible intervention in the data the time series plots and cusum charts were used. The three approaches of stochastic modelling which account for the effect of seasonality in different ways. i.e. multiplicative autoregressive integrated moving average (ARIMA) model. deseasonalised model and Thomas-Fiering model were used to model the observed pattern in water quality. The multiplicative ARIMA model having both nonseasonal and seasonal components were, in general, identified as appropriate models. In the deseasonalised modelling approach, the lower order ARIMA models were found appropriate for the stochastic component. The set of Thomas-Fiering models were formed for each month for all water quality parameters. These models were then used to forecast the future values. The error estimates of forecasts from the three approaches were compared to identify the most suitable approach for the reliable forecast. The deseasonalised modelling approach was recommended for forecasting of water quality parameters of a river.

Muscle sparing thoracotomy: a biomechanical analysis confirms preservation of muscle strength but no improvement in wound discomfort.

OBJECTIVES: This study compares the posterior auscultatory triangle thoracotomy incision (muscle sparing) with full posterolateral thoracotomy (where latissimus dorsi muscle is always cut across its full width), with particular attention to the difference between latissimus dorsi muscle strength, post operative pain and chronic wound related symptoms. METHODS: Ten patients who had undergone auscultatory triangle thoracotomy (ATT) at least 1 year previously were matched with ten patients who had undergone posterolateral thoracotomy (PLT). Each pair was matched for age, sex, dominant hand, side of the operation, time since operation and presence or absence of history of previous muscle training. Latissimus dorsi muscle strength was assessed by testing the shoulder adduction strength through an arc of 90-0 degrees using isokinetic technique. Early post-operative pain was assessed indirectly by calculating the analgesic requirement in the first 5 post-operative days. A subjective assessment of chronic post-thoracotomy pain was made using a questionnaire presented to the patients at the time of muscle testing. Variability of the torque curves, recorded as coefficient of variance at the time of muscle strength testing, provided objective measurements of chronic pain. Data were analysed using two sample t-tests. RESULTS: All patients reported at least one chronic post-thoracotomy symptom. There was no significant difference between the two groups in terms of acute or chronic wound pain and other long term wound related symptoms. Shoulder adduction strength was 24% greater in ATT than PLT (95% confidence limits=1-43%, P=0.04). CONCLUSIONS: All thoracotomy patients have long term wound related symptoms. This situation is not improved by performing a muscle sparing incision. However thoracotomy through the triangle of auscultation can preserve latissimus dorsi strength which is compromised in a posterolateral thoracotomy incision. We therefore recommend that a muscle sparing thoracotomy be considered for patients where preservation of muscle strength is deemed important, providing the operation is not compromised due to inadequate access.

Evidence-based medicine in nephrology: identifying and critically appraising the literature.

BACKGROUND: Uncertainties about best management of end-stage renal disease (ESRD) are reflected in wide variations in practice. Systematic reviews aim to reduce uncertainty by strengthening the evidence base for clinical practice, allowing estimation of the benefits and risks of particular interventions, whilst minimizing the potential for bias. This paper describes the methods and conduct of six systematic reviews of aspects of the management of ESRD, and the yield in terms of trials found. METHODS: Our methodology was based on that recommended by the Cochrane Collaboration (an international initiative set up to perform and disseminate systematic reviews of health care). It involved a systematic search of electronic databases and bibliographic reference lists, together with handsearching of Kidney International for studies relevant to the management of ESRD, followed by a systematic assessment of study quality. RESULTS: Around 12,000 abstracts were assessed which had been identified from electronic sources. Of these, 2085 (18%) were deemed to be reports of possible randomized or quasi-randomized controlled trials relevant to the management of ESRD. Three hundred and forty were relevant to the six specific reviews, and after assessment of the full manuscripts, 39 studies were finally included in our reviews. Reports of a further nine trials, which were identified from other sources, were also included. The broad search adopted allowed the parallel development of a register of trials of all aspects of the management of ESRD. CONCLUSIONS: This study has demonstrated that the methodology of systematic reviews, as promoted by the Cochrane Renal Group, is feasible but has significant resource implications. The development of a register of randomized controlled trials (RCTs) related to the management of ESRD will facilitate this form of research in the future.

