Vitamin D deficiency is a chronic condition which contributes to general ill health and seems to be re‐emerging in our catchment area since funding of vitamin D supplementation by Primary Care Trusts ceased. This study aims to verify this situation and to assess the cost effectiveness of reintroducing vitamin D supplementation in the Burnley Health Care NHS Trust.
Vitamin D deficient patients presenting between January 1994 and May 2005 were identified and data retrospectively collected from their case notes. The cost of treatment and the theoretical cost of primary prevention for the Trust population were calculated using previous and current DoH guidelines.
Fourteen patients were identified, of whom 86% presented in the last 5 years and 93% were of Asian origin. The incidence of vitamin D deficiency for our population is 1 in 923 children overall and 1 in 117 in children of Asian origin. The average cost of treatment for each such child is £2500, while the theoretical cost of prevention of vitamin D deficiency in the Asian population through primary prevention according to COMA guidance is £2400 per case.
Vitamin D deficiency is re‐emerging in our Trust. The overwhelming majority of our patients are of Asian origin. The cost of primary prevention for this high risk population compares favourably both medically and financially with treatment of established disease. We suggest that Primary Care Trusts provide funds for vitamin D supplementation of Asian children for at least the first 2 years of life.
cost‐benefit; hypocalcaemia; rickets; treatment; vitamin D deficiency; vitamin D supplementation
To test the following hypothesis in the assessment of head injury patients: only patients with 5 min or more of post‐traumatic amnesia (PTA) are at risk of acute olfactory dysfunction (OD).
This was a retrospective comparative study of olfactory status in head injury patients seen at a head injury clinic at Glasgow Royal Infirmary from 1985 to 2003. Of 828 clinic attenders, 101 had acute OD. These subjects were compared with a randomly selected control group of 102 patients with head injury but normal olfactory function. The main outcome measure was a significant likelihood of patients with PTA lasting for 5 or more minutes having acute OD compared with those with PTA of less than 5 min.
The likelihood of patients with a PTA of 5 min or more having acute OD compared to those with PTA of less than 5 min is clinically significant with an odds ratio of 9.6 (p<0.01).
Examination of patients with 5 min or more of PTA should include a simple test of sense of smell. Patients with impaired smell sensation should be aware of their condition prior to discharge from hospital. In addition, the need for a CT brain scan and appropriate follow up should be considered.
A&E; anosmia; head injury; olfactory dysfunction; post‐traumatic amnesia
Objective—A recent report on head injury management from the Royal College of Surgeons of England suggests that surgeons are unsuited to the inpatient care of head injuries (ICHI) and should hand over responsibility entirely to neurosurgeons and accident and emergency (A&E) specialists. This prompted a survey of A&E consultants to establish their opinions on the current and future practice of head injury care.
Methods—Questionnaires were sent to consultant members of the British Association for Accident and Emergency medicine. Of a possible 256 A&E departments from Great Britain and Ireland with over 20 000 annual new attenders 206 (80%) replied.
Results—General surgeons contribute to ICHI for adults in 107 of 206 hospitals (52%) compared with orthopaedic surgeons in 73 of 206 (35%) and A&E consultants in 71 of 206 (34%). There was frequent criticism that surgeons are uninterested in head injury care. Fifty nine units (30%) commented on the lack of neurosurgery beds and difficulties experienced in getting patients accepted. Few hospitals seem to have well integrated rehabilitation or follow up services targeted at head injury. One in six patients with head injury admitted to a general hospital or observation ward remain after 48 hours and one in 20 stay beyond one week. Of the 132 A&E units without responsibility for ICHI 54 (41%) either wish to take on this responsibility or are willing to do so if the necessary resources are first put in place. The perceived net revenue cost required to allow 67 A&E units to take on ICHI is about 12.5 million pounds per year. This does not include the cost of further care after 48 hours, follow up or rehabilitation.
Conclusion—Only one third of A&E units at present have even part of the ICHI role recommended in the RCS report; another third are prepared to accept a new role if training and resources are provided and support is forthcoming from other specialists to take over the care after 48 hours; the remaining third are unwilling to accept responsibility for ICHI.
OBJECTIVE: To review assault victim attendance at the accident and emergency department of Glasgow Royal Infirmary before and after a police initiative to curb knife carrying and tackle violent assaults ("Operation Blade"). METHODS: Assault victim attendance was reviewed for the month before the implementation of Operation Blade and for one month a year later. The number of victims requiring treatment in the resuscitation room for stab wounds before, during, and after Operation Blade was also reviewed as a crude indicator of the frequency of serious assaults in the city. RESULTS: There were no significant differences in the nature or number of assault victims attending this hospital one year after Operation Blade compared with the month before its implementation. Operation Blade reduced the number of serious stabbings for a period of 10 months, but subsequently numbers surpassed those prevailing before its implementation. CONCLUSIONS: Any attempt to combat this complex and multifactorial problem must be addressed through a combined public health and education initiative in conjunction with regular press and police campaigns to achieve a sustained effect.
Arterial complications from inadvertent arterial puncture in intravenous drug abusers are well recognised. Most reports describe injury to the femoral artery with occasional reports of brachial and radial artery injury. A case of subclavian artery injury is described in this paper, and the pathophysiology and treatment of intraarterial drug injection discussed.
