Protracted diagnosis of ACNES: a costly exercise.

This case report summarizes the course of events leading to diagnosis and eventual repair of anterior cutaneous nerve entrapment syndrome (ACNES) in a 58-year-old female. The time period elapsing from initial symptoms to final operative repair was 9 months. The diagnosis was missed by both medical and surgical specialists despite multiple outpatient appointments, investigative procedures and a battery of laboratory tests. The diagnosis of ACNES was first considered when reviewed by a hernia surgeon and subsequently confirmed following open exploration of the anterior abdominal wall. The nerve was released and pain symptoms resolved. Access to the NHS Scotland ISD register permitted an economic analysis of the diagnostic services utilized for this patient and these totalled nearly £11 500. At a time when the NHS is focused on cost effectiveness, this particular sequence of investigations illustrates a protracted and costly diagnostic pathway.

The learning environment for junior doctor training--what hinders, what helps.

As part of a larger study on learning outcomes for the first year of postgraduate medical training (already reported), semi-structured interviews with middle grade trainees were used to explore their perceptions of trainee development during this first training year. Data generated focused not only on learning outcomes, but also on important process issues. Dissatisfaction was expressed with formal and informal teaching and learning opportunities. Factors that enhance the learning environment were identified. These included being supported, a feeling of being a valued member of the team, being stretched but not over stretched, having a broad range of experiences, knowing the system, having a clear remit and being well organized. Factors inhibiting the learning environment included fractured working patterns, insufficient time with patients and seniors, as well as the converse of many of the enhancing factors. The process issues gathered in this paper will be of interest to those involved in the delivery of training for junior doctors.

Exit learning outcomes for the PRHO year: an evidence base for informed decisions.

OBJECTIVE: To evaluate potential learning outcomes for pre-registration house officer (PRHO) training and develop an evidence base for informed decision making. DESIGN AND SETTING: A 2-stage Delphi process was employed to establish the opinions of Scottish stakeholders with regard to learning outcomes for the PRHO year. PARTICIPANTS: Doctors involved in the provision of PRHO training, including deans, postgraduate tutors and general practitioners (GPs) with trainees, were invited to participate in the study. MAIN OUTCOME MEASURES: Respondents rated a range of outcomes according to which they believed should be included or excluded from the PRHO training year. RESULTS: Learning outcomes identified for PRHOs were grouped under the 12-domain framework of the 3-circle model: 'What the doctor can do', 'How they approach their practice' and 'Their professionalism'. Based on the consensus opinions gained in the Delphi study, the ratings were classified into priority groupings. Priority 1 contained 45 of the original 81 learning outcomes, representing each area of the 3-circle model, with emphasis on the domains of clinical skills, patient investigation/management, communication, appropriate attitudes and personal development. Health promotion and disease prevention was the only domain not represented at priority 1. Priority 2 contained 24 outcomes with emphasis on the understanding of clinical skills, patient management and personal development. Priority 3 contained 12 outcomes indicating a lack of emphasis for some outcomes, particularly the role of the doctor and health promotion. CONCLUSION: Consensus on the learning outcomes for PRHO training has been achieved, providing an evidence base for curriculum planning. The relative priority assigned to these outcomes can facilitate the use of the evidence. This evidence base should be referred to when reviewing any PRHO training programme.

New doctors' perceptions of their educational development during their first year of postgraduate training.

The General Medical Council (GMC) in the UK describes a wide range of competences in which the new medical graduate should develop during the first postgraduate year. New graduates are known as pre-registration house officers (PRHOs). In this study, semi-structured open interviews with PRHOs approaching the end of their first postgraduate year were used to explore the trainees' perceptions of their development. After the interview their views on the importance given in their experience to the GMC's competences were explored though a questionnaire. Most noticeable from the interview data was the PRHOs'emphasis in the development of generic skills required of working in the 'real world'--skills such as communication, team working and the ability to cope with responsibility. In some outcomes, their noticeable progression, e.g. communication, or lack of progression, e.g. health promotion, reflected their views on the importance given. With other outcomes there was a paradox, e.g. practical skills were rated highly but were not noticeably developed; the role of the doctor was noticeably developed but was not highly rated. Overall the PRHOs developed most strongly in the 'professionalism' domain with not all the skills in the 'tasks' domain being similarly developed. This study helps to define the benefits and opportunities of the PRHO year, as currently perceived by the trainees, and should be of interest to those involved in the planning and delivery of postgraduate training.

