Assessment of preoperative cases.

A total of 200 outpatients in Aberdeen were invited to complete a simple preoperative anaesthetic assessment questionnaire. Of these patients 45-5% had significant medical histories and 59% were on concurrent drug therapy. The form was thought to be valuable for day-case anaesthetists and surgeons.     

Management of the patient requiring leg amputation for peripheral vascular disease.

Most leg amputations are performed because of the effects of peripheral vascular disease. Only 50% of such amputations were performed below the knee in Ontario in 1972, although the knee joint should be preserved in most patients. Careful preoperative evaluation is essential. Postoperative problems include gas gangrene for which prophylactic measures are recommended; failure of the stump to heal, which necessitates early revision of the stump; and defects in stump contour, which necessitate late revision. An enthusiastic team approach to rehabilitation is necessary to overcome the physical and mental problems that result from amputation of a leg.     

Assessment of fitness for surgical procedures and the variability of anaesthetists' judgments.

Ten anaesthetists were asked to make judgments on fitness for elective operation on data derived from 200 patients. The extent of their agreement was measured using a kappa statistic, and clusters of anaesthetists who agreed well with each other were identified. Using an alternative technique, the "true" fitness category of each patient was estimated using a maximum likelihood method which estimated the error involved in making judgments on limited amounts of information. It was possible to compare the performance of each anaesthetist against the consensus and to measure deviation on an "optimism--pessimism" continuum. A simple questionnaire predicted fitness for operation by all 10 anaesthetists in 96% of cases.     

Lifestyle assessment: applying microcomputers in family practice.

A randomised trial of assessment by computer was conducted with 180 patients in a family practice clinic. Histories of alcohol, tobacco, and drug use were obtained by computer (n = 60), interview (n = 60), or self completed questionnaire (n = 60). The results of previous research suggest that some patients may provide more accurate information about "sensitive" problems to a computer. No significant differences, however, in levels of consumption or problems were reported for the three methods of assessment. Patients gave differential ratings about the method of assessment, with the computer rated as more interesting but also more mechanical, cold, and impersonal. Although the interview was initially preferred by most, patients who completed the assessment by computer showed a significant increase (13% to 43%) in their preference for the computer after the assessment. The results of our study indicate that patients'' acceptance of computers in family practice may be favourably influenced by direct experience with a microcomputer.     

Anthropometric evaluation of dysmorphology in craniofacial anomalies: Treacher Collins syndrome

Advances in surgical techniques for correction of craniofacial anomalies have necessitated the development of objective pre- and postoperative quantitative assessments. Standard anthropometric techniques, supplemented by additional methods oriented to specific clinical problems, have proved useful in defining surface dysmorphology in craniofacial patients. A series of 77 surface measurements of the head and face and 41 proportions were determined in 20 preoperative patients with Treacher Collins syndrome, a rare congenital defect of the first and second branchial arches. To permit comparison with age- and sex-specific data for healthy North American children, the patient data were converted to standard (Z) scores. To test the hypothesis Z = 0, Student's t-test was performed on all variables. The anthropometric findings verified many of the clinical findings in this syndrome. In addition, a number of previously unreported defects were found. The cranium was low and short with a low, narrow forehead and a narrow cranial base. The face was narrow and shallow, the mandible long and narrow, and the lower face receding. The eye fissures were short with an antimongoloid inclination, but the orbits were hyperteloric. The nasal root was high and wide, the nasofrontal angle open, and the bridge inclination low. The labial fissure was narrow, and the ears were microtic. Except in the nasal root the defects were hypoplastic. Most of these defects were either horizontal or anteroposterior. Recognition of the defective areas and their contribution to disproportions of the head and face is important in the development of surgical strategies.     

Prevalence of nosocomial infections in general surgery, orthopedic surgery and urological departments in the Czech Republic

Two prevalence studies of Nosocomial Infections carried out in 1987 (based on 4479 patients in 64 general surgery departments and 1603 patients in 29 orthopedic surgery departments) and in 1988 (based on 1263 patients in 32 urological departments) are summarized. The prevalence rate of nosocomial infections (NI) in general surgery departments was 14.0%, in orthopedic surgery departments 8.0% and in urological departments 20.9%. The highest degree of risk of acquiring NI was run by patients above 60 years of age in urological and general surgery departments. Surgical wound infections in departments of general surgery accounted for 60%, in orthopedic surgery departments for 47% and in urological departments for 37% of all NI. The prevalence of wound infections amongst general surgical patients was 8.4%, amongst orthopedic surgical patients 3.8% and in urological patients 7.7%. The prevalence of urinary tract infections in general surgery departments was 14.4%, in orthopedic surgery departments 18.6% and in urological departments 51.6%. The problems discussed include the role of intrinsic and in-hospital risk factors and the involvement of pathogens responsible for the onset of NI.     

