The prevention of emesis in plastic surgery: a randomized,prospective study

Perhaps the most unpleasant experience following outpatient plastic surgery procedures is postoperative nausea and vomiting. Postoperative nausea and vomiting often results in delayed recovery time and unintended admission, and it can be a contributing factor to the formation of hematoma following rhytidectomy. Ondansetron (Zofran) has proven benefit in preventing postoperative nausea and vomiting if given before general anesthesia in a variety of surgical procedures. Its utility in cases performed under conscious sedation has not been determined. The purpose of this study was (1) to test the ability of prophylactic ondansetron to prevent postoperative nausea and vomiting in plastic surgery cases performed under conscious sedation, and (2) to determine relative risk factors for postoperative nausea and vomiting and a selection policy for the administration of antiemetic prophylaxis. This was a prospective, randomized, double-blind study. One hundred twenty patients were enrolled after giving informed consent. Patients received a single dose of either placebo or ondansetron (4 mg intravenously) before administration of sedation. Sedation administration followed a standardized institutional protocol, using midazolam and fentanyl. Data were recorded from a series of three questionnaires: preoperatively, immediately postoperatively, and at the time of the first office return. Data were confirmed by means of telephone interview, chart analysis, and nursing documentation. Multivariate analysis was conducted. Nausea and emesis occurred with an overall frequency of 33 percent and 22 percent, respectively. Postoperative nausea and vomiting was associated with statistically longer recovery periods. The incidence of emesis was statistically higher among women, among those undergoing facial rejuvenation, and among those with a history of opioid-induced emesis or postoperative nausea and vomiting following a previous operation (p < 0.05). The incidence of postoperative nausea and vomiting paralleled increases in case duration; the incidence of emesis was zero in cases less than 90 minutes in duration. Ondansetron significantly reduced the incidence of emesis overall (placebo, 30 percent; ondansetron, 13 percent; p < 0.05). Postoperative perception of nausea was significantly lower among those who had received ondansetron (p < 0.05). These results confirm the efficacy of ondansetron for the prevention of postoperative nausea and vomiting in plastic surgery cases under conscious sedation. In those who are at increased risk, prophylaxis should be considered. Such risks include female gender, facial rejuvenation procedures, and a patient history of opioid-induced emesis or postoperative nausea and vomiting following a prior operation. The zero incidence of emesis in cases less than 90 minutes does not support the routine use of prophylaxis in such cases. Patient satisfaction in plastic surgery is derived from the overall subjective experience of the event as much as by the final result. By remaining attentive to patient concerns and optimizing perioperative care, we can improve the subjective experience for our patients.     

Pregnancy diagnosis in swine: A comparison of the technique of rectal palpation and ultrasound

The accuracy of pregnancy diagnosis in swine by rectal palpation and by ultrasound was compared using sows and gilts thirty days or more after breeding. A total of eighty-four pigs were included in this experiment and they were examined an average of thirty-nine days following breeding. Forty-nine animals were slaughtered within a few days of pregnancy examination and thirtyfive were allowed to farrow. Pregnancy status was correctly diagnosed by palpation per rectum in eighty-three of the eighty-four pigs (98.8%) and by ultrasound in eighty-one of the eighty-four pigs (96.6%) examined. The accuracy of the two methods was not significantly different.     

Functional MRI To Evaluate “Sense of Self” following Perforator Flap Breast Reconstruction

Background

Breast reconstruction is associated with high levels of patient satisfaction. Previous patient satisfaction studies have been subjective. This study utilizes functional magnetic resonance imaging (fMRI) to objectively evaluate “sense of self” following deep inferior epigastric perforator (DIEP) flap breast reconstruction in an attempt to better understand patient perception.

Methods

Prospective fMRI analysis was performed on four patients before and after delayed unilateral DIEP flap breast reconstruction, and on four patients after immediate unilateral DIEP flap breast reconstruction. Patients were randomly cued to palpate their natural breast, mastectomy site or breast reconstruction, and external silicone models. Three regions of interest (ROIs) associated with self-recognition were examined using a general linear model, and compared using a fixed effects and random effects ANOVA, respectively.

Results

In the delayed reconstruction group, activation of the ROIs was significantly lower at the mastectomy site compared to the natural breast (p<0.01). Ten months following reconstruction, activation of the ROIs in the reconstructed breast was not significantly different from that observed with natural breast palpation. In the immediate reconstruction group, palpation of the reconstructed breast was also similar to the natural breast. This activity was greater than that observed during palpation of external artificial models (p<0.01).

