Buckland Hospital

We aim to phenotype and genotype a cohort of newly described patients with Moyamoya disease who are of Polynesian or Māori (indigenous peoples of New Zealand) ancestry.

Background:In the United Kingdom, the new NHS contract for primary care mandates that practices use the Electronic Frailty Index (EFI) to screen for frailty and apply clinical judgment, based on knowledge of the patient, to decide whether they have a diagnosis of frailty. EFI has not yet been validated for this purpose. Many primary care clinicians would agree that although not formally investigated, there seems to be a strong association between being housebound or in institutional care and having a diagnosis of frailty. Although being housebound or in institutional care is not commonly coded in primary care computer record systems (IT), this cohort of patients do require home visits if they become unwell. Home visits are coded and it is simple to run a search on primary care IT to generate a list of older people who have received a home over given period.Aim:This study assessed whether being housebound and requiring home visits could form a new screening tool for frailty.Design and Setting:Retrospective cohort study from 1/3/15 to 29/2/16. Primary care, South Devon.Method:Medical records of 154 patients over 65 years of age were evaluated. Patients were divided into two groups: a group (n = 82) that had received a home visit and a second group consisting of a randomized sample of patients (n = 72) with similar baseline characteristics who had not. Patient records were analyzed by two clinicians to determine whether a frailty syndrome was present. Researchers were blinded to each other's results. An arbitrator determined the frailty status on disagreement.Results:Home visits have a sensitivity of 87.23% [95% confidence interval (CI): 74.35%–95.17%] and specificity of 61.68% (95% CI: 51.78%–70.92%). For frailty, Cohen's Kappa showed fair interobserver reliability.Conclusion:This study suggests that home visits are a good screen for frailty; the data are easy to retrieve from primary care IT and could be used as a valid screening tool to assist with identifying frailty in primary care.

Background: Amyotrophic lateral sclerosis (ALS) is a degenerative disease of motor neurons that causes progressive paralysis and eventually results in death from respiratory failure. Environmental factors that trigger ALS might result in a pattern of geographical clustering of cases. We tested this hypothesis using the South-East England ALS population register, which covers south-east London, Kent and parts of neighbouring counties. Methods: The register’s catchment area was divided into postcode districts and sectors. The expected rates of ALS (adjusted for age and sex) were compared with the observed rates using a standardised residuals method and the SaTScan programme. Results: There were 406 cases of ALS identified in the catchment area during the study period. Four of the 126 postcode districts, all in Greater London, had residuals >2.5 SDs from the mean. Similarly, there were 15 postcode sectors (out of 420) that had residuals >1.96 SDs from the mean. Nine of these were in Greater London. SaTScan identified an area that had a 5.61-km radius in which the relative risk of ALS was 1.70 (p = 0.012). This area overlapped with the postcode districts and some of the sectors identified using the residuals method. Conclusions: These findings suggest an excess of ALS cases in some postcode districts in south-east England.

Susan Holmes and Maureen Speed received the 2008 Multiple Sclerosis Nursing Award for saving and extending their MS specialist nursing service. They explain how they went about it

Intravenous immunoglobulin (IVIG) therapy has represented a major advance in the treatment of patients with primary immune deficiency disorders. In September 2000 a new IVIG formulation, Intragam P, was introduced into clinical use. Intragam P is prepared by delipidation of pooled plasma followed by an ion exchange chromatography step to eliminate immunoglobulin aggregates. It is then pasteurized for 10 h at 60 degrees C for viral inactivation before storage at pH 4.25 in 10% maltose. We report initial clinical experience with this new preparation. The details of adverse reactions of patients who received the new preparation were gathered shortly after it became apparent there was a change in IVIG formulation. Seven of 49 patients receiving Intragam P spontaneously reported adverse effects, which were temporally related to infusions. Subsequently, all seven patients have been able to tolerate the product with prophylactic use of antihistamines and paracetamol. This case series indicates that long-term tolerance of an older IVIG product does not necessarily equate to tolerance to a newer product, even if technically superior. Caution should be exercised when changing IVIG products, as they are not biologically equivalent.

To describe the first cases of serologically proven riskettsial disease reported in non-travelling New Zealanders. We used clinical and laboratory based surveillance, review of clinical records and patient interviews. Information collected included demographics, presenting signs and symptoms, laboratory results, treatment and outcome. A limited seroprevalence study of rural-living friends and relatives was performed. We tested for rickettsial antibodies in the sera of possums trapped on properties close to the area of residence of the first two cases. Serological results support the diagnosis of a rickettsial disease in nine patients. Clinical findings at presentation were nonspecific but included fever, rigors and headache. A rash was noted in four (44%). All had abnormal liver enzymes. Eight were hospitalised. No patient died but two were admitted to intensive care. There is strong clinical and serological evidence that Rickettsia typhi (the causative organism of murine typhus) or a Rickettsia typhi-like organism is present in the greater Auckland region. To prove it, the organism will need to be cultured or rickettsial DNA detected by molecular methods. Rickettsial infection needs to be included in the differential diagnosis of patients presenting with fever, headache and myalgia, particularly in those with rural lifestyles at least in the greater Auckland area.

Surgery in New Zealand is performed by more than 500 surgeons who serve a population of 3.8 million people. Most of the surgeons are trained in New Zealand under the auspices of the Royal Australasian College of Surgeons. Surgical services are consistent with the highest standards of Western countries.

To document current prescribing habits and attitudes of doctors in the Auckland region towards analgesic medication for soft-tissue injury and determine whether the available evidence supports this practice. A survey of 573 doctors in the Auckland region was conducted. There was a 71.4% response rate. The clinical and experimental evidence concerning non-steroidal, anti-inflammatory (NSAID) use in soft-tissue injury was reviewed. The side-effect profiles of NSAIDs were reviewed, with emphasis on the incidence of gastrointestinal side-effects when NSAIDs are prescribed for short periods and evidence implicating adverse renal effects on healthy exercising adults. Most doctors ranked NSAIDs more effective than paracetamol (70.4%, p<0.01). NSAIDs were the most prescribed single analgesic agents (47.8%, p<0.0001). Diclofenac was the NSAID of choice for 69.8% of doctors, who used NSAIDs (p<0.001). The incidence of gastrointestinal side-effects for short-term use of NSAIDs in acute soft tissue was 11%. The available evidence does not support the belief by the doctors surveyed that NSAIDs are more effective than paracetamol in soft-tissue injury. NSAIDs delay, but do not prevent the inflammatory response in injured tissue and may expose athletes to an increased risk of re-injury by delaying healing. Significant adverse effects do occur in previously healthy patients who receive NSAIDs.