A reverse ulnar hypothenar flap for finger reconstruction

A reverse-flow island flap from the hypothenar eminence of the hand was applied in 11 patients to treat palmar skin defects, amputation injuries, or flexion contractures of the little finger. There were three female and eight male patients, and their ages at the time of surgery averaged 46 years. A 3 x 1.5 to 5 X 2 cm fasciocutaneous flap from the ulnar aspect of the hypothenar eminence, which was located over the abductor digiti minimi muscle, was designed and transferred in a retrograde fashion to cover the skin and soft-tissue defects of the little finger. The flap was based on the ulnar palmar digital artery of the little finger and in three patients was sensated by the dorsal branch of the ulnar nerve or by branches of the ulnar palmar digital nerve of the little finger. Follow-up periods averaged 42 months. The postoperative course was uneventful for all patients, and all of the flaps survived without complications. The donor site was closed primarily in all cases, and no patient complained of significant donor-site problems. Satisfactory sensory reinnervation was achieved in patients who underwent sensory flap transfer, as indicated by 5 mm of moving two-point discrimination. A reverse island flap from the hypothenar eminence is easily elevated, contains durable fasciocutaneous structures, and has a good color and texture match to the finger pulp. This flap is a good alternative for reconstruction of palmar skin and soft-tissue defects of the little finger.     

General practitioners' knowledge of their patients' psychosocial problems: multipractice questionnaire survey.

OBJECTIVES: To evaluate general practitioners'' knowledge of a range of psychosocial problems among their patients and to explore whether doctors'' recognition of psychosocial problems depends on previous general knowledge about the patient or the type of problem or on certain characteristics of the doctor or the patient. DESIGN: Multipractice survey of consecutive adult patients consulting general practitioners. Doctors and patients answered written questions. SETTING: Buskerud county, Norway. SUBJECTS: 1401 adults attending 89 general practitioners during one regular working day in March 1995. MAIN OUTCOME MEASURES: Doctors'' knowledge of nine predefined psychosocial problems in patients; these problems were assessed by the patients as affecting their health on the day of consultation; odds ratios for the doctor''s recognition of each problem, adjusted for characteristics of patients, doctors, and practices; and the doctor''s assessment of previous general knowledge about the patient. RESULTS: Doctors'' knowledge of the problems ranged from 53% (108/203) of "stressful working conditions" to 19% (12/63) of a history of "violence or threats." Good previous knowledge of the patient increased the odds for the doctor''s recognition of "sorrow," "violence or threats," "substance misuse in close friend or relative," and "difficult conflict with close friend or relative." Age and sex of doctor and patient, patient''s educational level and living situation, and location of practice influenced the doctor''s awareness. CONCLUSIONS: Variation in the patients'' communication abilities, the need for confidence in the doctor-patient relationship before revealing intimate problems, and a tendency for the doctors to be entrapped by their expectations may explain these findings.     

Hypo- vs. normofractionated radiation therapy in breast cancer: A patterns of care analysis in German speaking countries

Aim and backgroundTo assess the use of hypofractionated (HG-RT) versus normofractionated radiation therapy (NF-RT) in Breast Cancer in German speaking countries.Materials and methodsBetween July 2017 and August 2017, an email-based survey was sent to all 1408 physicians that are members of the German Society of Radiation Oncology (DEGRO). The survey was completed by 180 physicians including 10 private practice owners and 52 heads of departments. The majority (82.1%) of the participants had >15 years of experience in radiation therapy (RT).ResultsThe majority (83.9%) of the heads of the departments agreed on using the normofractionated regimen of RT as standard treatment for breast cancer. Several physicians were skeptical about HF-RT with 6.5% of the heads refusing to use HF-RT. 40.3% of the departments had not seen the new German guidelines suggesting HF-RT as the standard treatment for all patients as positive or merely adopted a neutral position toward the guidelines (33.9%). The main points of criticism were increased side effects, an impaired toxicity profile and insufficient data. Most departments (46.8%) that perform HF-RT do so in an individual based manner.ConclusionsHF-RT remains controversial in German speaking countries. Our data shows that NF-RT remains the predominant method of treatment. HF-RT is only used in a defined group of patients as most German physicians agree that particular patients, especially those at higher risk of RT late effects, may benefit from a less intense, extended fractionation schedule.     

