How to improve low lymph node recovery rates from axillary clearance specimens of breast cancer. A short-term audit.
(9/5672)
AIM: To implement an audit scheme to increase the lymph node yield from axillary clearance specimens. METHODS: Two pathologists cut up each specimen after weighing it. The number of nodes and the dimensions of the largest and smallest nodes were recorded, together with the number of non-lymph node structures recovered. Fifty consecutive audited cases were compared with 50 consecutive cases assessed before the audit process. RESULTS: It proved possible to increase the median number of lymph nodes from 10 to 22. There was an obvious learning period, during which the number of nodes recovered during the second pathologist's cut-up gradually decreased, while the total number remained relatively constant. The increase in lymph node yield resulted from the recovery of smaller nodes. The identification of lymph nodes also improved, and fewer non-lymph node structures were recovered by the end of the study. CONCLUSIONS: Such an audit scheme can be recommended for all institutions where the lymph node yield of axillary clearance specimens seems suboptimal. The relevance of recovering more nodes remains to be determined; from this small series, it seems to have no clinical impact. (+info)
Improving the quality of perinatal and infant necropsy examinations: a follow up study.
(10/5672)
AIM: To compare the quality of perinatal and infant necropsy examinations in 1996 with those performed in 1993. METHODS: Cohort analysis, with data from the All Wales Perinatal Survey, of 1027 deaths (540 in 1993; 487 in 1996) of babies between 20 weeks' gestation and one year of age. The quality of the necropsy was assessed by scoring aspects identified as being part of the investigation. RESULTS: Necropsy was performed in 335 cases (62%) in 1993 and in 320 cases (66%) in 1996. The proportion done in a regional centre increased significantly from 39% (131/335) in 1993 to 76% (243/320) in 1996 (p < 0.0001). The quality of necropsy was above the minimum standard in 54% of cases in 1993 (171/314) compared with 93% in 1996 (289/312) (p < 0.0001). Improvement occurred in all categories. For stillbirths, 35% (46/133) were above the minimum standard in 1993 compared with 90% (104/116) in 1996 (p < 0.0001); for cases not classified as sudden unexpected death in infancy (SUDI), the improvement was from 62% in 1993 (40/65) to 97% in 1996 (73/75) (p < 0.0001); and for SUDI cases, the improvement was from 32% in 1993 (10/31) to 91% in 1996 (21/23) (p < 0.0001). The quality of both non-regional and regional necropsies improved. For non-regional cases, the score was above the minimum standard in 28% (51/183) in 1993 compared with 69% (52/75) in 1996 (p < 0.0001); for regional cases it improved from 92% (120/131) in 1993 to 100% (237/237) in 1996 (p < 0.0001). CONCLUSIONS: The quality of perinatal and infant necropsies improved considerably between 1993 and 1996, reflecting better awareness of the importance of good quality examination and an increase in referrals to paediatric centres. (+info)
How well is pelvic inflammatory disease managed in general practice? A postal questionnaire survey.
(11/5672)
OBJECTIVE: Many patients with pelvic inflammatory disease (PID) present to their general practitioners. Chlamydia trachomatis is the organism most commonly implicated in this condition. This study aims to examine how well PID is managed in the primary care setting and highlight areas for improvement. METHODS: The study was performed by sending postal questionnaires to 180 randomly selected general practitioners in Birmingham. Given the example of a woman presenting clinically with PID, the doctors were asked questions on diagnosis and treatment. To assess factors that may influence the answers, they were also asked about their sex, year of qualification, and postgraduate training. RESULTS: 139 questionnaires (77%) were returned. 91.4% of the respondents feel confident in managing patients with PID, and only 9.3% would usually refer these patients on. However, 54.7% do not perform an endocervical swab for C trachomatis, 37.4% do not include anti-chlamydial antibiotics in their treatment regimen, and 24.5% do not advise sexual partners to be screened. Female doctors, those with higher degrees, or obstetrics and gynaecology experience were more likely to give anti-chlamydial therapy, but no factors of the respondents significantly influenced contact tracing behaviour. CONCLUSIONS: The management of a patient presenting with PID should include investigation for C trachomatis and treatment with an appropriate antibiotic. As PID is often a sexually transmitted disease, contact tracing of sexual partners should be undertaken. The study suggests that a significant proportion of general practitioners would not have offered optimal management to patients with PID. (+info)
Reducing antibiotics for respiratory tract symptoms in primary care: consolidating 'why' and considering 'how'.