Evaluation of clinical guidelines for the management of end-stage renal disease in europe: the EU BIOMED 1 study.

BACKGROUND: There are wide national and international variations in the management of patients with end-stage renal disease (ESRD). The aim of this study was to develop, harmonize, implement, and evaluate consensus-based clinical guidelines for the management of renal anaemia and renal bone disease in patients with ESRD, and for the prevention and management of cytomegalovirus disease in renal transplant recipients across six renal centres in Europe. METHODS: The trial was a prospective, multicentre, randomized balanced incomplete block design. Nephrologists from the six European renal units were randomized to develop and implement guidelines for two out of the three conditions and to act as a control for the third condition. Data were collected pre- (1 year) and post- (9 months) intervention on aspects of patient monitoring, management, and outcome. RESULTS: Eight hundred and twenty-nine dialysis patients from the six European dialysis centres were included in the study. Multivariate analysis (adjusting for case-mix and secular trends) showed a significant increase in the number of monitoring events in the guideline group compared with control group (6%, 95% CI, 1-11%). There was no concomitant increase in either appropriate management or the number of favourable patient outcomes. CONCLUSIONS: In the first European collaboration on renal guidelines, the introduction of the guidelines improved the monitoring of the patients, but did not improve patient management or outcome. This study suggests the potential for creating clinical guidelines with the aim of standardizing treatment protocols across international boundaries, and improving the quality of the medical care provided.

Can we improve early mortality in patients receiving renal replacement therapy?

BACKGROUND: Approximately one in eight patients with end-stage renal disease (ESRD) die within the first three months of starting renal replacement therapy (RRT). We investigated which factors might improve this early mortality. METHODS: We performed a prospective nationwide study of all patients commencing RRT for ESRD in Scotland over one year. Patients were classified according to how they presented to start RRT, their burden of comorbid diseases, access prepared for dialysis, and duration of care by a nephrologist prior to commencing RRT. Those factors most strongly associated with death within 90 days of commencing treatment were determined by logistic regression analysis. RESULTS: Patients with an acute unexpected element to their presentation for RRT had early mortality rates between 6.0 and 8.9 times greater than those who commenced RRT electively after a period of care from a nephrologist. Patients in high and medium comorbidity risk groups had early mortality rates of 4.7 and 2.2 times greater than those in the low-risk group. Low serum albumin had a significant association with early death. Patients who progressed steadily to ESRD, who had a planned start to dialysis, and who had mature access were 3.6 times more likely to survive beyond three months than those with no access; they were, however, also younger with less comorbidity. CONCLUSIONS: The factors principally associated with early mortality are nonelective presentation for RRT, comorbid illness, and low serum albumin. Patients cared for by a nephrologist before requiring RRT who have mature access have better short-term survival than those without access. They are also younger with less comorbidity. It may be possible to improve short-term survival in this "unplanned" group if referred early to facilitate reducing cardiovascular risk factors and preparation for RRT.

Equity of renal replacement therapy utilization: a prospective population-based study.

This 1-year prospective survey assessed the incidence and characteristics of all patients starting renal replacement therapy (RRT) for end-stage renal disease in Scotland, and whether there is equity of utilization of RRT in terms of age, domicile and social circumstance. In the year studied, 104 patients per million population (533 patients) started RRT (390 per million population aged 65-75). In 23.5% the cause of ESRD could not be determined. Diabetes was the single most frequently identified cause (16%). The requirement for RRT rose with age, but over the country as a whole, patients aged over 75 years were under-represented. The majority of health boards provided RRT at a rate within 20% of the national rate. There was no difference in the median age at starting RRT between health boards. The spectrum of social deprivation of patients starting RRT was the same as that of the general population. There was no evidence that social deprivation influences acceptance on to the RRT program, although the relationship between ESRD and deprivation is complex. The utilization of RRT exceeded the minimum rate recommended by the Renal Association, although there was fluctuation between health board areas. The national requirement for resources to provide RRT is likely to rise further to care for an increasingly elderly population.

A national survey of thoracic surgical practice in the UK.

