Mianserin and agranulocytosis.

An alcoholic woman who was admitted to hospital for detoxification was prescribed thyroxine because of hypothyroidism and mianserin to alleviate severe depression. After several weeks'' treatment she became unwell and was readmitted to hospital. Haematological examination indicated agranulocytosis. Further extensive investigations elicited no cause for this other than the mianserin, since no such disturbance has been reported for thyroxine after years of use. Thus mianserin is probably implicated in this case of agranulocytosis. Although the response may have been idiosyncratic, it highlights the need to monitor new drugs during the early phases of widespread use.     

Factores pronósticos de remisión a largo plazo tras cirugía transesfenoidal en la enfermedad de Cushing

There is no consensus on the remission criteria for Cushing's disease or on the definition of disease recurrence after transsphenoidal surgery, and comparison of the different published series is therefore difficult. A long-term recurrence rate of Cushing's disease ranging from 2%-25% has been reported. Predictors of long-term remission reported include: 1) adenoma–related factors (aggressiveness, size, preoperative identification in MRI), 2) surgery-related factors, mainly neurosurgeon experience, 3) clinical factors, of which dependence on and duration of glucocorticoid treatment are most important, and 4) biochemical factors. Among the latter, low postoperative cortisol levels, less than 2 mcg/dL predict for disease remission. However, even when undetectable plasma cortisol levels are present, long-term recurrence may still occur and lifetime follow-up is required. We report the preliminary results of the first 20 patients with Cushing's disease operated on at our hospital using nadir cortisol levels less than 2 mcg/dl as remission criterion.     

A geriatric day hospital: the Sunnybrook experience.

A review of the first 7 years of experience with the geriatric day hospital at Sunnybrook Medical Centre in Toronto revealed the following about the patients attending the day hospital during that time: most were 60 to 79 years old; over 85% attended 1 or 2 days a week; more than two thirds lived with a spouse or relatives; and more than half had diseases of the circulatory system or mental disorders. The day hospital offers a varied therapeutic program while easing the demands on the energy and time of the patient''s spouse or family and thus helps the elderly to remain in the community rather than live in an institution. The experience at Sunnybrook has shown that geriatric day hospitals can be a valuable component of the broad spectrum of integrated services and programs that must be developed to provide adequate health care for the growing number of older people in our population.     

Establishing a robust chimeric antigen receptor T-cell therapy program in Australia: the Royal Prince Alfred Hospital experience

>himeric antigen receptor (CAR) T-cell therapy is a novel approved cancer treatment that has shown remarkable efficacy in the treatment of patients with relapsed leukemia and lymphoma. Implementation of CAR T-cell therapy in a hospital setting requires careful and detailed planning because of the complexities in delivering this specialist service. A multi-disciplinary approach with dedicated funding is required to meet clinical, scientific, logistic and regulatory requirements. Tisagenlecleucel was the first approved CAR T-cell therapy in Australia. The treatment has been made available to Australian patients in specialist public hospitals through federal and state funding. Royal Prince Alfred Hospital (RPAH) is one of Australia's oldest tertiary referral public health care institutions and was approved for the provision of CAR T-cell therapy service in 2019. A multi-disciplinary clinical program has been established for the collection and cryopreservation of donor cells shipped for manufacturing as well as for the receipt, storage and administration of CAR T-cell therapy and patient management. The program encompasses a Therapeutic Goods Administration-accredited apheresis unit and a state-of-the-art facility for cell processing, cryopreservation and storage. The program's clinical expertise extends to hematology, oncology, intensive care, pharmacy, neurology and radiology services with direct experience in managing patients receiving CAR T-cell therapies. The introduction of CAR T-cell therapies at RPAH was a complex undertaking facilitated by the existing infrastructure and clinical expertise.     