The Scottish doctor--learning outcomes for the medical undergraduate in Scotland: a foundation for competent and reflective practitioners.

This paper describes a set of learning outcomes that clearly define the abilities of medical graduates from any of the five Scottish medical schools. The outcomes are divided into 12 domains that fit into one of three essential elements for the competent and reflective medical practitioner.

Early graft function and patient survival following cadaveric renal transplantation.

BACKGROUND: The influence of events that occur early following renal transplantation such as delayed graft function (DGF) and acute rejection on long-term graft survival has been widely reported, but its association with patient survival has received less attention. METHODS: We studied 589 patients who received their first cadaveric transplants between 1984 and 1993, all of whom received cyclosporine-based immunosuppression and who had a median follow-up of seven years. The following factors were identified, and both univariate and multivariate analyses were used to determine their association with long-term patient and graft survival: age, sex, duration of pretransplant dialysis, primary renal disease, immediate graft function (IGF), DGF, primary nonfunction (PNF), acute rejection, and serum creatinine at 3, 6, and 12 months. RESULTS: Patients with PNF had a poorer survival than those with DGF and IGF (P = 0.01), but there was no difference in survival between DGF and IGF (P = 0.54). Good graft function (serum creatinine of less than 200 mumol/liter) at three months was predictive of better long-term patient survival (P = 0.03). Other factors associated with poor patient outcome were older age, diabetes, adult polycystic kidney disease, male gender, and acute rejection. Cardiovascular disease was the most common cause of death (51.8%). Good graft function at three months (P < 0.001) and an absence of rejection episodes (P = 0.01) were associated with better graft survival. CONCLUSION: Patients with poor levels of early graft function (but not DGF) and those with either acute rejection episodes or early graft loss are at an increased risk of early death. These high-risk groups should be targeted for interventional studies in an attempt to improve patient survival.

Long-term outcome of a prospective randomized trial of conversion from cyclosporine to azathioprine treatment one year after renal transplantation.

BACKGROUND: Since the introduction of cyclosporine (CsA), 1-year renal allograft survival has improved, but concern persists about the long-term adverse effects of CsA, especially with respect to renal function and blood pressure. This randomized controlled trial was set up to establish whether withdrawal of CsA would alter long-term outcome. METHODS: Adult patients who, at 1 year after renal transplantation, had a stable serum creatinine of less than 300 micromol/L and who had not had acute rejection within the last 6 months were eligible for entry. Patients were randomized either to continue on CsA (n=114) or to stop CsA and start azathioprine (Aza, n=102). All patients remained on prednisolone. Median follow-up was 93 months after transplantation (range: 52-133 months). RESULTS: There was no significant difference in actuarial 10-year patient or graft survival (Kaplan-Meier), despite an increased incidence of acute rejection within the first few months after conversion. Median serum creatinine was lower in the Aza group (Aza: 119 micromol/L; CsA. 153 micromol/L at 5 years after randomization, P=0.0002). The requirement for antihypertensive treatment was also reduced after conversion to Aza; 75% of patients required antihypertensive treatment at the start of the study, decreasing to 55% from 1 year after randomization in the Aza group and increasing to >80% in the CsA group (55% (Aza) and 84% (CsA) at 5 years after randomization, P<0.005). CONCLUSIONS: Conversion from CsA to Aza at 1 year after renal transplantation results in improvement in both blood pressure control and renal allograft function, and is not associated with significant adverse effects on long-term patient or graft survival.

Long-term outcome of the use of OKT3 to treat steroid-resistant acute renal allograft rejection.