Conclusions

Similar activation patterns were observed during palpation of the reconstructed and natural breasts as compared to the non-reconstructed mastectomy site and artificial models. The cognitive process represented by this pattern may be a mechanism by which breast reconstruction improves self-perception, and thus patient satisfaction following mastectomy.     

Demografía,características clínicas y genéticas de pacientes con carcinoma medular de tiroides en los últimos 16 años en Castilla-La Mancha

ObjectiveMedullary thyroid cancer is a rare tumor that is more aggressive and has a worse prognosis than differentiated thyroid cancer. The purpose of this study was to report the demographic, clinical, and genetic characteristics of patients seen in the health care system of the community of Castilla-La Mancha over a 16-year period.Patients and methodsData were collected through a review of patients’ medical records.ResultsThe medical records of 58 patients (mean age at diagnosis, 51 years; range, 6-82 years; 63.8% women) were reviewed. Prevalence rate was 2.84 cases per 100,000 inhabitants, with a high variability between areas (range, 0-5.4 cases per 100,000 inhabitants). Familial cases accounted for 34.5% of all medullary thyroid cancers, and the most common mutation was C634Y. The condition was most commonly diagnosed following palpation of a cervical lump (70.6%). At diagnosis, 56 of 58 patients underwent ultrasound and 8 of 58 patients were tested for serum calcitonin. Tumor multicentricity was reported in 59 and 50% of patients with multiple endocrine neoplasia syndrome type 2A and 2B, respectively, and in no sporadic cases. Fifty-two percent of patients had an advanced stage (iii or iv) at diagnosis. Median follow-up was 36 months (interquartile range, 14-210); 11 patients were lost to follow-up.ConclusionsIn Castilla-La Mancha, medullary thyroid cancer is diagnosed by cervical ultrasound, rather than calcitonin assay. There is a high prevalence of both familial and sporadic medullary thyroid cancer, and a significant variability in the type of proto-oncogen rearranged during transfection mutation as compared to the rest of the Spanish population.     

Marked depression of radiation-induced emesis in frogs following prior exposure to a brief dose of X-rays

Acute emesis response to harmful doses of X-rays on frogs (Rana porosa porosa) was examined. Results showed that the number of radioemesis events following exposure to 0.85 Gy was slightly higher than in the sham control animals. The increase in emesis action became more pronounced when the total dose of radiation was raised to 2.5 Gy. Only 1 frog out of a total of 12 did not show vomiting following radiation, while no response was observed in sham control animals. Note that animals in which the low dose rate of radiation was applied to whole body did not display any changes in the emesis response relative to control animals. The present studies, and those by others, showed that a brief dose of X-rays prior to a second exposure to a sub-lethal dose might induce a tolerance to radiation. An additional experiment was conducted to examine whether a small conditioning dose could induce a depression of radioemesis (tolerance) following an exposure to high dose X-ray. With prior exposure to 0.3 Gy, only 1 frog out of a total of 5 frogs vomited as a result of radiation exposure. Suppression of the emetic response became significant when the pre-radiation dose was decreased to 0.1 Gy. On the contrary, increasing the small conditioning dose to 0.5 Gy resulted in a remarkable rise of radiation-induced emesis. This results indicate that exposure to the smaller dose of X-rays elicits a tolerance effect to toxic dose level of radiation.     

Pregnancy diagnosis in swine by palpation and by amplitude-depth ultrasound scanning

The relative accuracy of two pregnancy testing methods for swine were compared in a field study. The procedures used were manual palpation and amplitude-depth ultrasonic scanning. A total of 369 sows were examined by both methods. Seven additional gilts were examined by ultrasound only and 46 sows by palpation per rectum only. The number of correct positive and negative diagnoses made by both methods were calculated, and determination of accuracy as well as comparison between the tests were made on this basis. The relative accuracy was 97.6% for the manual method and 96.8% for the ultrasound method. Both tests had a high sensitivity, 99.2 and 98.9%, respectively. The ability of the tests to detect the non-pregnant animals was not as high, which is reflected by a lower specificity. No significant differences were noted between the two methods. A lower specificity and a lower negative predictive value were provided by ultrasound scanning as compared with those acquired by manual palpation. Both procedures were considered to be quick and convenient to perform. It was concluded that in spite of the new pregnancy testing methods introduced in the swine industry, manual palpation remains the most practical in terms of its accuracy, ease, and the minimal requirement for equipment. In gilts, palpation is unsuitable and ultrasonography currently remains the best choice for the diagnosis of pregnancy.     