甲状腺次全切除术与甲状腺全切除术治疗结节性甲状腺肿的疗效对比分析

目的:研究甲状腺次全切除术与甲状腺全切除术治疗结节性甲状腺肿的临床疗效。方法:选取2011年1月至2012年12月我院收治的84例结节性甲状腺肿患者,随机分为甲状腺次全切除术组(A组)和甲状腺全切除术组(B组),比较分析两组患者围手术期指标、治疗效果及并发症发生情况。结果:A组镇痛剂使用量、手术时间、术中出血量及住院时间少于B组,差异有统计学意义(P0.05)。A组和B组有效率差异无统计学意义(P0.05),A组复发率高于B组,差异有统计学意义(P0.05)。并发症发生率A组低于B组,差异有统计学意义(P0.05)。结论:甲状腺次全切除术与甲状腺全切除术治疗结节性甲状腺肿疗效相似,甲状腺次全切除术复发率更高,但并发症发生率更低。     

PICCO在重型颅脑损伤患者容量管理中的临床应用价值研究

目的:探讨脉搏指数连续心输出量(PICCO)技术在重型颅脑损伤患者液体管理中的临床应用价值。方法:回顾性分析重型颅脑损伤患者46例(男性27例,女性19例),以应用PICCO技术监测血流动力学指标指导液体管理的患者为治疗组(n=26),未应用PICCO技术指导液体管理的患者为对照组(n=20)。比较两组患者的日平均液体量、格拉斯哥昏迷评分(GCS)、急性生理与慢性健康评分(APACHE II)、肺水肿发生率、住院时间、住院总费用以及治疗6个月后的格拉斯哥预后评分(GOS)、生存率、颅脑损伤恢复良好率。结果:治疗期间,治疗组的GCS评分以及APACHEII评分均优于对照组,而治疗组的住院总费用高于对照组,但差异并无统计学意义(P0.05)。治疗组的日平均液体量、肺水肿发生率及住院时间均明显少于对照组,差异有统计学意义(P0.05)。治疗6个月后,治疗组患者的GOS评分、生存率和颅脑损伤恢复良好率均高于对照组,但差异亦无统计学意义(P0.05)。结论:应用PICCO技术监测血流动力学指标指导重型颅脑损伤患者的容量管理可在一定程度上缩短危重患者的住院时间并降低肺水肿的发生率,但并不能明显改善患者的预后。     

Lithium treatment: prescribing and monitoring habits in hospital and general practice.

OBJECTIVES--To define current clinical practice of lithium prescribing and monitoring and to compare hospital based practice with general practice. DESIGN--Prospective study of doctors'' practice. SETTING--Psychiatric hospital day and outpatient facilities and general practices in Edinburgh and Midlothian district (population 600,000). SUBJECTS--458 patients taking lithium who had been stabilised and who remained as outpatients during the year of study. 219 were treated by their general practitioner and 190 by the hospital; 49 had shared care or care transferred during the study. MAIN OUTCOME MEASURES--Daily dose, duration of treatment, psychiatric diagnosis, mean annual serum lithium concentration, frequency of occurrence of and response to raised serum concentrations. RESULTS--Compared with hospital doctors general practitioners were more likely to prescribe lithium three or more times daily (43/219 (general practice) v 10/190 (hospital); chi 2 = 18.6, p = 0.001) and to estimate serum concentrations less frequently (4.5 v 5.3 measurements/year; t = 3.04, p = 0.003), and their patients were more likely to experience raised lithium concentrations (39/219 v 17/190; chi 2 = 6.8, p = 0.01). One third of doctors made no response to raised lithium concentrations in the next six weeks. CONCLUSIONS--General practitioners and hospital doctors care for similar types of patients and the stringency of lithium surveillance varies greatly among doctors. Certain aspects of practice give cause for concern and could be improved by following more uniform guidelines.     

Treatment of Crohn's disease with an unrefined-carbohydrate,fibre-rich diet.

Thirty-two patients with Crohn''s disease were treated with a fibre-rich, unrefined-carbohydrate diet in addition to conventional management and followed for a mean of four years and four months. Their clinical course was compared retrospectively with that of 32 matched patients who had received no dietary instruction. Hospital admissions were significantly fewer and shorter in the diet-treated patients, who spent a total of 111 days in hospital compared with 533 days in the non-diet-treated control group. Whereas five of the controls required intestinal operation, only one diet-treated patient needed surgery. This is in strong contrast to general experience with this disease. Treatment with a fibre-rich, unrefined-carbohydrate diet appears to have a favourable effect on the course of Crohn''s disease and does not lead to intestinal obstruction.     

