Norwich Community Hospital

Statistics with Confidence. 2nd Ed. Edited by Douglas G Altman, David Machin, Trevor N Bryant, and Martin J Gardner. (Pp 240; £18.95.) BMJ Books, 2000. ISBN 0-7279-1375-1.\**\*|\* This book is written by senior statisticians with a wealth of experience in both statistical research and teaching. The first section of the book deals with the different statistical methods …

These guidelines for management of urticaria and angio-oedema have been prepared for dermatologists on behalf of the British Association of Dermatologists. They present evidence-based guidance for treatment, with identification of the strength of evidence available at the time of preparation of the guidelines, and a brief overview of aetiology, diagnosis and investigation.

Dupuytren's disease may present with well-defined subcutaneous cords or as more diffuse disease with involvement of the skin. Fasciectomy is the procedure commonly carried out for the full range of disease, but is associated with rates of recurrence of up to 66%. We reviewed 143 rays in 103 patients undergoing dermofasciectomy for diffuse disease with involvement of the skin. We found recurrence in 12 rays (8.4% of rays; 11.6% of patients) during a mean follow-up of 5.8 years, eight as cords and four as nodules. We suggest that dermofasciectomy is a better method of disease control than fasciectomy for the more diffuse type of disease with involvement of the skin.

In response to recent advancements in inflammatory bowel disease (IBD) management, the British Society of Gastroenterology (BSG) Clinical Services and Standards Committee (CSSC) has commissioned the BSG IBD section to update its guidelines, last revised in 2019. These updated guidelines aim to complement the IBD standards and promote the use of the national primary care diagnostic pathway for lower gastrointestinal symptoms to enhance diagnostic accuracy and timeliness. Formulated through a systematic and transparent process, this document reflects a consensus of best practices based on current evidence. The guideline, while developed primarily for the UK, is structured to support IBD management internationally. It is endorsed by the BSG executive board and CSSC without external commercial funding, with involvement primarily supported through professional roles in public institutions and the National Health Service (NHS). Methodological revisions since the prior guidelines have enhanced rigor in technical review and development, with methodology details published independently following peer review. In developing the recommendations, 89 clinical experts and stakeholders participated in an online survey, identifying primary outcomes, such as clinical and endoscopic remission, as well as adverse event metrics, all stratified by clinically relevant effect sizes. These guidelines are intended to support clinical decision-making but are not prescriptive, recognizing that individual clinical scenarios may warrant tailored approaches. Further research may inform future revisions as new evidence emerges.

1. The demonstration of increase of muscle potential of the vocal organs in a case of schizophrenia experiencing verbal hallucinations suggested further investigation. Accordingly, electromyograms of the vocal musculature were obtained from 100 patients and 100 normal controls by means of an electroencephalograph machine. 2. Forty of a group of 48 patients experiencing verbal hallucinations (83%) had increased potential. Of a combined group of 64 having or probably having auditory hallucinations, 53 (82%) had increased potential. 3. Of the group of 33 patients not experiencing hallucinations, 30 (90%) had no increase of muscle potential. Of the combined group of 36 not experiencing or probably not experiencing hallucinations, 31 (86%) showed no increase of muscle potential. 4. In the group of 56 schizophrenic patients who were hallucinating or probably hallucinating, 45 (85%) had an increase of muscle potential. 5. Tension in the "throat" exists in 28% of a sampling of the normal population, whereas it is present in 58% of a sampling of patients in a mental hospital. 6. Hyperactivity of vocal musculature in the psychotic appears related to the presence of verbal hallucinations. 7. The electromyogram of the vocal musculature offers a laboratory method for determination of presence of verbal hallucinations and for the graphic portrayal of change of tension following treatment. 8. A theory of verbal hallucinations is tentatively reaffirmed concerning involuntary intensification of the psychomotor mechanism of speech. 9. A study of muscle tension patterns by means of simultaneous electromyograms is suggested.

In the early part of the century, when adrenaline first became widely available, it was used in an uncontrolled manner and cases of ischaemic necrosis led to it falling into disfavour for hand surgery. Local anaesthesia with adrenaline is currently widely used for palmar and dorsal hand surgery but there remains a very deeply ingrained resistance to its use for digital anaesthesia. It is widely thought that it will cause irreversible digital artery vasospasm. This prospective study reports the effect of 2% lignocaine with 1:80,000 adrenaline digital blocks on various parameters of digital arterial blood flow in 100 consecutive patients. Our findings show that adrenaline only temporarily reduced digital blood flow. Perfusion of the digits persisted in every case.