Patients’ attitudes to the summary care record and HealthSpace: qualitative study

Objective To document the views of patients and the public towards the summary care record (SCR, a centrally stored medical record drawn from the general practice record) and HealthSpace (a personal health organiser accessible through the internet from which people can view their SCR), with a particular focus on those with low health literacy, potentially stigmatising conditions, or difficulties accessing health care.Design 103 semistructured individual interviews and seven focus groups.Setting Three early adopter primary care trusts in England where the SCR and HealthSpace are being piloted. All were in areas of relative socioeconomic deprivation.Participants Individual participants were recruited from general practice surgeries, walk-in centres, out of hours centres, and accident and emergency departments. Participants in focus groups were recruited through voluntary sector organisations; they comprised advocates of vulnerable groups and advocates of people who speak limited English; people with HIV; users of mental health services; young adults; elderly people; and participants of a drug rehabilitation programme.Methods Participants were asked if they had received information about the SCR and HealthSpace and about their views on shared electronic records in different circumstances.Results Most people were not aware of the SCR or HealthSpace and did not recall receiving information about it. They saw both benefits and drawbacks to having an SCR and described a process of weighing the former against the latter when making their personal choice. Key factors influencing this choice included the nature of any illness (especially whether it was likely to lead to emergency care needs); past and present experience of healthcare and government surveillance; the person’s level of engagement and health literacy; and their trust and confidence in the primary healthcare team and the wider NHS. Overall, people with stigmatising illness were more positive about the SCR than people who claimed to speak for “vulnerable groups.” Misconceptions about the SCR were common, especially confusion about what data it contained and who would have access to it. Most people were not interested in recording their medical data or accessing their SCR via HealthSpace, but some saw the potential for this new technology to support self management and lay care for those with chronic illness.Conclusion Despite an extensive information programme in early adopter sites, the public remains unclear about current policy on shared electronic records, though most people view these as a positive development. The “implied consent” model for creating and accessing a person’s SCR should be revisited, perhaps in favour of “consent to view” at the point of access.     

Radial forearm and fibula free flap reconstruction after radical resection of head and neck malignancies

The incidence of head and neck cancer has been rapidly increasing in Hungary during the last decade. Most of these tumors are discovered in advanced stage, consequently, surgical removal of the tumor results in large complex defects in the soft tisses and bone elements of the face and neck. For optimal anatomical and functional reconstruction we perform free flap transfer in increasing number of cases. Between December 1993 and March 2001 in the Head and Neck Surgery Department of the National Institute of Oncology the defects after resection of head and neck tumors were reconstructed with free flaps in 85 cases. Radial forearm flap in 64 cases, fibula osteoseptocutaneous flap in 14 cases were used. In 87% of the patients the postoperative period was uneventful, the surgical complications were not more numerous than following traditional reconstructions. The average duration of operations became shorter by 2.5 hours during the last two years than before. In most of the cases we achieved good functional and esthetic results. The quality of life of the patients was excellent in 14%, almost normal in 73% and bad with serious problems of social life in 13%. It is surprising that there was no significant difference between the survival of neck node positive and negative patients. In our practice the replacement of large defects in the head and neck region with free flaps is a reliable and useful method for reconstruction.     