Predictive value of palpation per rectum for detection of the CL in Zebu cattle as evaluated by progesterone concentrations and ultrasonography

The main objective of this study was to calculate the predictive value of the positive and negative diagnosis of the presence of a corpus luteum by palpation per rectum in Zebu cattle. Gyr breed (n = 16) heifers were palpated by a veterinarian every 3 d during March and April, and every 5 days during May. The presence or absence of a CL was recorded for 442 examinations. A blood sample was obtained after each examination, and a functional CL was considered to be present if plasma progesterone concentrations were above 1 ng/ml. Progesterone results were used as the reference to calculate the sensitivity and specificity of palpation per rectum for the diagnosis of a functional CL on different months. Predictive values for the positive and negative diagnoses were calculated using different hypothetical rates of the prevalence of CL. To evaluate the morphological basis of an erroneous diagnosis, ultrasonographic scanning of the ovaries was performed in 264 cases and the physical presence or absence of a CL was registered. The calculations were repeated using the ultrasonographic findings as the reference to evaluate the sensitivity and specificity of the diagnosis of a structural CL by per rectum palpation. Several heifers were not cyclic in March but began to cycle during the study. Thus, the prevalence of both functional and structural CL increased with time. As a result, the proportion of palpation diagnoses classified as true positives increased in May, while the proportion of true negatives decreased. Although the values of sensitivity and specificity remained constant from month to month, the predictive values changed markedly in May, when the predictive value of the positive test increased while the predictive value of the negative test decreased. These changes were due to differences in the prevalence of a CL and not to differences in the palpable characteristics of CLs in different months. The prevalence of a structural CL was always higher than that of a functional CL. The Cohen's Kappa test for concordance revealed better correspondence between palpation per rectum and ultrasound (k = 0.82) than between progesterone and either ultrasound (k = 0.68) or palpation (k = 0.66). These results show that a large proportion of the errors imputed to deficient palpation when progesterone concentrations are used as a reference are in fact the result of lack of correspondence between the physical and functional presence of a CL.     

Effect of reproductive disorders previous to conception on pregnancy attrition in dairy cows

This study was undertaken to determine whether reproductive disorders previous to conception influence pregnancy attrition in dairy cows. Reproductive disorders were registered and pregnancy diagnoses were performed as a part of a reproductive health program at 9 commercial dairy herds in northeastern Spain. Data from 3022 diagnosed pregnant lactating cows were used. Pregnancy diagnosis by palpation per rectum was performed from 33 to 70 d post insemination. Pregnancy attrition was registered when the pregnancy diagnosis was negative at the second palpation carried out between 120 and 150 d following insemination. Data analysis was performed by multiple logistic regression methods. Pregnancy attrition rates were 2.6 and 1.8 times higher in cows with previous pyometra and retained placenta, respectively, than in cows without these disorders. No effect of endometritis, ovarian cysts and repeat breeding was shown on pregnancy attrition. Our results suggest that additional efforts to reduce the risk of retained placenta and pyometra should decrease the incidence of pregnancy attrition in dairy cows.     

Predictive value of palpation per rectum vs milk and serum progesterone levels for the diagnosis of bovine follicular and luteal cysts

Diagnosis of bovine follicular and luteal cysts by palpation per rectum was compared with diagnosis by progesterone status, as determined by an enzymeimmunoassay (EIA). A 2x2 contingency table analysis allowed the calculation of predictive value, sensitivity and specificity for the palpation diagnosis of both cyst types. The results were 75.0, 61.9 and 50.0% for follicular cysts and 35.1, 50.0 and 61.9% for luteal cysts, respectively. The EIA results were compared to radioimmunoassay (RIA). The predictive value for a low progesterone determination (<5ng/ml) was 91.8% and for high progesterone (5ng/ml or >) it was 83.3%. The sensitivity and specificity for the EIA were both 88.2%. Within the EIA system, milk and serum samples agreed a total of 85 out of 87 times (97.7%). Definitive diagnosis of follicular or luteal cysts should not be based upon palpation per rectum alone. The EIA was found to be the better definitive diagnostic technique.     

