Four years' experience of an interim secure unit.

An interim secure unit of 14 beds (Rainford Ward) at Rainhill Hospital has been functioning for four years. During that period 78 patients were referred and 39 were admitted from various sources. Of those admitted, 40% were women, all had committed dangerous acts, and the most common diagnosis was schizophrenia. Only seven patients have stayed for one year or more, and only one seems set to stay indefinitely. Patients discharged are followed up in roughly equal numbers by their catchment area psychiatric teams and by the regional forensic psychiatric service. The number of patients in the ward has settled to about 12 for a population of one million. The unit now functions unobtrusively in a large psychiatric hospital, has a high morale, has had few recruiting problems, and has suffered extremely few disturbing incidents.     

Five years' experience with aortocoronary bypass grafting.

During a 5-year period (Apr. 14, 1970 to Apr. 14, 1975) 930 patients underwent aortocoronary bypass grafting; the procedure was done as an emergency in 141. Of the entire group 3.3% died at operation, 1.6% died in hospital and 5.8% died later; of the patients undergoing emergency grafting 12.1% died at operation and 5.7% died later. From a detailed analysis of the first 600 patients it was found that both operative and late mortality were clearly related to two factors: severe left ventricular dysfunction at the time of operation and inadequate surgical treatment because of insertion of insufficient numbers of grafts or because of poor blood flow through the grafts.     

Laryngotracheobronchitis: 2 years' experience with racemic epinephrine.

A relatively new form of treatment of laryngotracheobronchitis, administration of racemic epinephrine by intermittent positive-pressure breathing, was begun in 1973 in the pediatric unit of a large community hospital. A review of 2 years'' experience with this treatment, compared with the experience of the 3 years prior to its introduction, has shown that it has reduced significantly the necessity for tracheostomy, to nearly zero, and the duration of hospital stay. A total of 119 children (33.15% of those admitted) received this treatment, the average number of treatments required being 1.8. There were no important complications of treatment and no deaths.     

Carcinoembryonic antigen: 3 years' experience in a cancer clinic.

Long-term studies on multiple plasma samples of 988 patients with carcinoma of entodermal origin indicate that, especially for patients with colorectal cancer, repeatedly elevated or rising carcinoembryonic antigen (CEA) values are a sign of poor prognosis when found preoperatively, postoperatively or during chemotherapy. Persistently elevated CEA values in postoperative patients apparently free of disease are a useful marker for early detection of recurrence or metastases. Normal CEA values are of little or no prognostic value.     

Maternal alpha-fetoprotein screening: two years' experience in a low-risk district.

Over a two-year period, 3479 pregnant women in the Kings'' Lynn Health District were screened for neural tube defects by estimation of maternal serum alpha-fetoprotein. Most pregnancies were scanned by sonar for fetal maturity. Eight women had fetuses with open neural tube defects; four with anencephaly were associated with very high alpha-fetoprotein values. Of the four with open neural tube defects without anencephaly, only one was detected by screening and confirmed after amniocentesis. One other had a raised serum alpha-fetoprotein but a normal amniotic fluid value. The other two affected fetuses were missed. This disappointing outcome was attributed to the poor predictive value of alpha-fetoprotein in detecting open neural tube defects (anencephaly apart) rather than to errors in its estimation or in assessment of fetal maturity by sonar scan. We question the validity of screening, particularly in areas of intermediate or low incidence.     

Rifampicin for lepromatous leprosy: nine years' experience.

Over 100 patients with lepromatous leprosy were treated with rifampicin in a series of pilot, uncontrolled, and controlled trials in 1968-77. The rapid bactericidal effect of rifampicin on Mycobacterium leprae was confirmed. Clinical improvement became apparent sometimes as early as 14 days after the start of treatment. Nevertheless, a few persisting viable M leprae were detected as long as five years after the start of treatment with rifampicin either by itself or in combination with the bacteriostatic drug thiambutosine. Treatment with rifampicin and dapsone for six months reduced the number of persisting leprosy bacteria more than treatment with dapsone alone. Although rifampicin proved more effective than dapsone, it is unlikely that used by itself if can significantly shorten the length of treatment in lepromatous leprosy. Therefore initial intensive combined treatment with two or more bactericidal drugs (including rifampicin) warrants further investigation in both untreated leprosy and lepromatous leprosy resistant to dapsone.     