We conducted a survey of thoracic surgery in the UK today. Questionnaires were sent to 75 cardiothoracic surgeons, known to perform thoracic surgery regularly; we had a 100% response. The commonest preoperative investigations for carcinoma of the oesophagus were serum alkaline phosphatase (90%), GGT (69%), contrast swallow (80%), ultrasound of abdomen (71%) and CT scan of chest and abdomen (60%). After oesophagectomy, 84% of the surgeons inserted nasogastric tubes and 31% sent their patients to the intensive care unit. Oral fluids were started on days 3-5 in 81% of cases, and 58% of the surgeons requested a postoperative contrast swallow, usually between the seventh and tenth postoperative days, after oral fluids had been started. Most of the surgeons nearly always used staplers for a given procedure or else completely avoided them for that part of the operation. The commonest use of staplers was for bronchial closure in pneumonectomy (67%) and lobectomy (48%) and in constructing an oesophageal anastomosis (25%). Twenty per cent of the surgeons did not insert a chest drain after pneumonectomy, while 65% observed the protocol of chest drain insertion with short intermittent unclamping, usually every hour, followed by removal of the drain, usually the next morning. Thoracic surgeons vary widely in their surgical practices. In a well structured training programme, trainees should rotate between several units so they are exposed to different techniques and ideas and acquire a broad based training.

Glycoside primers of Psittacanthus cucullaris.

Bioassay-directed chromatographic separation of the ethyl acetate extract of the whole plant of Psittacanthus cucullaris afforded a new phenolic xyloside, ellagic acid-4-O-beta-xyloside-3,3', 4'-trimethyl ether (1) together with four known compounds, ellagic acid-4-O-beta-xyloside-3,3'-dimethyl ether (2), gallic acid, beta-sitosterol, and beta-sitosterol beta-D-glucoside. The structure of the new compound was determined by spectroscopic methods. Like other beta-D-xylosides, compounds 1 and 2 stimulated the formation of glycosaminoglycan chains when fed to the cultured Chinese hamster ovary cells.

Role of the SH3-ligand domain of simian immunodeficiency virus Nef in interaction with Nef-associated kinase and simian AIDS in rhesus macaques.

The nef gene of the human and simian immunodeficiency viruses (HIV and SIV) is dispensable for viral replication in T-cell lines; however, it is essential for high virus loads and progression to simian AIDS (SAIDS) in SIV-infected adult rhesus macaques. Nef proteins from HIV type 1 (HIV-1), HIV-2, and SIV contain a proline-Xaa-Xaa-proline (PxxP) motif. The region of Nef with this motif is similar to the Src homology region 3 (SH3) ligand domain found in many cell signaling proteins. In virus-infected lymphoid cells, Nef interacts with a cellular serine/threonine kinase, designated Nef-associated kinase (NAK). In this study, analysis of viral clones containing point mutations in the nef gene of the pathogenic clone SIVmac239 revealed that several strictly conserved residues in the PxxP region were essential for Nef-NAK interaction. The results of this analysis of Nef mutations in in vitro kinase assays indicated that the PxxP region in SIV Nef was strikingly similar to the consensus sequence for SH3 ligand domains possessing the minus orientation. To test the significance of the PxxP motif of Nef for viral pathogenesis, each proline was mutated to an alanine to produce the viral clone SIVmac239-P104A/P107A. This clone, expressing Nef that does not associate with NAK, was inoculated into seven juvenile rhesus macaques. In vitro kinase assays were performed on virus recovered from each animal; the ability of Nef to associate with NAK was restored in five of these animals as early as 8 weeks after infection. Analysis of nef genes from these viruses revealed patterns of genotypic reversion in the mutated PxxP motif. These revertant genotypes, which included a second-site suppressor mutation, restored the ability of Nef to interact with NAK. Additionally, the proportion of revertant viruses increased progressively during the course of infection in these animals, and two of these animals developed fatal SAIDS. Taken together, these results demonstrated that in vivo selection for the ability of SIV Nef to associate with NAK was correlated with the induction of SAIDS. Accordingly, these studies implicate a role for the conserved SH3 ligand domain for Nef function in virally induced immunodeficiency.