Indications for admission to a coronary care unit in patients with unstable angina.

One hundred cases with an admission diagnosis of acute coronary insufficiency or unstable angina were reviewed to establish criteria for admission to a coronary care unit. Myocardial infarction was subsequently diagnosed in 20 of the patients. Ventricular tachycardia occurred in 16 patients and ventricular fibrillation in 1 patient. Clinical features found to predict an increased risk of myocardial infarction included chest pain for more than 30 minutes within 24 hours prior to admission, new nonspecific electrocardiographic abnormalities consistent with ischemia, and diaphoresis. All patients with ventricular tachydysrhythmias had presented with both prolonged chest pain prior to admission and new electrocardiographic changes. The sensitivity, specificity and predictive value of various clinical criteria for identifying patients likely to have a myocardial infarction were calculated, and criteria with very high (greater than 90%) sensitivity were identified. These could be used to establish which patients are at increased risk of myocardial infarction and therefore require admission to a coronary care unit.     

The relationship of the interval from breeding to uterine palpation for pregnancy diagnosis with calving outcomes in holstein cows

This study used data collected prospectively at 32 dairy herds to examine the effect of interval from breeding to uterine palpation for pregnancy diagnosis on calving interval and likelihood of calving. Multivariable statistical models were used to control for other factors that were significantly associated with the outcomes of interest. Cows diagnosed pregnant from 30 to 36 d post breeding had 2-wk longer calving intervals than cows palpated at later intervals. The interval from breeding until a cow was diagnosed open had a significant positive association with the calving interval. The interval to palpation was not associated with the probability of remaining in the herd to calve when controlling for the effects of herd, season of freshening, number of services, days to first service and mature equivalent milk production. Among cows diagnosed pregnant, 3.4% subsequently were bred and 1.5% were diagnosed open by palpation at a later date. About 5% of the cows diagnosed open calved at a time consistent with being pregnant when the diagnosis was made.     

Influence of management factors on pregnancy attrition in dairy cattle

The present study was conducted to determine the influence of management factors on pregnancy attrition in dairy cattle. Data from 3162 diagnosed pregnancies in parous cows and 1050 in heifers at 9 commercial dairy herds in northeastern Spain were used. Pregnancy diagnosis by palpation per rectum was performed from 30 to 70 d post insemination. Pregnancy attrition was registered when pregnancy diagnosis resulted negative in a second palpation carried out between 120 and 150 d following insemination. Overall proportion of pregnancy losses was 7.9% (9.6% in parous cows and 2.8% in heifers). Data analysis was performed by multiple logistic regression methods. For all animals, effect of time of pregnancy diagnosis was shown (Odds ratio = 0.97 for 1 d increase; P = 0.0042). Conceptus loss in heifers was lower than in parous cows (Odds ratio = 0.28; P = 0.0001), and a higher proportion of pregnancy attritions was detected in animals inseminated in spring, summer and winter, compared to those inseminated in autumn (P < 0.04). Herd effect on pregnancy attrition was also significant. Similar results were observed in the subanalysis for parous cows and, furthermore, no effect of lactation number and of interval from previous calving to pregnancy was shown in this group. In heifers, no effect of time of pregnancy diagnosis and of insemination season on pregnancy attrition was shown, and only a herd effect was observed. Our data suggest that the influence of parity status (heifer vs cow) could affect the proportion of pregnancy attrition rather than early diagnosis, and, in pregnant cows, adaptation to seasonal changes associated with temperature decreases seem more efficient.     

The predictive value, sensitivity and specificity of palpation per rectum and transrectal ultrasonography for the determination of bovine luteal status

Luteal status (classifications 1 and 3 = high progesterone levels, 2 and 4 = low progesterone levels) was diagnosed in randomly cyclic Holstein cows, using palpation per rectum and B-mode transrectal ultrasonography, respectively. The results were compared in 2x2 contingency tables with radioimmunoassay (RIA) classifications. Cows with milk progesterone levels of 5.0 ng/ml or higher were classified high and cows with levels below 5.0 ng/ml of progesterone were low. The predictive value, sensitivity and specificity results were 1) 88.2, 68.2 and 88.9% for Classification 1; 69.6, 88.9 and 68.2 for Classification 2; 90.9, 83.3 and 87.5 for Classification 3; and 77.8, 87.5 and 83.3 for Classification 4. Within each test, the diagnosis of high progesterone status was more accurate than of low status. The types of errors are discussed. A correlation coefficient of 0.68 resulted between RIA progesterone concentration and ultrasonographic luteal diameter. Ultrasonography was a better diagnostic test than palpation per rectum.     

