Collapse, hoarseness of the voice and swelling and bruising of the neck: an unusual presentation of thoracic aortic dissection.

A 66 year old woman presented to the accident and emergency department with history of collapse, hoarseness of the voice, and swelling and bruising of the neck. The diagnosis was not initially obvious because of the absence of chest pain. The findings on the radiograph of the soft tissue of the neck and chest radiograph suggested the need for computed tomography of the neck and chest.

An analysis of calls referred to the emergency 999 service by NHS Direct.

Introduction: NHS Direct was launched in West Yorkshire in April 1999. A 999 ambulance can be dispatched to the patient as a result of a call to NHS Direct. The aim of this study is to compare cases that had been referred by NHS Direct via the 999 service, with those who had dialled 999 themselves.

The effect of the introduction of NHS Direct on requests for telephone advice from an accident and emergency department.

Objectives: To assess the effect of the introduction of NHS Direct on advice seeking calls to an accident and emergency (A&E) department.

Methods: Review of departmental telephone advice logbook before and after the introduction of NHS Direct together with recording of the number of calls redirected to NHS Direct by the hospital switchboard and the A&E department.

Results: The number of advice calls responded to within the department fell by 72.

Early infective complications and late recurrent cancer in stapled colonic anastomoses.

Between 1978 and 1981, 73 patients with colonic or rectal cancer were randomized to have their anastomoses made by either a single interrupted layer of braided polyester sutures, or by a circular stapling instrument. Of these operations, 20 were considered to have been palliative, the remaining 53 being potentially curative. The incidence of local recurrence in the latter group was analyzed in relation to initial septic and anastomotic complications.

Antimicrobial bowel preparation. Oral, parenteral, or both?

It has been suggested that wound infection rates after colorectal operations are influenced more by the presence of adequate tissue levels of antimicrobials at the time of contamination than by the extent of bacterial colonization of the intestinal lumen. There are, however, theoretical grounds for the belief that both levels are important. The authors therefore conducted a random control trial in 119 consecutive patients undergoing elective colorectal operations, comparing the results in a group receiving purely parenteral antimicrobial prophylaxis with those in one having a combined oral and parenteral regimen.

Pre-operative assessment of fitness score.

Death within 30 days or survival after a major operation depends on three things: the severity of the disease and the operation, the technical proficiency of the surgeon and the ability of the patient to withstand both disease and operation. The first of these can be estimated by reference to published figures, the second can only be guessed at and the third has in the past been a matter of subjective judgement. With the aim of producing an objective assessment of the likelihood of survival, we have constructed a score system comprising 26 items including age, chronic disease and acute presenting disease.

Peroperative lavage of the obstructed left colon to allow safe primary anastomosis.

A series of 44 patients with complete or partial left-colon obstruction underwent laparotomy and intraoperative colonic lavage. Irrigation was unsuccessful in three, the operation being concluded by a Hartmann resection. In the remaining 41, the achievement of an empty colon allowed primary anastomosis after resection of the obstructing lesion.

Fluid sequestration: an early indicator of mortality in acute pancreatitis.

Complete daily intake and output charts were available for 218 patients with acute pancreatitis. The patients were divided into three groups according to the relation between fluid intake and output. In 105 patients in whom there was negligible fluid sequestration (daily output within 2 litres of intake) there were six deaths (5.

The prediction of incisional hernias by radio-opaque markers.

On the hypothesis that incisional defects occur soon after operation but the resulting hernia may not be diagnosed until months or years later, we attached three to five pairs of stainless steel haemostatic clips to the cut edges of the anterior aponeurosis during the closure of 59 major laparotomy incisions and X-rayed the abdomen one month later. Three patients were withdrawn and the remaining 56 were examined with special reference to incisional herniation at their six-month follow-up visit. The senior author subsequently arranged a series of extra clinics for surviving patients up to three years later (median 30 months after operation).

Single-dose antibiotic prophylaxis of abdominal surgical wound infection: a trial of preoperative latamoxef against peroperative tetracycline lavage.

A randomized controlled clinical trial was undertaken in 542 consecutive emergency and elective abdominal operations, with one group of patients receiving tetracycline peritoneal and wound lavage and the other a single intravenous injection of 1 g latamoxef at induction of anaesthesia. Seventy-five patients were withdrawn because no potentially contaminated hollow viscus was opened, and a further 36 because they could not be assessed for wound infection. Of the remaining 431 patients, 212 received latamoxef resulting in 5 major and 8 minor wound infections in hospital; another 4 minor infections occurred at home (total incidence 8.

Suction drainage of the gallbladder bed does not prevent complications after cholecystectomy: a random control clinical trial.

