Fatal salmonella aortitis with mycotic aneurysm rupture

Salmonellae most commonly cause uncomplicated cases of gastroenteritis but have a predilection for damaged blood vessels, especially those damaged by atherosclerosis. The abdominal aorta is most frequently affected. The most serious complication of aortitis is mycotic aneurysm formation with subsequent rupture. The authors present the case of a 61-year-old man who was found unresponsive at home 3 days after discharge from the hospital for treatment of gastroenteritis with bacteremia. Postmortem examination revealed a ruptured mycotic aneurysm with a large retroperitoneal hematoma. Numerous gram-negative rods were embedded in the wall of the aorta and surrounding inflammatory infiltrate, compatible with the patient's previously isolated. Whereas abdominal aortic aneurysm rupture is most commonly associated with atherosclerosis, the isolation of from blood cultures, coupled with radiographic evidence of gas surrounding the aorta, should raise the suspicion of infectious aortitis. Whereas fatal rupture of an aortic aneurysm secondary to atherosclerosis alone or in conjunction with aortitis will not have an impact on the manner of death, infections are reportable and thus have public health implications.     

The identification of sodium fluoroacetate (compound 1080) employing NMR spectroscopy

Nuclear magnetic resonance (NMR) spectroscopy was employed for the purpose of identifying samples of materials suspected of containing sodium fluoroacetate (Compound 1080). Acquisition of routine proton (1H) and carbon (13C) NMR spectra provided a straight-forward means for determining the presence of Compound 1080 in the samples and thus afforded a simple method for analysis and identification of this compound.     

Adjusting to New Ways of Working: Experiments with Service Delivery in the Public Sector

In response to the perceived failure of both the state and market models of service delivery, governments have embarked on a reform program that draws on the community sector to expand the suite of available policy and service delivery arrangements. This paper explores and identifies the nature of changed relationships between government and the community sector. It uses a case study that examines the operation of a new type of community organisation, and analyses the affectivity and outcomes from the experience of a community based networked arrangement. Although there is evidence of a shift to more relationship‐ oriented models of operation because of either mandate or preference both community and government sectors have found it difficult to make the necessary adjustments to these new ways of working. Community has begun the shift to this new relational approach but finds it difficult to sustain the momentum and tends to revert to more independent and competitive modes. Governments find it difficult to make the necessary adjustments to power‐sharing and resource allocation and continue to operate as ‘business as usual’ through the traditional bureaucratic authority of command and control. In this way, the rhetoric of collaboration and partnership between government and the community sector is not necessarily matched by policy and action supporting the practice of ‘new ways of working’ although these ‘experiments in service delivery’ have opened the way for adopting more innovative and effective approaches to service delivery.     

What could be achieved with greater public hospital autonomy? Comparison of public and PNFP hospitals in Uganda

The policy of hospital autonomy has been discussed for some time in Uganda. There is little evidence from Uganda or elsewhere that increased autonomy will improve hospital performance. This article compares the performance of three private not‐for‐profit (PNFP) and public hospital pairs to address this question. PNFP and public hospitals have similar management structures but PNFP hospitals had better trained managers and a church affiliated chair in the hospital management committee. Both types have problems with personnel management but these appear more pronounced in public hospitals. Drug supply management appears better in PNFP hospitals. Overall, workloads are similar, but analysis of patterns of utilisation and prices across services suggest that patient choice of facilities is influenced by relative price levels, and that willingness to pay is higher for PNFP services. PNFP hospitals are more successful at generating revenue. There are no clear differences in efficiency between PNFP and public hospitals but there is some evidence of higher quality levels in PNFP hospitals. PNFP hospitals' performance is plausibly related to three areas of managerial autonomy. First, better management of drug supply is facilitated by their freedom to purchase drugs from the open market. Second, greater success with personnel management is plausibly related to their greater autonomy over staffing. Third, higher levels of cost recovery are enabled by their freedom to set fees. However, differences in accountability and competence of hospital management, and population willingness to pay for services may also help to explain differences. Further, the use of PNFP financing strategy by public hospitals has implications for universal access to hospital services. Although there appear to be potential advantages from greater public hospital autonomy, the Ugandan government should ensure it has developed strategies to enhance public hospital management and to protect access to public hospitals before advancing further with hospital autonomy policy. Copyright © 2002 John Wiley & Sons, Ltd.     

When silence threatens safety: lessons from the first Canberra Hospital neurosurgical inquiry

Despite widespread institutional and professional support, the recommendations of the Bristol Royal Infirmary Inquiry may be insufficient to reduce patient risk from impaired senior medical practitioners. Using the First Inquiry into Neurosurgical Services at the Canberra Hospital as a case study, this article argues that the Bristol-type recommendations--which emphasise reformulation of clinical governance structures, including early reporting of "sentinel events" and compulsory clinical audits--will be ineffective without a reformed institutional ethos that encourages open transparency and respect for those committed to such processes. Such reformulation may need to commence in medical education and involve new strategies including the use of portable digital technology to facilitate self-assessment of performance and immediate reporting of adverse incidents.     

Some implications of the Human Rights Act 1998 for the medical treatment of children

Although the Gillick decision was hailed as an important step in the furtherance of respect for children's autonomy, subsequent judgments seemed to undermine this important principle. While it would be difficult to criticise the outcomes of some of the key cases, the reasoning by which these were achieved is rather more contentious. There have been some interesting discussions suggesting more constructive approaches but there is still a great deal of anecdotal evidence indicating that conservative assessments of children's ability to be involved in decisions about their medical treatment remain the norm. The new Department of Health consent forms should help to create a climate where assessment of a child's competence will become more sophisticated. This paper will argue that the Human Rights Act 1998 offers another opportunity to reassess more traditional approaches to children's capacity; indeed, this could be violation, inter alia, of the right not to be subject to inhuman and degrading treatment under Article 3 in extreme circumstances and the right to private and family life enshrined in Article 8. Clearly, it is not always practicable to carry out assessments rigorously and some health professionals may feel they do not have the expertise to do this, but some basic criteria could assist here; courts are not likely to expect more than a demonstration that best endeavors have been employed in reasoned decision-making. Additionally, other privacy rights may have implications for the medical decision-making process as it affects children and their carers particularly where conflict arises. Disputes may also ensue from the right to manifest religion and other beliefs",' under the Act. This paper will explore how such challenges to those responsible for the medical treatment of children may fare.