Hyponatraemia and death or permanent brain damage in healthy children.

OBJECTIVE--To determine if hyponatraemia causes permanent brain damage in healthy children and, if so, if the disorder is primarily limited to females, as occurs in adults. DESIGN--Prospective clinical case study of 16 affected children and a review of 24,412 consecutive surgical admissions at one medical centre. PATIENTS--16 children (nine male, seven female; age 7 (SD 5) years) with generally minor illness were electively hospitalised for primary care. Consultation was obtained for the combination of respiratory arrest with symptomatic hyponatraemia (serum sodium concentration less than or equal to 128 mmol/l). MAIN OUTCOME MEASURES--Presence, gender distribution, and classification of permanent brain damage in children with symptomatic hyponatraemia in both prospective and retrospective studies. RESULTS--By retrospective evaluation the incidence of postoperative hyponatraemia among 24,412 patients was 0.34% (83 cases) and mortality of those afflicted was 8.4% (seven deaths). In the prospective population the serum sodium concentration on admission was 138 (SD 2) mmol/l. From three to 120 inpatient hours after hypotonic fluid administration patients developed progressive lethargy, headache, nausea, and emesis with an explosive onset of respiratory arrest. At the time serum sodium concentration was 115 (7) mmol/l and arterial oxygen tension 6 (1.5) kPa. The hyponatraemia was primarily caused by extrarenal loss of electrolytes with replacement by hypotonic fluids. All 16 patients had cerebral oedema detected at either radiological or postmortem examination. All 15 patients not treated for their hyponatraemia in a timely manner either died or were permanently incapacitated by brain damage. The only patient treated in a timely manner was alive but mentally retarded. CONCLUSIONS--Symptomatic hyponatraemia can result in high morbidity in children of both genders, which is due in large part to inadequate brain adaptation and lack of timely treatment.     

The accuracy of rectal diagnosis of corpora lutea in water buffalo (Bubalus bubalis)

The accuracy of rectal diagnosis of corpora lutea (CL) was determined by direct inspection of the ovaries by laparoscopy in 68 suckled water buffalo (Bubalus bubalis). Thirty-eight (81%) of the 47 CL diagnosed by rectal palpation were confirmed at laparoscopy. Errors in rectal diagnosis of CL were due to failure to palpate early CL (8.5%) and to follicles (> 10 mm in diameter) raised above the ovarian surface (10.6%) being diagnosed as CL. Twenty-six (89.7%) of the 29 diagnoses of luteal tissue by the progesterone assay were confirmed. Errors were due to the presence of CL with low progesterone (10.3%). The overall accuracy of diagnosing a follicle or a CL by rectal palpation and plasma progesterone assay was 81 and 86% respectively. The study indicated that rectal palpation is as reliable as the progesterone assay for the diagnosis of CL in the buffalo.     

Efficacy of the pain pump catheter in immediate autologous breast reconstruction

The purpose of the investigation was to evaluate the efficacy of a slow bupivacaine infusion at postoperative surgical sites in immediate breast reconstruction patients. This prospective study included 16 patients who underwent autologous breast reconstruction with a latissimus dorsi pedicled flap immediately after mastectomy. A two-site infusion kit with dual split-flow catheters was secured at the operative sites before skin closure. A spring-loaded disposable pump then infused 0.25% bupivacaine at a rate of 2.08 cc per catheter per hour for 48 continuous hours. Patient pain levels, nausea/emesis, and oral and intravenous narcotic use were then recorded at 12-hour intervals. Medication use was converted to pain units for results comparison (one pain unit was defined as the equivalent of 10 mg of intravenous morphine). A retrospective control group comprised 16 consecutive patients from December of 1999 to October of 2002 who underwent the same surgery by the same surgeon using oral and intravenous pain medications. The experimental group demonstrated a more than fivefold decrease in the use of oral and intravenous pain medications compared with the historical controls (6.7 versus 1.7 pain units) (p < 0.001). The overall pain experienced by the catheter patients was nearly twofold less than the pain experienced by those without the catheter (1.8 versus 3.4 on the visual analog pain scale) (p < 0.017). Twenty-eight percent of the experimental group experienced nausea/emesis compared with 61 percent in the control group. No complications occurred with the use of the pain pump catheter. A 48-hour infusion of 0.25% bupivacaine significantly decreases the need for postoperative narcotics and the over-all pain experience in immediate breast reconstruction patients. This effective form of pain control may alleviate patient concerns of postoperative pain and may safely downstage many plastic surgery procedures, such as immediate breast reconstruction, and many cosmetic procedures to same-day status when the primary indication for admission is pain management.     