缬沙坦对高血压合并肾小球肾炎患者Scr和GFR水平的影响

目的:探讨缬沙坦治疗高血压并肾小球肾炎临床疗效及对Scr(血清肌酐)、GFR(肾小球滤过率)水平变化的影响及临床意义。方法:选取我院收治的126例高血压合并肾小球肾炎患者为研究对象,随机分成A、B两组,各63例。A组给予低剂量(80mg/d)缬沙坦,B组给予高剂量(160 mg/d)缬沙坦。记录两组患者治疗前后SBP,Scr,GFR等临床指标变化情况及不良反应。结果:治疗前两组各项指标对比无明显差异(P0.05);治疗后,A,B两组SBP均较治疗前显著下降(P0.05);A组Scr呈升高趋势(P0.05),B组Scr呈轻微下降趋势(P0.05);A组、B组GFR变化不明显(P0.05)。A组不良反应率为4.76%,B组为9.52%,差异不显著(P0.05)。结论:对高血压合并肾小球肾炎患者给予高剂量缬沙坦,降压效果及耐受性好,毒副作用低,患者血清肌酐及肾小球虑过率水平无明显变化,值得临床推广。     

Randomised controlled trial of intravenous antibiotic treatment for cellulitis at home compared with hospital

Objectives To compare the efficacy, safety, and acceptability of treatment with intravenous antibiotics for cellulitis at home and in hospital.Design Prospective randomised controlled trial.Setting Christchurch, New Zealand.Participants 200 patients presenting or referred to the only emergency department in Christchurch who were thought to require intravenous antibiotic treatment for cellulitis and who did not have any contraindications to home care were randomly assigned to receive treatment either at home or in hospital.Main outcome measures Days to no advancement of cellulitis was the primary outcome measure. Days on intravenous and oral antibiotics, days in hospital or in the home care programme, complications, degree of functioning and pain, and satisfaction with site of care were also recorded.Results The two treatment groups did not differ significantly for the primary outcome of days to no advancement of cellulitis, with a mean of 1.50 days (SD 0.11) for the group receiving treatment at home and 1.49 days (SD 0.10) for the group receiving treatment in hospital (mean difference 0.01 days, 95% confidence interval -0.3 to 0.28). None of the other outcome measures differed significantly except for patients'' satisfaction, which was greater in patients treated at home.Conclusions Treatment of cellulitis requiring intravenous antibiotics can be safely delivered at home. Patients prefer home treatment, but in this study only about one third of patients presenting at hospital for intravenous treatment of cellulitis were considered suitable for home treatment.     

Frequency of premolar teeth extractions for orthodontic treatment

It is of interest to evaluate the frequency of premolar extractions during orthodontic treatment in patients reporting to the Saveetha dental hospital in Chennai from 2019-2020. We used the records from 987 patients who underwent orthodontic treatment from June 2019 to March 2020 in a dental hospital for this analysis. Digital case records of patients who underwent therapeutic extractions of premolars were isolated. A sample dataset of 340 case records were selected for this study. Data shows that 34.4% of subjects underwent premolar extractions amongst a total of 987 subjects who underwent orthodontic treatment. 89.4% of patients were Angle''s Class I malocclusion patients, and the rest were Class II patients. However, no premolar extractions were done in Class III patients. Data also shows that 67.1% of subjects underwent all 4 first premolar extractions and 13.2% underwent only upper first premolar extractions. Thus, a significant association was found between Type of Malocclusion and the Type of premolar extractions with p < 0.05. Moreover, only 34.4% of patients underwent premolar extractions and the majority of them underwent all 4 first premolar extractions.     

A year's experience with a mobile coronary resuscitation unit

A mobile unit for the emergency treatment of cases of coronary thrombosis in the patient''s home and for their supervised conveyance to hospital has been operating in the City of Newcastle upon Tyne for a year. In that time 134 cases have been attended, and of these 39 benefited appreciably from use of the unit. The value of such a unit must be balanced in relation to the current mortality of the disease outside and inside hospital and the staff available     

Acute lymphoblastic leukaemia: cyclical chemotherapy with three combinations of four drugs (COAP-POMP-CART regimen).

