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Cooke, M. W.; Cooke, H. M.; Glucksman, E. E.
doi: 10.1136/bmj.304.6836.1207pmid: 1515788
OBJECTIVE--To assess facilities available for the suddenly bereaved in accident and emergency departments and variations in care of bereaved relatives. DESIGN--Postal questionnaire survey. SETTING--England and Wales. SUBJECTS--All 98 accident and emergency departments treating over 50,000 patients a year, 78 of which replied. MAIN OUTCOME MEASURES--Number of departments with specific facilities, staff training, and procedures for dealing with bereavement. RESULTS--60 hospitals had a specific room for bereaved relatives; the remainder used multipurpose rooms. In 49 hospitals relatives were taken to the room by a nurse with sole responsibility for caring for them. In 40 hospitals the nurse stayed with the relatives and 66 updated relatives on the patient's condition. Facilities for viewing the body privately were poor, and relatives often had to ask to be left alone. 25 departments gave no written information on bereavement and only four routinely followed up relatives. Further training was requested by staff in 44 departments. CONCLUSIONS--Although facilities could be improved, immediate care of relatives is good. Care over subsequent weeks and preparation for this period is invariably inadequate.
Hirschowitz, L.; Raffle, A. E.; Mackenzie, E. F.; Hughes, A. O.
doi: 10.1136/bmj.304.6836.1209pmid: 1325232
OBJECTIVE--To follow up and assess the significance of borderline change in cervical smears. DESIGN--Retrospective study of women undergoing routine cervical cytological screening in 1981. SETTING--Avon Cervical Screening Programme, covering 250,000 women in Bristol and Weston super Mare. SUBJECTS--437 women showing borderline cervical changes in 1981 and 437 age matched controls with normal results in 1981. MAIN OUTCOME MEASURES--Cytological progression to high grade dyskaryosis (cervical intraepithelial neoplasia grade III or invasive carcinoma). RESULTS--During follow up ranging from 13 to 106 months 98 of the 437 women (22.4%) with borderline cytological changes on routine cervical cytology screening had a subsequent smear test showing high grade dyskaryosis compared with three of the 437 women (0.9%) in the control group. The risk of progression was greater in women aged 20 to 39 than in those aged 40 and over. Human papillomavirus infection had initially been diagnosed cytologically in 101 of the 437 (23%) women with borderline results. Significantly fewer of these women developed high grade dyskaryosis (13/98 (13%) v 88/339 (26%), p less than 0.05). CONCLUSIONS--Women with borderline smear test results are at increased risk of developing high grade dyskaryosis, particularly if the borderline changes occur without cytological features of human papillomavirus infection. Progression occurs within three years in 50% of cases, although a linearly increasing risk was sustained over the nine years of follow up and was greatest in women aged 20 to 39. Careful follow up of these women is indicated.
Hussain, S. F.; Watura, R.; Cashman, B.; Campbell, I. A.; Evans, M. R.
doi: 10.1136/bmj.304.6836.1213pmid: 1515789
OBJECTIVE--To determine the efficiency of tuberculosis contact tracing in South Glamorgan 1987-9. DESIGN--Review of records of contact tracing clinic and of data from the Mycobacterium Reference Unit. The clinic's practice was compared with 1983 British Thoracic Society's recommendations. SETTING--Health authority tuberculosis control programme. MAIN OUTCOME MEASURES--Proportion of contacts screened, follow up attendance rates, number of secondary cases detected, and quality of record keeping. RESULTS--101 index patients and 611 contacts were identified. 596 (97.5%) contacts were screened, of whom 139 should not have been. Of 356 contacts requiring a Heaf test, 237 were tested, seven refused the test, and 112 had chest radiography without a Heaf test. 95 contacts were unnecessarily tested. 87 contacts had chest radiography unnecessarily and seven should have had radiography but did not. 34 contacts were given follow up appointments inappropriately and seven were overlooked for follow up. Tuberculosis was diagnosed in five asymptomatic contacts, all at initial screening and all close contacts of index patients with pulmonary disease. CONCLUSION--Inadequacy of data, non-adherence to contact tracing guidelines, and failure to define the term highly infectious index case resulted in many contacts being unnecessarily screened or followed up. IMPLICATIONS--The efficiency of tracing contacts would be improved by specifying smear results and ethnic origin of the index case on the notification form, clearly classifying contacts as close or causal, and clearly defining the term highly infectious.
Chale, S. S.; Swai, A. B.; Mujinja, P. G.; McLarty, D. G.
doi: 10.1136/bmj.304.6836.1215pmid: 1515790
OBJECTIVE--To estimate the costs of diagnosis and treatment of diabetes in Tanzania. DESIGN--Costs estimated from the reported and recorded experience of patients with newly presenting diabetes in 1989-90 and of diabetic patients first seen in 1981-2. SETTING--Muhimbili Medical Centre, Dar es Salaam. SUBJECTS--464 patients (315 men and 149 women). 262 patients diagnosed during 1 September 1989-31 August 1990 (group 1) and 202 during 1 June 1981-31 August 1982 (group 2). RESULTS--The average annual direct cost of diabetes care in 1989-90 was $287 for a patient requiring insulin and $103 for a patient not requiring insulin. Purchase of insulin accounted for 68.2% ($156) of the average annual outpatient costs for patients requiring insulin. For patients not requiring insulin the cost of oral hypoglycaemic drugs and treatment of chronic complications and infections accounted for 42.5% ($29.3) and 48.8% ($33.7) of costs respectively. Cost of outpatient care of diabetic patients for the whole of Tanzania was estimated at $2.7m, *75,128 (32.2%) of which was for insulin. Doctors' and nurses' costs accounted for 0.2% of total costs of outpatient care. The annual direct inpatient care costs were estimated at $1.25m. Around 0.2% of the Tanzanian population aged 15 years and over used the equivalent of 8% of the total government health expenditure, which was $47,4088,382. CONCLUSION--Diabetes places a severe strain on the limited resources of developing countries. If African patients with diabetes have to pay for their treatment most will be unable to do so and will die.
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