Roaming Companion Cats as Potential Causes of Conflict and Controversy: A Representative Questionnaire Study of the Danish Public

Cats have grown in popularity as companion animals, but there are also people who strongly dislike them. Companion cats allowed to roam freely outdoors are seen by some as a nuisance. This paper, drawing on research conducted in Denmark, aims to quantify potentially conflicting attitudes to cats among the public that may feed into cat-related conflicts and controversies. Questionnaire data were collected from a representative sample of the Danish population (n = 2,003), where 21% (n = 415) owned cats and 79% (n = 1,588) did not. In all, 65% of respondents confirmed that they liked cats, 21% reported that they did not, and 14% were undecided. The main reasons for disliking cats concerned “behavior,” not hazards such as the spread of diseases and predation. Of the 21% of the surveyed Danes who reported that they currently had a cat in the household, 72% allowed their cat to roam outdoors. Sixty percent of the respondents did not perceive this as a problem. However, the potential for conflict was demonstrated by the fact that 27% of respondents regarded outdoor roaming as problematic. Of these, about a quarter saw free-roaming cats as a big problem and as a cause of strife between neighbors. Comparatively fewer of those who owned cats saw their animals as a cause of problems. Thus, only 12% of those owning outdoor cats thought that problems were caused when their cats defecated in a neighbor’s garden, which compares with the 17% of the total population who are bothered by other people’s cats defecating in their gardens. Our data show that while the majority of Danes believe cats should be allowed to roam in public spaces, a significant minority strongly dislikes cats and would prefer restrictions on roaming.     

Preoperative Evaluations by an Internist—Are They Worthwhile?

The value of preoperative examinations done by internists on ophthalmology patients was assessed. A retrospective chart review of 258 consultations was conducted and information about surgical risk, as defined by strict criteria, was abstracted. A total of 59 surgical risk conditions and 62 incidental problems were detected. In 65% of the risk conditions internists intervened to lessen the patients'' risk. Most of these benefits were in patients older than 60 years and very few important problems were detected in those younger than 50. The average cost of the consultation and additional laboratory tests was $146.60. It is concluded that significant benefit was derived at a reasonable cost by patients older than 50 years.     

Do personal computers make doctors less personal?

Ten months after the installation of a computer in a general practice surgery a postal survey (piloted questionnaire) was sent to 390 patients. The patients'' views of their relationship with their doctor after the computer was introduced were compared with their view of their relationship before the installation of the computer. More than 96% of the patients (n=263) stated that contact with their doctor was as easy and as personal as before. Most stated that the computer did not influence the duration of the consultation. Eighty one patients (30%) stated, however, that they thought that their privacy was reduced.Unlike studies of patients'' attitudes performed before any actual experience of use of a computer in general practice, this study found that patients have little difficulty in accepting the presence of a computer in the consultation room. Nevertheless, doctors should inform their patients about any connections between their computer and other, external computers to allay fears about a decrease in privacy.     

Health checks on patients 75 years and over in Nottinghamshire after the new GP contract.

OBJECTIVE--To investigate annual health checks for patients of 75 years and over required by the 1990 contract for general practitioners. DESIGN--Visits to practices to collect information on how assessments were organised and carried out; completion of questionnaires for every patient who had been assessed in a sample month, using information provided by the practice records. SETTING--20 general practices in one family health services authority. SUBJECTS--Patients of 75 years and over in 20 general practices. RESULTS--Three practices (15%) had not performed checks. Thirteen practices sent a letter to invite patients to undergo a check. Of these practices, seven followed up non-responders. Two practices visited patients'' homes unannounced, and two did checks on an opportunistic basis only. Sixteen practices used a checklist. Sixteen practices involved their practice nurses; at eight of these, doctors also performed checks; in six practices the nurses undertaking the checks had no training in assessing old people. Ten practices assessed more than 75% of their old people in the first year of the new contract. Practices that did not follow up patients who had not responded to the invitation for assessment completed significantly fewer checks. During the sample month, 331 patients were assessed in the 17 practices. 204 new problems were discovered in 143 patients. Significantly more problems per patient were found in inner city areas. CONCLUSIONS--The way health checks were performed varied greatly, both in their organisation and the practices'' attitudes. Many old people did not respond to letters asking if they wanted an assessment but very few refused one if followed up. Forty three per cent of those assessed had some unmet need. The number of new problems found per patient may reduce over the next few years if the assessments are successful. The need for annual assessment should be kept under review and adequate resources made available for the needs uncovered. Improved training for practice nurses in assessment is needed. Effectiveness of the checks must be monitored. If most unmet need falls in particular high risk groups it would seem sensible to modify the annual check to target these groups.     

The low specificity of postoperative perfusion lung scan defects.