OKT3 was used to treat steroid-resistant acute renal allograft rejection in 30 of 496 adult patients transplanted over a 6-year period. Rejection was reversed (defined as a fall in serum creatinine by 50% or more within 30 days of treatment with OKT3) in 40% of cases. Successful reversal was significantly more likely when rejection occurred shortly after transplantation (t ratio -2.53; P = 0.019). The long-term outcome was disappointing; the actuarial graft survival at 1 year from the start of treatment with OKT3 was 42%, and no grafts have thus far survived longer than 3 years. Graft survival was shorter in older patients (coefficient/standard error 2.226; P < 0.05), and no other predictor of long-term outcome was identified. Patient survival at 3 years was 88%. Serious infection occurred in 33% of patients, with two deaths. Our experience suggests that treatment with OKT3 is unlikely to reverse acute renal allograft rejection in more than half of patients where rejection is resistant to steroids. Although long-term graft survival occurred in a few cases, the overall long-term outcome was disappointing, particularly in older patients. Finally, our analysis indicates the difficulty of predicting which patients will derive long-term benefit when OKT3 is used to treat steroid-resistant rejection.

Excision of residual masses after platinum based chemotherapy for non-seminomatous germ cell tumours.

Between January 1980 and June 1987, 42 patients receiving platinum based combination chemotherapy for advanced non-seminomatous germ cell tumours had residual masses, detected by computed tomography, after four or six treatment courses without tumour marker evidence of active disease. Resection of retroperitoneal (n = 32), pulmonary (n = 4) or thoracoabdominal (n = 2) disease revealed residual malignancy in nine patients (21%), differentiated teratoma in 14 (33%) and fibrosis or necrosis in 15 (36%). Laparotomy showed no evidence of a mass in four instances. Of the 42 patients, 14 had malignant teratoma undifferentiated in the primary tumour only one of whom (7%) had evidence of malignancy in the specimen resected post-chemotherapy. Conversely, six of 15 patients (40%) whose primary tumour was malignant teratoma intermediate had residual malignant tissue after treatment. With a median follow up of 36 months from post-chemotherapy surgery, 36 patients (86%) are continuously disease-free. Relapses occurred in one of nine patients with residual malignancy (11%), three of 14 with differentiated teratoma (21%), one of 15 with necrosis or fibrosis (7%) and in one patient who had a normal laparotomy. Four patients have died from their tumours, but two are currently disease-free following further surgery and chemotherapy for relapse. Neither primary nor post-chemotherapy histology was predictive of relapse, and although relapse was numerically more common in patients whose residual mass was incompletely excised (three of 12), this was not statistically significant.

Acute torsion of the gallbladder.

Acute torsion of the gallbladder is an acute surgical emergency which may be encountered more frequently in the presence of an ageing population. We report a 98-year-old patient in whom the diagnosis was made at exploratory laparotomy performed for unexplained peritonism. Emergency cholecystectomy was followed by an uncomplicated post-operative recovery.

Malignant phaeochromocytoma.

Malignant phaeochromocytoma is a rare tumour and experience in its management is therefore limited. Five patients are discussed in whom the development of metastases was associated with rapidly progressive disease.

Relief of pain by infusion of morphine after operation: does tolerance develop?

To see whether continuous intravenous infusion of opiates provides more effective postoperative relief of pain than conventional intramuscular injection these regimens were compared in a prospective double blind trial. Thirty patients undergoing elective cholecystectomy were allocated randomly to receive an infusion of morphine or an infusion of placebo (control group) for 24 hours. Both groups were allowed supplementary morphine boluses as requested. During the first 48 hours after operation the degree of pain was almost identical between the groups. Surprisingly, the group that was given the infusion of morphine received as much supplementary morphine as the control group during the first 24 hours and appreciably more during the 24 hours after the infusion had been withdrawn. Nausea and vomiting were more prevalent among the patients given the infusion of morphine. These results suggest that continuous infusion of morphine may be an inferior regimen to intermittent bolus administration in the relief of postoperative pain. This may be explained by the development of tolerance in patients who received the infusion of morphine.

Early detection of obstructed ureter by ultrasound following renal transplantation.

Serial ultrasound examinations were carried out following 144 renal transplants. Eleven patients (8%) required surgery for ureteric obstruction and in all cases the ultrasound correctly identified the obstruction at an early stage. One false positive result was obtained with the ultrasound and this compared favourably with both the intravenous urogram (IVU) and isotope renogram. There were false positive and false negative results with both the IVU and renogram in addition to which neither of these techniques, particularly the IVU, is as simple or atraumatic for the patient as the ultrasound. Serial ultrasound examinations have a useful role in the detection of ureteric obstruction as well as being of value in the detection of perinephric fluid collections and acute rejection.