Diagnosis and management of a malignant granulosa cell tumor in a holstein nulligravida: a case study

Transrectal palpation of an 18-mo-old, anestrous Holstein nulligravida revealed an enlarged left ovary. Ultrasonographically, the mass resembled known equine granulosa cell tumor (GCT) images. Slowly, virilism developed. Fifty-five days after initial diagnosis, unilateral ovariectomy was performed The presurgical serum concentration of testosterone was equal to that of a mature bull. During the 3 mo period following surgery, estrus expression resumed, the serum testosterone concentration returned to baseline, and the heifer was diagnosed pregnant following AI. A low grade, malignant GCT was the final histopathologically diagnosis. Clinical diagnosis of GCT should involve ultrasonography and steroid hormone assay. An ultrasound image, similar to the one shown, may be characteristic of GCT in the bovine.     

Hospitalización Domiciliaria Integral para la atención a pacientes mayores con procesos agudos discapacitantes: factores predictivos de éxito terapéutico

IntroductionSeveral authors have demonstrated the efficacy of different hospital-at-home strategies in older patients. The identification of prognostic factors is key for improving the targeting process of candidates.MethodsWe performed an analysis of a cohort of older patients attended due to disabling health crises (medical, orthopaedics, or stroke) by a hospital-at-home scheme developed in an integrated care institution over a 5-year period. Main outcomes were: health crisis resolution (discharge to Primary Care); functional resolution (relative functional gain ≥ 35%), and their combined variable. A logistic regression analysis was performed, including clinical variables from Comprehensive Geriatric Assessment at admission to detect factors related to favourable outcomes.ResultsA total of 484 patients were included. The main characteristics were: age 84.4 (6.7), female gender 69%, baseline Barthel score 74.2 (22.6), family-private caregiver/nursing home 82%/18%, referral from hospital wards/emergency department-community in 55%/45%. The main results (for selected processes medical/orthopaedics/stroke) were: health crisis resolution 71.7/87.5/77.6%; functional resolution 72.1/84.9/73.5%; favourable crisis resolution (health crisis resolution with functional resolution) 67.1/81.6/67.3%. Favourable crisis resolution was associated with [OR (95% CI)]: orthopaedic as main diagnosis [2.00 (1.22-3.29)], Barthel score at admission higher than 40 points [2.00 (1.18-3.38)], and the absence of pressure ulcers at admission [2.80 (1.68-4.65)].ConclusionsPatients presenting with an orthopaedic diagnosis, not having severe disability at admission, and not having pressure ulcers at admission could obtain better results on favourable crisis resolution. Suffering cognitive impairment or delirium, or being institutionalised, was not found related with less favourable results.     

First electrocardiogram in recent myocardial infarction.

The admission electrocardiogram (ECG) was studied in 898 patients admitted to a coronary care unit over two years. The diagnosis made from this tracing was compared with that made at the end of the patient''s stay. About half the cases of recent myocardial infarct were diagnosed from the admission ECG, but accuracy rose to 83% with serial ECG''s in the unit. The ECG is important but not entirely reliable in the early detection of acute myocardial infarction, which should be largely a clinical diagnosis.     

The community hospital: a three-year study.

In a three-year period a community hospital of 40 beds discharged 2086 patients, their mean length of stay being 14.8 days. Some 68% of the patients treated were over 65, and 8.9% died in hospital. While the most common diagnosis on admission was disease of the respiratory tract, this does not indicate the actual cause of admission. For 142 patients from one practice this was acute illness in 44% of the cases, assessment in 20%, and a need for nursing care in 36%. If the community hospital had not been available about half these patients would have been admitted to the general hospital.