BACKGROUND: A study was undertaken to determine if arterial blood gas estimation is always necessary in the assessment of patients presenting to hospital with acute severe asthma, or whether oxygen saturation as measured by pulse oximetry is a reliable screening test for predicting those in respiratory failure. METHODS: A prospective study was conducted in a specialist respiratory medical unit. Arterial blood gas tensions and pulse oximetry were measured in 89 consecutive patients admitted with acute severe asthma. Respiratory failure was defined as PaO2 < 8.0 kPa or PaCO2 > 6 kPa. RESULTS: When oxygen saturation was 92% or higher (72 patients) respiratory failure was found in three (4.2%) cases. In the 82 patients with a saturation of 90% or higher six patients (7.3%) had respiratory failure. CONCLUSIONS: In the initial assessment of acute severe asthma an oxygen saturation of > 92% suggests that respiratory failure is unlikely and therefore arterial blood gas measurement is unnecessary. This study is only relevant to the assessment of asthmatic patients at presentation. Other parameters of severity must be continually assessed in all asthmatic patients admitted to hospital irrespective of the initial SaO2, and blood gases measured when clinically indicated.

We have reviewed 90 rays in 67 patients who had undergone radical digital dermofasciectomy. Follow-up was from 24 to 100 months. Problems with skin grafts, moving two-point discrimination and active range of joint movement were noted. The recurrence rate in this series was 8%, a very much better figure for disease control than has been reported for standard approaches for Dupuytren's disease. Radical digital dermofasciectomy is strongly recommended for all cases of recurrent Dupuytren's disease requiring reoperation and as a primary procedure when there is significant skin involvement.

Twelve patients (8 men), aged 33-67 (mean 49) years, with histologically proved sarcoidosis underwent bronchoscopy. All had symptoms, signs (wheeze in 11, high pitched inspiratory "squeaks" in six, stridor in three), and physiological abnormalities characteristic of severe or worsening airways obstruction. Eleven patients also underwent bronchography. At the time of bronchoscopy four patients had stage II, one stage III, and seven stage IV sarcoidosis. All patients had a peak expiratory flow (PEF) of 70% predicted or less and a maximum expiratory flow at 50% (MEF50) and 25% (MEF25) of vital capacity below 35% predicted. The ratio of their forced expiratory volume in one second to forced vital capacity (FEV1/FVC) ranged from 37% to 65%. Fibreoptic bronchoscopy showed single or multiple areas of segmental bronchial stenoses in 10 patients, two of whom had stenotic webs. Bronchography showed that the sites and severity of stenoses were more widespread than suspected from the bronchoscopic findings. Five of the 11 patients undergoing bronchography had bronchiectasis, which was restricted to the upper lobes in three and a lower lobe in one and affected both upper and lower lobes in one patient. The bronchiectasis had not been suspected or diagnosed from the chest radiography or the bronchoscopy.

BACKGROUND: Mental health services continue to develop service user involvement, including a growth in employment of peer support workers (PSWs). Despite the importance of the views and attitudes expressed by psychiatrists, this topic has not previously been studied. AIMS: To gain insight into the views and attitudes psychiatrists have about PSWs. METHODS: A qualitative study based on semi-structured interviews with 11 psychiatrists in the East of England. RESULTS: Psychiatrists were broadly positive and supportive of PSWs. Interviewees not only could anticipate a range of possible benefits of employing PSWs, but also had concerns regarding their implementation and management. There was a lack of clarity and consistency between interviewees about what the exact role of a PSW might involve. CONCLUSION: This study provides insights into how PSWs are perceived by psychiatrists. While broadly positive attitudes exist, the research highlights certain challenges, particularly role ambiguity.

Poverty and the

Historically, radiology research has been dominated by chest and breast screening. Few studies have examined complex interpretative tasks such as the reading of multidimensional brain CT or MRI scans. Additionally, no studies at the time of writing have explored the interpretation of stroke images; from novices through to experienced practitioners using eye movement analysis. Finally, there appears a lack of evidence on the clinical effects of radiology reports and their influence on image appraisal and clinical diagnosis. A computer-based, eye-tracking study was designed to assess diagnostic accuracy and interpretation in stroke CT and MR imagery. Eight predetermined clinical cases, five images per case, were presented to participants (novices, trainee, and radiologists; n=8). The presence or absence of abnormalities was rated on a five-point Likert scale and their locations reported. Half cases of the cases were accompanied by clinical information; half were not, to assess the impact of information on observer performance. Results highlight differences in visual search patterns amongst novice, trainee and expert observers; the most marked differences occurred between novice readers and experts. Experts spent more time in challenging areas of interest (AOI) than novices and trainee, and were more confident unless a lesion was large and obvious. The time to first AOI fixation differed by size, shape and clarity of lesion. 'Time to lesion' dropped significantly when recognition appeared to occur between slices. The influence of clinical information was minimal.