Some surgeons drain the gallbladder bed routinely, some selectively and some not at all. We aimed to clarify this confusion by entering 155 consecutive patients undergoing emergency and elective cholecystectomy without exploration of the common bile duct into a random control clinical trial. In 78 patients a 3 mm suction drain was left in the gallbladder bed and in 77 the abdomen was closed without drainage.

Can nocturnal emergency surgery be reduced?

A prospective study of emergency operations was performed over three months in a district general hospital. Before starting surgery surgeons completed a questionnaire recording clinical details together with time of admission and were asked to state whether in their opinion the case could be safely deferred until the next morning assuming operating time was available. Of 251 operations performed, forms were completed for 244.

Functional recovery of the exocrine pancreas after acute pancreatitis.

A tubeless pancreatic function test (BTP test) using N-benzoyl-l-tyrosyl-p-aminobenzoic acid was used to assess exocrine function from urinary recovery of p-aminobenzoic acid produced by hydrolysis of the peptide by chymotrypsin. Patients with acute pancreatitis were studied at various time intervals after the acute attack and compared with controls with abdominal pain that was not pancreatic in origin. The initial BTP test carried out in the convalescent period was abnormal in all of 30 patients with acute pancreatitis but normal in 10 patients with non-pancreatic abdominal pain and also in 8 patients who had recovered from an attack of acute pancreatitis 2-6 years previously.

Parathyroid function during acute pancreatitis.

The renal handling of calcium and phosphate, which normally reflects parathyroid hormone (PTH) activity, was studied during the first 5 days after admission to hospital in 18 patients with acute pancreatitis. The ionized calcium level in plasma was calculated from the total calcium, albumin, total protein and pH. Hypocalcaemia (Ca less than 1.

The amylase-to-creatinine clearance ratio--a non-specific response to acute illness?

It was felt that the apparent specificity of the amylase-to-creatine clearance ratio (ACCR) in several previous studies of pancreatitis might reflect a failure to utilize adequately ill control subjects. The ACCR and the renal clearances of beta 2-microglobulin (B2-m), similarly related to creatinine (BCCR) as well as the urinary concentration of albumin, were compared in 27 patients with acute pancreatitis, 8 with a perforated peptic ulcer and 7 with mild biliary colic, during the first 5 days in hospital. Acute pancreatitis was graded as mild (6), moderate (14) or severe (7), using a combination of clinical data, diagnostic peritoneal lavage and multiple criteria.

Identification of risk factors for acute pancreatitis from routine radiological investigation of the biliary tract.

The size and shape of gallstones, the diameter of the common bile duct and the presence of reflux into the pancreatic duct were studied by examining routine contrast investigations of the biliary tract in 174 patients with gallstones. Patients were divided into two groups: 69 who had been admitted to hospital with an attack of acute pancreatitis (group 1) and 105 patients with gallstones who had not had a known attack of pancreatitis (group 2). Four or more gallstones were present in 38 (78 per cent) of 49 visualized gallbladders in group 1 compared with 45 (52 per cent) of 87 in group 2 (P less than 0.

The management of haemorrhagic complications of pseudocysts and abscesses of the pancreas.

We have reviewed the literature relating to experience of haemorrhage associated with pancreatic pseudocysts and abscesses in an attempt to evaluate different types of management. A further case, where extensive pancreatic resection successfully halted bleeding which followed drainage of a pancreatic abscess, is described to illustrate some of the principles of management.

Early prediction of severity of acute pancreatitis using peritoneal lavage.

Diagnostic peritoneal lavage was attempted in 96 out of a consecutive series of 168 attacks of acute pancreatitis, in order to evaluate its ability to predict severe disease. Lavage was successful in 89 instances, and resulted in relief of pain in many patients, and in one complication. Lavage indicated (by the presence of numerous organisms) that the diagnosis was incorrect in 1 patient with suspected acute pancreatitis; the correct diagnosis, biliary peritonitis, was revealed at post mortem examination.

A compaative study of methods for the prediction of severity of attacks of acute pancreatitis.

Diagnostic peritoneal lavage was carried out in 79 patients with acute pancreatitis, at a mean time of 7 h after admission to hospital. The presence of more than 10 ml of free peritoneal fluid, brown-coloured free fluid or mid-straw-coloured lavage fluid was the criterion used for the prediction of a severe attack by lavage. Prior to lavage the attack was assessed as mild or severe by the clinician and reassessed by him at 24 and 48 h.

The indications for simple closure of perforated duodenal ulcers.

One hundred and sixty-one patients undergoing simple suture of a perforated duodenal ulcer are reviewed retrospectively. Nine patients (6 per cent) suffered a complication of their ulcer during the postoperative period and 3 (2 per cent) of them died. The mean length of follow-up was 26 months and during this period a total of 14 complications was seen in 12 patients.