Background. Considerable changes have occurred over the last 5 years in the organization of out-of-hours care in the UK. Users' experiences of their care are an important part of 'quality of care' and are valuable for identifying areas for improvement.
ObjectivesThe objective of this study is to discuss some of the issues and give some examples of dealing with clustering in individually and cluster randomised trial sample size calculations.
Compression of median nerve at elbowCompression of the median nerve at the wrist causing carpal tunnel syndrome is an entrapment neuropathy known to every final year medical student.What is not so well known, however, is that com- pression of the median nerve may occur in the region of the elbow and simulate the clinical features of carpal tunnel syndrome. Case reportA 46-year-old man was admitted to St Helier Hospital, Carshalton, for treatment of primary hypercholesterolaemia.He was observed to have considerable wasting of the muscles of the left thenar eminence and probable wasting of the left forearm.On direct questioning he admitted that he had had some weakness of the left hand for several years but denied sensory symptoms.Neurological examination showed gross weakness of the left thumb with wasting of abductor pollicis brevis, flexor pollicis brevis, and possibly flexor carpi radialis.Perception of sharp and blunt in the pulp of the left index finger was diminished, but sensation in the hand was otherwise normal.There were no localised areas of tenderness in the arm or hand.Investigations included normal radiographs of the chest, elbows, and cervical spine.No supracondylar spurs were present.Electromyography suggested compression of the median nerve at the level of the elbow and it was decided to explore this region.
Conflicting data on the diagnostic and prognostic value of auscultation abnormalities may be partly explained by inconsistent use of terminology.To describe general practitioners use of chest auscultation abnormality terms for patients presenting with acute cough across Europe, and to explore the influence of geographic location and case mix on use of these terms.Clinicians recorded whether 'diminished vesicular breathing', 'wheezes', 'crackles' and 'rhonchi' were present in an observational study of adults with acute cough in 13 networks in 12 European countries. We describe the use of these terms overall and by network, and used multilevel logistic regression to explore variation by network, controlling for patients' gender, age, comorbidities, smoking status and symptoms.2345 patients were included. Wheeze was the auscultation abnormality most frequently recorded (20.6% overall) with wide variation by network (range: 8.3-30.8%). There was similar variation for other auscultation abnormalities. After controlling for patient characteristics, network was a significant predictor of auscultation abnormalities with odds ratios for location effects ranging from 0.37 to 4.46 for any recorded auscultation abnormality, and from 0.25 to 3.14 for rhonchi.There is important variation in recording chest auscultation abnormalities by general practitioners across Europe, which cannot be explained by differences in patient characteristics. There is a need and opportunity for standardization in the detection and classification of lung sounds.
Editor's note:The significant growth in the quantity of data in biology and related fields has spawned the need for novel computational solutions. The authors show how a key search task in proteomics, the large-scale study of proteins, can be accelerated by several orders of magnitude by the use of FPGA-based hardware.—George A. Constantinides (Imperial College London) and Nicola Nicolici (McMaster University)
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