Postgraduate Medical Journal recent issues

[Editorials] Auscultation in the diagnosis of respiratory disease in the 21st century

Ceresa, C. C, Johnston, I. D A — 2008-10-02

[Education] How to measure severity of mitral regurgitation

Grayburn, P A — 2008-10-02

[Reviews] Prognostic and predictive factors in colorectal cancer

Zlobec, I, Lugli, A — 2008-10-02

Prognostication of newly diagnosed colorectal cancer (CRC) predominantly relies on stage as defined by the UICC-TNM and American Joint Committee on Cancer classifications. Tumour extent, lymph node status, tumour grade and the assessment of lymphatic and venous invasion are still the most important morphological prognostic factors. Evidence suggests that tumour budding and tumour border configuration are important, additional histological parameters but are not regarded as essential in prognosis. Although several molecular features, such as LOH18q and TP53 mutation analysis, have shown promising results in terms of their prognostic value, the American Society of Clinical Oncology Tumor Markers Expert Panel does not currently recommend their use in routine practice. cDNA-microarray, PCR and fluorescence in situ hybridisation are now frequently used to identity potential prognostic indicators in CRC, but the applicability of these methods in routine use is likely to have limited impact. Reliable prognostic markers identified by immunohistochemical protein profiling have yet to be established. Randomisation of data sets, assessment of interobserver variability for protein markers and scoring systems, as well as the use of receiver operating characteristic curve analysis in combination with multimarker-phenotype analysis of several different markers may be an effective tactical approach to increase the value of immunohistochemical findings. This article reviews the well established and additional prognostic factors in CRC and explores the contribution of molecular studies to the prognostication of patients with this disease. Additionally, an approach to improve the prognostic value of immunohistochemical protein markers is proposed.

[Reviews] Early neurological deterioration in acute ischaemic stroke: predictors, mechanisms and management

Thanvi, B, Treadwell, S, Robinson, T — 2008-10-02

Early neurological deterioration (END) in acute ischaemic stroke is a common event. The underlying mechanisms are heterogeneous. The clinical predictors of END include severity of the initial stroke, large vessel occlusion, diabetes mellitus, hypotension, and atrial fibrillation. Serial observations and detailed assessment by the trained staff in specialised stroke units are key to the successful management of these patients. Advances in brain and vascular imaging have provided insight into the underlying mechanisms, enabling clinicians to use preventative and therapeutic interventions specifically targeted at them, though several questions still remain unanswered. END has potentially serious consequences on the short term (morbidity and death) and long term (recovery from stroke) outcomes for the patient. Therefore, attempts to prevent and treat END should be made promptly and aggressively.

[Images in medicine] Transcendental meditation and hypertension

Dear, J W, Gough, K, Webb, D J — 2008-10-02

[Reviews] Common acute oncological emergencies: diagnosis, investigation and management

Walji, N, Chan, A K, Peake, D R — 2008-10-02

In the UK an aging population is resulting in more people being diagnosed with cancer, and an increasing number of treatment options means that many patients live significantly longer with their disease. It is anticipated therefore that an increasing number of patients will present to primary and secondary care with acute complications of cancer, or the treatment thereof. Many doctors have limited experience in managing patients with cancer and acute oncological emergencies. This article reviews the diagnosis and management of four common oncological emergencies: febrile neutropenia, metastatic spinal cord compression, superior vena cava obstruction, and malignancy associated hypercalcaemia. It is vital to recognise these conditions, as failure to implement immediate and appropriate treatment may result in significant morbidity or death.

[Original articles] Cross-sectional survey of disturbed behaviour in patients in general hospitals in Leeds

2008-10-02

Aim:

To describe the prevalence and nature of disturbed behaviour, in the general hospital setting.

Method:

A cross-sectional survey was conducted, from July to October 2006, in all adult inpatient wards within the six general hospitals in Leeds of patients presenting with disturbed behaviour in the preceding 7 days. Disturbed behaviour was defined as behaviour interfering with care of the patient or with that of other patients, or behaviour that placed the patient, the staff or others at risk. Anonymised data were collected using a semi-structured questionnaire.