Waiting for coronary revascularization in Toronto: 2 years' experience with a regional referral office.

OBJECTIVES: To determine the frequency of major adverse events among patients awaiting coronary revascularization; to assess the match between referring physicians'' estimates of urgency, a computer-generated multifactorial urgency rating score and actual waiting times; to determine the changes in waiting times as capacity for bypass surgery increased; and to evaluate the influence of choice of procedure or operator on waiting times. DESIGN: Consecutive case series. SETTING: Greater Toronto region. SUBJECTS: All 571 patients referred to an organized referral office by cardiologists at hospitals without on-site revascularization facilities between Jan. 3, 1989, and June 30, 1991. MAIN OUTCOME MEASURES: Preoperative fatal or nonfatal myocardial infarction; proportions of patients waiting longer than the maximum period recommended for their urgency rating; mean waiting times for various subgroups; and correlations among referring physicians'' urgency ratings, computer-generated multifactorial urgency scores and waiting times. RESULTS: Of the 496 patients accepted for a procedure 5 had fatal cardiac events and 3 nonfatal myocardial infarction. Events occurred three times more often in patients with left mainstem disease than in those in other anatomic categories (relative risk [RR] 3.05, 95% confidence interval [CI] 1.48 to 6.27, p = 0.03). Both the computer-generated scores and the referring physicians'' scores were correlated with the actual waiting time (r = 0.46 and 0.57 respectively). Waiting times and the proportion of patients with excessive waiting times fell during the study period (p < 0.0001). However, urgent cases were much less likely to be done "on time" than those with a recommended waiting time of more than 2 weeks (RR 0.16, 95% CI 0.11 to 0.25, p < 0.0001). The mean wait for coronary artery bypass grafting (CABG) was 22.73 days if the referral office was allowed to find a surgeon or interventional cardiologist and 35.31 days if one was requested (p = 0.002 after adjustment for urgency scores). CONCLUSIONS: Death of a patient on the waiting list is uncommon in an organized referral system. Patients with left main-stem disease are at higher risk of death than those in other anatomic categories. There were significant correlations between referring physicians'' ratings of urgency, multifactorial urgency scores and actual waiting times. Expansion of capacity for CABG led to shorter waiting times, but patients with unstable symptoms continued to wait longer than recommended. Requests for a specific surgeon caused significantly longer delays.     

Seventeen years' experience of a voluntarily based drug rationalisation programme in hospital.

A study was carried out analysing the operation of a drug rationalisation programme in a central London teaching district that had evolved from experience over 17 years. Creation of a limited list of about 700 drugs had been achieved by local consensus. Drug selection was based on appraisal of efficacy, safety, and cost and was undertaken by means of collaborative participation of most consultant specialists in the district. Educative and other non-restrictive strategies for reinforcing the rationalisation policy had achieved a consistently high rate of compliance in prescribing recommended drugs. The concept of selectivity in drug use and its continuous local reappraisal had a beneficial impact on the prescribing habits of doctors at all levels of seniority as well as on the training of medical undergraduates and nurses in the therapeutic use of medicines. Peer review and self audit were encouraged by use of an extensive monitoring system which incorporated continuous "facilitative" dialogue between ward pharmacists and prescribers. Two models of drug rationalisation programme were studied, the second of which together with other local initiatives had been associated with substantial and sustained reductions in drug spending each year over nine years since 1978. It is concluded that the second drug rationalisation programme model substantially improves the cost effective use of drugs in hospital and furthermore has the potential of being extended to general practice, especially in types of prescribing that are common to both forms of patient care.     

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     

"Short report" staffing in practice: five years' experience of a consultant based service in obstetrics and neonatal paediatrics.