Ventilation and perfusion lung scans were performed preoperatively and postoperatively in 169 patients and classified blindly according to preset criteria. Perfusion lung scan abnormalities were present in 25 (15%) of the preoperative scans and 42 (25%) of the postoperative scans; 16 (38%) of the 42 abnormal postoperative scans were identical to the preoperative scans. Perfusion defects indicating a "high probability" of pulmonary embolism (lobar or segmental defects) were present in 5 preoperative scans and 10 postoperative scans; the 10 postoperative scans were classified as showing "definite" (5), "possible" (1) or "no" (4) pulmonary embolism on the basis of the preoperative scan and the ventilation scan; none of the 10 patients had clinical evidence of pulmonary embolism. Venous thrombosis was present in 12 patients, including 4 of the patients whose lung scans showed definite pulmonary embolism. Thus, postoperative perfusion lung scan defects are potentially misleading even when large.     

某大型综合医院手术前检查流程的干预研究

手术科室的良性流程运转直接影响到整个医院的效益。进一步简化手术病人的术前检查流程,使病人得到优质、高效、可及的医疗服务。通过对某军队大型综合医院所有手术科室（23个）2010年7—12月全麻手术病例共6 803例的运行情况进行回顾性研究,分析手术病人术前检查流程,找出制约整个检查的瓶颈所在并进行干预,达到优化术前检查流程、缩短术前平均住院日、减少无效或低效住院日、加快手术科室床位周转率的目的。

     

Self referral to accident and emergency department: patients' perceptions.

A study was conducted (a) to assess the number of patients registered with a south London general practice who over 11 weeks referred themselves to an accident and emergency department, (b) to identify the characteristics of those patients, and (c) to determine their perceptions of the services and resources available within their general practices and of the role of accident and emergency departments. Two hundred and thirty four patients referred themselves to a casualty department during the study period, of whom 217 (93%) were interviewed by means of a semistructured questionnaire. Of the 217 patients interviewed, only 15 had tried to contact their general practitioner before attending the casualty department. Eighty nine patients considered that their problem was urgent and required immediate attention and many that they would need an x ray examination. A substantial minority of patients thought that their doctor would not be available. It is concluded that patients'' perceptions of their problems and of access to their doctors are the main determinants of self referral to a casualty department. These findings have important implications for patient education.     

Prevention of falls in the elderly--a key role for the falls clinic

Falls are a major health problem among elderly people, because of the incidence and because of the consequences. Current practice commonly focuses on the injury with little attention of the underlying cause, the risk factors for a new fall and the possibilities for future prevention. Most of the falls are a result of multiple risk factors. Several of this risk factors are potentially modifiable. The Dutch Falls Prevention Collaboration have made a protocol to assist health care professionals at a standardised and evidence based way with their assessment of fall risk. With the risk factors identified in the assessment it is possible to make an individual multifactorial fall prevention program. Such an intervention can give a significant reduction of falls in the elderly. The protocol is presented in this article.     

Assessment of patients aged over 75 in general practice.

OBJECTIVES--To evaluate the assessment scheme for people aged 75, to establish doctors'' and nurses'' views on the value of the assessment scheme, and to seek patients'' opinions on elderly assessments. DESIGN--Data on the assessment process were collected from individual practices. Questionnaires were sent to doctors and practice nurses undertaking assessments and to a sample of elderly patients. SUBJECTS--31,565 patients aged 75 and over and all doctors registered with Wiltshire Family Health Services Authority, as well as practice nurses assessing elderly patients. A 2% random sample of elderly patients was selected to answer questions on patient satisfaction. MAIN OUTCOME MEASURES--Numbers of patients accepting the invitation for assessment, who carried out the assessments and where, what unmet needs were identified, and by whom. RESULTS--20,192 patients (64%) accepted the assessment offer. Doctors carried out 8786 assessments and nurses 10,779. Although 12,317 (61%) were carried out in the home, nurses did most domiciliary assessments (7122/11,883). Nurses with extra qualifications identified the highest number of unmet needs (400/1000 visits). 155 of 228 (68%) doctors thought assessments unnecessary whereas 25 of 48 (52%) of nurses thought them important. 93% of patients found assessment useful. CONCLUSIONS--Doctors see no merit in the scheme; most undertake assessments opportunistically and pick up few new problems. Nurses who see it as important require further training to fit them to do home visits confidently. Patients who were assessed found it worth while. The case for developing a specialist community nurse for elderly people should be investigated.