Forty-two adults and children with previously untreated acute lymphoblastic leukaemia (ALL) were entered into a programme of chemotherapy in which three combinations, each of four drugs were administered in a predetermined cyclical rotation together with cranial irradiation and intrathecal injections of methotrexate. Forty-one patients (98%) entered remission and no patient developed neuroleukaemia. Relapse of ALL occurred in 10 patients, and three patients died during remission, while eight patients stopped treatment after two and a half years and have remained in remission for two to 26 months. Comparison of remission and survival experience in this mixed group of children and adults with the experience of children treated at Memphis and in the Medical Research Council''s UKALL-I trial showed no significant differences. On the other hand, analysis by prognostic factors showed that neither age nor blast cell count at presentation had any adverse effect in patients treated in this study. No relapses occurred in nine patients with blast cell counts greater than 20 x 109/1 at presentation. This regimen is effective treatment for ALL and may be of special value in patients with poor prognoses. The regiment has not as yet proved superior for the treatment of children with ALL who do not have adverse prognostic features.     

Neonatal screening in Vancouver for congenital dislocation of the hip.

After 20 years'' experience throughout the Western world the effectiveness of screening newborns for congenital dislocation of the hip remains controversial. Is the clinical test for hip instability (the Ortolani or "jump" sing) reliable? Are other equally important physical signs frequently missed by inexperienced examiners? Do some dislocations develop after the newborn period when no abnormality was identifiable during the first week of life? In Vancouver, screening for this condition was initiated in 1964. In the 5-year period 1967-1971 an orthopedic surgeon screened all the infants in the newborn nursery of one hospital, while orthopedic residents screened all those at another hospital. Their rates of neonatal and late (after the first month of lfe) diagnosis of congenital hip abnormalities were, respectively, 6 and 0.3/100 lives births for the surgeon and 5 and 0.8/1000 for the residents. In contrast, at 20 hospitals that did not have regular screenign the average rates were 1.2 and 1.4. Systematic screening the early treatment have great potential for reducing the need for immobilization and surgical treatment of infants who congenital dislocation of the hip is missed in the first month of life. it may also prevent the arthritic sequelae that in adult life afflict many patients whose treatment was begun after the newborn period.     

Cervical Cancer—Use of a Non-Physician Health Team for Screening Procedures

A team of non-physician personnel has been trained in cytologic screening for cervical cancer. In a county hospital clinic setting among low income women whose annual pelvic examinations were being by-passed by physicians, this three-person team has performed pelvic examinations and screening under physician supervision for one year.Results of the first year''s experience, measured in cancer detection and in recognition and referral of benign gynecological disease as well, would suggest that a non-physician team, with a registered nurse doing a pelvic examination of screening type, can screen for cervical cancer and other pelvic disease efficiently and without a significant lowering of the quality of medical care.The training and use of teams of allied health care personnel directed by physicians is suggested as a practical means of overcoming the increasing shortage of physician services in annual screening for cervical cancer among low income women.     

Study of smoking habits in hospital and attitudes of medical staff towards smoking.

Most hospital policies place little or no restriction on patients'' smoking in hospital. In this study patients were surveyed to determine if they smoked and if their doctors advised or ordered them to stop smoking in hospital. As well, the smoking habits and attitudes towards smoking of the medical staff and other hospital workers were explored. Of 741 patients 37% were smokers, and those who responded fully to a questionnaire 86% continued to smoke in hospital. Patients who were advised or ordered not to smoke (59%) were no more likely to stop smoking than those who were not so advised or ordered. Physicians were less likely to smoke than other hospital staff, and those who did smoke were much more likely not to smoke while in the hospital. Physicians appear to have a reasonable appreciation of the health hazards of smoking, and almost two thirds are in favour of stricter restrictions on patients'' smoking in hospital. The ineffectiveness of their efforts is primarily due to hospital policies that are not in keeping with physicians'' standards of practice and with established knowledge of the deleterious effects of smoking on health.     

Evaluation of a stroke family care worker: results of a randomised controlled trial.