Recent government plans include the concept of a core of doctors of intermediate grade providing 24 hour emergency cover in hospital departments. Hinchingbrooke Hospital has, since its opening in 1983, been run on a two tier basis, with consultants and a part time senior registrar supported only by senior house officers in their first post, usually on general practice vocational training schemes. With a planned rate of around 2000 deliveries per year all high risk obstetric and neonatal paediatric procedures, including ventilation of very small babies, have been carried out within the hospital. A study of the first five complete years of operation of the obstetric and paediatric departments showed that the perinatal mortality rate was low (hospital rate 4.7/1000 in 9149 deliveries during 1984-8 v district rate 5.1/1000 during 1986-8), and patient satisfaction seemed to be high. In a separate prospective study of out of hours work performed by consultants in paediatrics (four weeks) and obstetrics (20 days) three consultants in paediatrics spent 71 hours working out of hours; for the obstetricians, of the 56 request for advice and 38 interventions, only five and six respectively occurred between midnight and 9 am. Although successful at this hospital, the two tier system would be expensive under the Royal College of Obstetricians'' guidelines of one consultant to a maximum of 500 deliveries. An equal mixture of two tier and three tier systems might be the best solution for patient care and training of junior doctors.     

Hydrogen sulfide poisoning: review of 5 years' experience.

The workforce of Alberta, a province rich in fossil fuel, faces an increasing risk of exposure to hydrogen sulfide (H2S). Basic knowledge of the population exposed during the years 1969 to 1973 inclusive was accumulated to identify the immediate medical and management problems. Data were recorded from three sources of records: the Workers'' Compensation Board of Alberta, the Alberta Hospital Services Commission and the provincial coroner''s office. There were 221 cases of exposure to H2S. The overall mortality was 6%; 5% of victims were dead on arrival at hospital. Admission to hospital was required for 65% of the victims arriving at a hospital emergency room (78% of the 221). Acute problems were coma, dysequilibrium and respiratory insufficiency with pulmonary edema. Increased attention to cardiopulmonary resuscitation at the exposure site and during transportation to hospital is necessary to reduce the mortality from H2S exposure. No long-term adverse effects were apparent in the survivors.     

Health surveillance of preschool children: four years' experience.

OBJECTIVES--To monitor the implementation of a programme of health surveillance for preschool children and measure its effect on child health. DESIGN--Regular reporting to primary care teams of their own performance, and determining the overall effect of the programme on children in the district. SETTING--All practices in Northumberland health district. SUBJECTS--All children of preschool age in Northumberland (3600 births each year). MAIN OUTCOME MEASURES--Proportion of eligible children immunised and screened for abnormalities. Age at diagnosis of congenital deafness, cerebral palsy, and special educational needs. RESULTS--Over 90% of eligible children were covered by the health surveillance scheme. Child health improved over the four years after the scheme was implemented. Uptake of immunisation against measles rose from 68% to 93% of eligible children, and the average age at which congenital deafness was diagnosed fell to 9 months. CONCLUSIONS--Maintaining the effectiveness of a surveillance programme and reporting this back to primary health care teams are processes which themselves improve health.     

Home peritoneal dialysis: 3 years' experience in Toronto.

From November 1972 to November 1975, 52 males and 39 females aged 11 to 71 years were trained for home peritoneal dialysis. Dialysis was performed through a permanent catheter 4 nights a week. The first 11 patients used the manual system, exchanging 2 / of dialysate solution every 50 to 60 minutes. Subsequently 73 patients used the automatic cycler and commercially available dialysate and 7 patients used Tenckhoff''s reverse osmosis peritoneal dialysis machine. The average duration of training was 15, 11.6 and 15 dialysis days, respectively, for the three methods. For the 83 patients followed up, the average duration of home dialysis was 8.3 months (range, 0.5 to 33 months); the total number of dialyses at home was 10 571. Ten received a transplant, 20 were transferred to hospital peritoneal dialysis or hemodialysis, 8 died and 48 continued with home dialysis. Twenty-three patients had a total of 33 episodes of peritonitis, an incidence of 27.7% among the patients in the program for up to 3 years or 0.3% among all the dialyses. By November 1975, 46 patients had returned to their predialysis lifestyle, 18 were working part-time, 10 were able to work but were not doing so, and 9 were unable to work or care for themselves.