\**\*|\* This book is compiled by multiple authors from the disciplines of nursing, information technology, general practice, and audit and its preparation has been funded by the National Institute for Clinical Excellence. The first section covers preparing for audit including details on sources of information, priorities for assessment, the purposes of audit and …

PURPOSE: To evaluate patient comfort during cataract surgery performed using modified topical and peribulbar anesthesia. SETTING: Sunderland Eye Infirmary Cataract Treatment Centre, Sunderland, United Kingdom. METHODS: In this prospective study, 50 consecutive patients scheduled for cataract surgery with local anesthesia were randomly assigned to receive topical bupivacaine hydrochloride plus 0.1 mL subconjunctival lignocaine or standard peribulbar anesthesia. All surgery was performed by one surgeon using a scleral pocket bimanual phacoemulsification technique. Patients were asked to grade the pain experienced during administration of the anesthetic and during cataract surgery using a visual analog scale. RESULTS: No statistically significant difference in patient comfort was demonstrated between the two groups during cataract surgery (P < .4, Wilcoxon rank-sum test), and all patients were satisfied with the anesthesia. However, administration of topical bupivacaine was significantly less painful than peribulbar injections (P < .001, Wilcoxon rank-sum test). In eight patients in the topical anesthesia group, the cataract in the fellow eye was removed using peribulbar anesthesia; seven of these patients stated a preference for the modified topical method, while one patient thought there was no difference between the two methods. There was no difference between the groups in surgical complications, but 24% of the peribulbar group had a minor subconjunctival hemorrhage at the needle entry site. CONCLUSION: The modified topical technique provided satisfactory patient comfort during cataract surgery; it was comparable to the comfort achieved using peribulbar injections. The speed and ease of administering topical anesthesia coupled with the rapid visual recovery after surgery makes this method a suitable and safe choice for day-case phacoemulsification cataract surgery.

BACKGROUND AND PURPOSE: There have recently been highly publicized examples of suboptimal outcomes with some newer implant designs used for total hip replacement. This has led to calls for tighter regulation. However, surgeons do not always adhere to the regulations already in place and often use implants from different manufacturers together to replace a hip, which is against the recommendations of the Medicines and Healthcare Products Regulatory Agency (MHRA) and the directions of the manufacturers. PATIENTS AND METHODS: We used data from the National Joint Registry of England and Wales (NJR) to investigate this practice. RESULTS: Mixing of components was common, and we identified over 90,000 cases recorded between 2003 and 2013. In the majority of these cases (48,156), stems and heads from one manufacturer were mixed with polyethylene cemented cups from another manufacturer. When using a cemented stem and a polyethylene cup, mixing of stems from one manufacturer with cups from another was associated with a lower revision rate. At 8 years, the cumulative percentage of revisions was 1.9% (95% CI: 1.7-2.1) in the mixed group as compared to 2.4% (2.3-2.5) in the matched group (p = 0.001). Mixing of heads from one manufacturer with stems from another was associated with a higher revision rate (p < 0.001). In hip replacements with ceramic-on-ceramic or metal-on-metal bearings, mixing of stems, heads, and cups from different manufacturers was associated with similar revision rates (p > 0.05). INTERPRETATION: Mixing of components from different manufacturers is a common practice, despite the fact that it goes against regulatory guidance. However, it is not associated with increased revision rates unless heads and stems from different manufacturers are used together.

This study compares the accuracy of computer-aided goniometry with standard goniometry. 109 finger joint angles at the extremes of flexion and extension were measured by a senior hand therapist using standard goniometry. Lateral digital photographs were then taken of the hands and the same angles were read from these by computer. There was good correlation (r(2)=0.975) between the results. Computer goniometry averaged 1 degrees (95%Cl=0 degrees -+2 degrees ) more than the standard goniometry. We feel that computer goniometry of finger joints is accurate and compares well with standard goniometry.

or less failed to meet this standard's requirement that generic names and dose should be 1P5 mm or more and 10 out of 11 ampoules of greater than 2 ml failed to meet its minimum of 2-5 mm. We believe that a British standard for size and clarity of drug ampoule labels is urgently required.

This is a comparative study of a hydrocellular foam (Allevyn, Smith and Nephew) and a calcium alginate (Kaltostat, ConvaTec) in dressing split-thickness skin-graft donor sites. The dressing materials were used in equal halves of each donor site in 20 patients undergoing skin-graft harvest. The donor sites dressed with Allevyn showed a tendency to earlier healing, but this was not confirmed statistically. However, Allevyn was found to be more comfortable than Kaltostat and this difference was statistically significant. Due to its increased patient comfort, cheaper cost and comparable time to healing with Kaltostat, the authors recommend the use of Allevyn as a dressing for split-thickness skin-graft donor sites.

This paper reviews published audit activity for a single common condition (asthma). Has this effort brought about better care for the patient? The result of this audit of audits reveals that specialists do follow the guidelines on the management of acute asthma with good results, but that general physicians, in whose care perforce many acute episodes are managed, do not seem to be aware of the published good practice guidelines.

The numerous methods used for treating ingrowing toe-nails are testimony to the lack of a generally acceptable procedure with a low failure rate. A simple procedure with nail preservation is described, and the results of treatment assessed. The procedure consists of making a transposition flap of the nail wall after preliminary curettage of the granulation tissue in the nail groove. A total of 82 patients were treated by this method over a 3-year period, and the results in 63 patients were assessed between 18 months and 3 years after surgery. A total of 120 operations were carried out and 110 (92%) were successful. The treatment is effective, well tolerated, not technically difficult, and should be considered as an alternative to current methods of treatment.