(12/5672)
We summarize recently published evidence showing that antibiotic treatment offers little or no benefit to most patients presenting with sore throats, acute otitis media, maxillary sinusitis, and acute bronchitis. Despite this research, the prescription of antibiotics for respiratory tract conditions is rising in Britain. This wastes money, encourages people to consult for self-limiting conditions, and causes bacteria to become resistant to antimicrobials. Ways of changing present practice are underresearched. Enhanced consulting skills, guidelines and monitoring strategies, patient education, and anti-inflammatory drugs for recurrent and chronic sufferers all hold promise. (+info)
Hospital doctors' assessment of baseline spirometry.
(13/5672)
Baseline spirometry is useful in diagnosing and managing pulmonary disease. In a questionnaire survey of 100 hospital doctors in two hospitals in the Mersey region, their views and ability to interpret baseline spirometry was assessed. Of the 70 doctors who responded, 65% felt they could accurately interpret baseline spirometry. However, only 12% accurately interpreted all five vitalographs in the questionnaire. The majority (72%) felt they had not had adequate teaching in interpretation of spirometry, and 63% would prefer a report from a respiratory technician. These result suggest that improvement needs to be made in interpretation of baseline spirometry. (+info)
Randomised controlled trial of educational package on management of menorrhagia in primary care: the Anglia menorrhagia education study.
(14/5672)
OBJECTIVE: To determine whether an educational package could influence the management of menorrhagia, increase the appropriateness of choice of non-hormonal treatment, and reduce referral rates from primary to secondary care. DESIGN: Randomised controlled trial. SETTING: General practices in East Anglia. SUBJECTS: 100 practices (348 doctors) in primary care were recruited and randomised to intervention (54) and control (46). INTERVENTIONS: An educational package based on principles of "academic detailing" with independent academics was given in small practice based interactive groups with a visual presentation, a printed evidence based summary, a graphic management flow chart, and a follow up meeting at 6 months. OUTCOME MEASURES: All practices recorded consultation details, treatments offered, and outcomes for women with regular heavy menstrual loss (menorrhagia) over 1 year. RESULTS: 1001 consultation data sheets for menorrhagia were returned. There were significantly fewer referrals (20% v 29%; odds ratio 0. 64; 95% confidence interval 0.41 to 0.99) and a significantly higher use of tranexamic acid (odds ratio 2.38; 1.61 to 3.49) in the intervention group but no overall difference in norethisterone treatment compared with controls. There were more referrals when tranexamic acid was given with norethisterone than when it was given alone. Those practices reporting fewer than 10 cases showed the highest increase in prescribing of tranexamic acid. CONCLUSIONS: The educational package positively influenced referral for menorrhagia and treatment with appropriate non-hormonal drugs. (+info)
Rural background and clinical rural rotations during medical training: effect on practice location.
(15/5672)
BACKGROUND: Providing health care services in rural communities in Canada remains a challenge. What affects a family medicine resident's decision concerning practice location? Does the resident's background or exposure to rural practice during clinical rotations affect that decision? METHODS: Cross-sectional mail survey of 159 physicians who graduated from the Family Medicine Program at Queen's University, Kingston, Ont., between 1977 and 1991. The outcome variables of interest were the size of community in which the graduate chose to practise on completion of training (rural [population less than 10,000] v. nonrural [population 10,000 or more]) and the size of community of practice when the survey was conducted (1993). The predictor or independent variables were age, sex, number of years in practice, exposure to rural practice during undergraduate and residency training, and size of hometown. RESULTS: Physicians who were raised in rural communities were 2.3 times more likely than those from nonrural communities to choose to practise in a rural community immediately after graduation (95% confidence interval 1.43-3.69, p = 0.001). They were also 2.5 times more likely to still be in rural practice at the time of the survey (95% confidence interval 1.53-4.01, p = 0.001). There was no association between exposure to rural practice during undergraduate or residency training and choosing to practise in a rural community. INTERPRETATION: Physicians who have roots in rural Canada are more likely to practise in rural Canada than those without such a background. (+info)
Implications of laparoscopic cholecystectomy for surgical residency training.
(16/5672)
BACKGROUND: Widespread adoption of minimal access techniques forced a generation of abdominal surgeons to re-learn many standard abdominal procedures. This threatened to reduce the pool of suitable "training" operations for surgical residents. METHODS: Operator grade, duration of operation, acute/elective operation, conversion rate, complications, and postoperative stay were recorded prospectively on all laparoscopic cholecystectomies (LC) since 1992. This data was evaluated to determine how the introduction of LC affected residents' training. RESULTS: The percentage of LCs performed by residents increased progressively to reach 58%. Operating time was longer for trainee surgeons, particularly for acute cases (145+/-50 minutes vs 111+/-54 minutes, p<0.05); however, conversion rate, incidence of complications, and postoperative stay were no different. CONCLUSIONS: LC can be performed by surgical trainees with similar complication rates and outcomes as those of qualified surgeons. Once institutional experience has accumulated, this procedure can be integrated into residency training. (+info)