Results:

All of the 87 hospital wards were studied, containing a total of 1773 beds. 42 male and 26 female patients (n = 68) were identified by nursing staff as patients with disturbed behaviour in the time period covered, with 33 patients being <=65 years of age and 35 being elderly (>65 years of age). An almost equal proportion of the younger and older patient groups placed themselves or others at risk. In the majority of cases, aggressive behaviour by patients was directed towards staff rather than other patients. 60 patients required additional staff time due to the disturbed behaviour, 34 required additional medication, and 22 patients were referred to liaison psychiatry.

Conclusions:

Disturbed behaviour presents in the general hospital in less than 4% of patients, both above and below the age of 65 years, but consumes a disproportionate amount of resources. Responses required to manage this include additional medication, additional staff time or other interventions. The quantity and nature of disturbed behaviour in the general hospital have implications for effective service provision and development.

[Original articles] Phasic characteristics of inspiratory crackles of bacterial and atypical pneumonia

Norisue, Y, Tokuda, Y, Koizumi, M, Kishaba, T, Miyagi, S — 2008-10-02

Background:

No known physical findings are available to differentiate between bacterial pneumonia (BP) and atypical pneumonia (AP) in patients with community-acquired pneumonia (CAP).

Objective:

To evaluate the possible differences in phasic characteristics of inspiratory crackles between BP and AP in patients with CAP.

Methods:

Retrospective chart reviews were conducted to obtain phasic characteristics of inspiratory crackles (early, early-to-mid, late and pan-inspiratory crackles) in AP and BP groups in a community teaching hospital in Japan (n = 183).

Results:

100 patients with BP and 83 patients with AP were evaluated. Patients with BP were significantly more likely to present with pan-inspiratory crackles (49 (49.0) vs 5 (6.0); p<0.0001), whereas patients with AP were more likely to present with late inspiratory crackles (28 (33.7) vs 9 (9.0); p<0.0001) (mean (SD)). Among pneumonia patients with audible crackles, the sensitivity and specificity of pan-inspiratory crackles for BP were 83.1% and 85.7%, respectively, and the sensitivity and specificity of late inspiratory crackles for AP were 80.0% and 84.7%, respectively.

Discussion:

In patients with CAP and audible crackles, phasic characteristics of inspiratory crackles may be used to distinguish AP from BP. Prospective studies are needed to confirm these findings.

[Faculty matters] Changing education to improve patient care

Leach, D C — 2008-10-02

Health professionals need competencies in improvement skills if they are to contribute usefully to improving patient care. Medical education programmes in the USA have not systematically taught improvement skills to residents (registrars in the UK). The Accreditation Council for Graduate Medical Education (ACGME) has recently developed and begun to deploy a competency based model for accreditation that may encourage the development of improvement skills by the 100 000 residents in accredited programmes. Six competencies have been identified for all physicians, independent of specialty, and measurement tools for these competencies have been described. This model may be applicable to other healthcare professions. This paper explores patterns that inhibit efforts to change practice and proposes an educational model to provide changes in management skills based on trainees’ analysis of their own work.

[Self-assessment questions] A case of refractory hypoxaemia

Church, A C, Fuld, J P, Screaton, N, Chilvers, E R — 2008-10-02

[Case reports] Acute thyroiditis due to septic emboli derived from infective endocarditis

Cabizuca, C A, Bulzico, D A, de Almeida, M H, Conceicao, F L, Vaisman, M — 2008-10-02

Acute infectious thyroiditis is a rare condition of the thyroid gland, most often arising in children with congenital conditions connecting the thyroid directly to the oropharynx, such as a piriform fistula or thyroglossal duct. We report a case of acute thyroiditis due to septic emboli derived from infective endocarditis.

[On reflection] Thinking in three dimensions

Launer, J. — 2008-10-02