OBJECTIVE: To examine the effect of contact with a stroke family care worker on the physical, social, and psychological status of stroke patients and their carers. DESIGN: Randomised controlled trial with broad entry criteria and blinded outcome assessment six months after randomisation. SETTING: A well organised stroke service in an Edinburgh teaching hospital. SUBJECTS: 417 patients with an acute stroke in the previous 30 days randomly allocated to be contacted by a stroke family care worker (210) or to receive standard care (207). The patients represented 67% of all stroke patients assessed at the hospital during the study period. MAIN OUTCOME MEASURES: Patient completed Barthel index, Frenchay activities index, general health questionnaire, hospital anxiety and depression scale, social adjustment scale, mental adjustment to stroke scale, and patient satisfaction questionnaire; carer completed Frenchay activities index, general health questionnaire, hospital anxiety and depression scale, social adjustment scale, caregiving bassles scale, and carer satisfaction questionnaire. RESULTS: The groups were balanced for all important baseline variables. There were no significant differences in physical outcomes in patients or carers, though patients in the treatment group were possibly more helpless less well adjusted socially, and more depressed, whereas carers in the treatment group were possibly less hassled and anxious. However, both patients and carers in the group contacted by the stroke family care worker expressed significantly greater satisfaction with certain aspects of their care, in particular those related to communication and support. CONCLUSIONS: The introduction of a stroke family care worker improved patients'' and their carers'' satisfaction with services and may have had some effect on psychological and social outcomes but did not improve measures of patients'' physical wellbeing.     

Production d'oxygène sur site appliquée aux hôpitaux de campagne

The first mission of Armies health services 'Field Hospitals' is the injured people treatment for whom operative delay turns down the possibility of evacuation to France. Field hospitals enable diagnosis and medical treatment capabilities and thus, settle a surgical and medical hospital, which constitutes a real projection of a hospital technical site. Nevertheless, several situations of emergency can deal to a very high consumption of medical oxygen. We can assert in this case, that the previously scheduled endowments, which are a limited stock of oxygen bottles, are quickly exhausted. Medical oxygen supply is often hazardous and difficult. For this reason, producing directly this gas on the hospital settlement site could be a much more safe and practical solution. Nowadays, worldwide interventions of the Health Service require a great mobility of its own equipment, which must be easily transferred by air or sea. Recently, a study dealing with the in situ oxygen production modules for hospital use has been done. These modules are able to combine autonomy, reliability, reduced weight and dimensions as well as a constant quality of supplied oxygen, considering the different constraints met on site. This article successively deals with the study of the problems raised by field hospital supply with oxygen, a comparison of different production means which can be settled on an 'external theatre of operations' and lastly the achievement and tests of the new oxygen production module.     

Effectiveness of teaching general practitioners skills in brief cognitive behaviour therapy to treat patients with depression: randomised controlled trial

ObjectiveTo assess the effectiveness of teaching general practitioners skills in brief cognitive behaviour therapy.DesignParallel group, cluster randomised, controlled trial of an educational package on cognitive behaviour therapy.SettingGeneral practices in north London.Participants84 general practitioner principals and 272 patients attending their practices who scored above the threshold for psychological distress on the hospital anxiety and depression scale.InterventionA training package of four half days on brief cognitive behaviour therapy.ResultsDoctors'' knowledge of depression and attitudes towards its treatment showed no major difference between intervention and control groups after 6 months. The training had no discernible impact on patients'' outcomes.ConclusionGeneral practitioners may require more training and support than a basic educational package on brief cognitive behaviour therapy to acquire skills to help patients with depression.

What is already known on this topic

Trained professionals can deliver effective cognitive behaviour therapy to depressed patients presenting to general practitionersLimited evidence shows that cognitive behaviour therapy is effective when delivered by general practitioners who have received extensive instructionMost doctors do not have the time or inclination to carry out such comprehensive training

What this study adds

Basic training in brief cognitive behaviour therapy has little effect on general practitioners'' attitudes to the identification and treatment of depression or the outcome of their patients with emotional problemsGeneral practitioners may require more extensive training and support if they are to acquire skills in brief cognitive behaviour therapy that will have a positive impact on their patients