OBJECTIVES: To describe the work, both qualitatively and quantitatively, of an accident and emergency (A&E) ward, and discuss some of the advantages and disadvantages associated with this ward. METHODS: An observational study was carried out of all patients admitted to the A&E ward of Glasgow Royal Infirmary from 1 January 1992 to 31 December 1992. Epidemiological and management data were collected for all patients admitted. RESULTS: There were 2460 admissions, of which 69% were related to trauma and 45% to head injury; 47% of the patients had consumed alcohol before admission. Accidental trauma was the commonest reason for admission (57%), followed by assault (33%). Ninety two per cent of admissions stayed for less than 3 d, but 33% of the workload was spent on a small number of patients admitted for longer than 7 d. CONCLUSIONS: This A&E ward presents a significant workload, and some of its most serious problems lie with those patients who stay longer than 72 h. The safe and effective use of the ward depends upon it being well resourced, along with the department it serves.
The management of 483 patients presenting with minor head injury to the accident and emergency (A&E) departments of two Scottish hospitals was studied prospectively. Such patients comprised 5.7 and 3.9% of the total attendances to each department. Of the 277 patients assessed in the former department, 83 (30%) fulfilled at least one of the currently accepted criteria for recommending admission to hospital and 49 (17.7%) patients were actually admitted. Patients in whom head injury was not the principal reason for admission were excluded from the study. In the same time period the second department dealt with 206 patients with minor head injury, 49 (24%) of whom had criteria for admission. However, significantly fewer, 10 (4.9%) patients, were actually admitted. The major relevant factor when comparing the two departments was the existence in the former of an observation ward. These results support the view that easy access to hospital beds is a major determinant of management in patients presenting with minor head injury to the A&E department and may be more influential than clinical findings.
Machines for automatic non-invasive blood pressure (BP) monitoring are increasingly available in British accident and emergency departments. Our department recently acquired two machines with this capability for use in the resuscitation room. This provided us with an opportunity to compare the speed and frequency of automatic BP recording with the previously used manual method. We found no significant difference in either the median time to the first recording of BP or in the median number of documented recordings in the first hour. However, the overall frequency of BP recording did show a statistically significant increase. We conclude that automation alone does not improve standard practice in this area greatly.
The object of this study was to assess the ability of junior doctors in the accident and emergency department to detect electrocardiographic (ECG) abnormalities. The ECG's performed in this department were monitored over a 4 week period. The initial diagnosis by the accident and emergency doctor was compared with the report from the cardiologist on 126 ECG's which showed abnormalities. The error rate was 19.8%. Of those abnormalities which were graded as clinically significant only 2 (4.4%) were missed. The danger of missing acute changes is emphasized and proposals discussed which may reduce their frequency.
In an attempt to establish what the general practitioner expects from an accident and emergency department, and how closely the service provided correlates with that view, a 12-point questionnaire was sent to the general practitioners in the Glasgow Royal Infirmary catchment area. Out of the 61.2% of general practitioners who replied, the majority wish to have responsibility for their own patients for conditions which are neither accidents nor emergencies. There is less agreement as to how much should be done within an accident and emergency department and on the appropriate modes of referral and communication between the general practitioner and the hospital service. Further consultation and cooperation are necessary to interpret and resolve these differences.
A retrospective study of 661 adult patients with open scalp wounds attending the Accident and Emergency Department of Glasgow Royal Infirmary, Glasgow, Scotland, was performed. Detailed information was recorded about history, nature of open wounds ('contused' or 'incised'), wound exploration and radiological findings. The commonest cause of injury was assault (40%), followed by falls (34%). Half of the patients had been drinking alcohol. The majority of scalp wounds were 'contused' (84%) resulting equally from assaults and falls; 'incised' wounds (16%) were more commonly due to assault. Although division of the occipitofrontalis aponeurosis was infrequent (18%), most (78%) of the skull fractures occurred in this group. Wound exploration detected nine fractures not evident on skull X-rays. To maximise fracture detection rate, careful wound exploration should be an important adjunct to skull radiography and, in particular, division of the occipitofrontalis aponeurosis should alert the casualty officer to the likelihood of a skull fracture.
A study was made of patients with stab wounds who attended the Accident and Emergency Department of Glasgow Royal Infirmary during 1978 and 1983. There were 318 patients. The majority, 304 (96%), were males. A total of 87 (27%) were teenagers. The most common sites of the wounds were the chest (143 patients) and the abdomen (113 patients). The features of the patients and their wounds are compared with those of a previous study carried out at the same hospital in the early 1960s (Batey & MacBain, 1967). The post-mortem reports of 25 fatal stab injury cases occurring in Glasgow between 1971 and 1978 are also reviewed. Some aspects of diagnosis, management and prevention of stab wounds are discussed.
Fifty children were admitted to hospital with symptoms of illness that were attributed, by the parent or general practitioner, to the process of teething in the course of one year. In all but 2 cases an organic cause, other than teething, could be found and the most serious conditions were meningitis in one patient and febrile convulsion in 11.
A family history of appendicectomy was sought in two groups of children admitted to Llandough Hospital over sixteen months. The study group consisted of 29 children with histologically confirmed acute appendicitis, while the control group consisted of 29 children admitted for reasons unrelated to abdominal pain. A history of appendicectomy was elicited in first-degree relatives--that is, siblings and parents of 20 of the children in the study group and of four of the controls--a statistically significant difference. The results obtained from this study suggest that a familial predisposition to appendicitis exists.
The osmolality of urine increased in 10 term infants receiving phototherapy. Phototherapy units made locally were likely to emit more infrared radiation than a unit available commercially, but both types led to falsely increased incubator thermometer readings. Interposing a 6-mm acrylic sheet prevents these effects.