Cytomegalovirus colitis in AIDS: plain abdominal radiograph findings

The findings on the plain abdominal radiographs of 15 patients with cytomegalovirus (CMV) colitis and AIDS were reviewed and compared to an age, sex, CD4 count and symptom-matched control group. The radiographs were examined for mucosal thickening, bowel dilatation, pneumatosis and perforation. Nodular mucosal lesions were the most significant abnormality in those with CMV colitis being present in seven compared to none in the control group (P = 0.006 two tailed). Differences between the CMV colitis group and the control group as regards the other features were not significant. The finding of pneumatosis is the first time this has been described in patients with CMV colitis and AIDS. No evidence of perforation was demonstrated and this is attributed to a high index of suspicion in those with characteristic signs and symptoms in addition to early sigmoidoscopy and prompt treatment.

The efficacy of a single posteroanterior radiograph in the assessment of metastatic pulmonary melanoma

Posteroanterior (PA) and lateral chest radiographs are performed as part of the routine staging and follow-up investigation of patients with malignant melanoma. We have assessed the contribution of the lateral chest radiograph in the follow-up of 227 consecutive patients with proven malignant melanoma. In only once case was an abnormality evident on the lateral radiograph which was not previously detected on the PA films. Our department, as a result of this study, has discontinued the routine use of lateral chest radiography in the follow-up of patients with malignant melanoma.

Case report: pneumatosis intestinalis occurring in association with cryptosporidiosis and HIV infection

We report a case of pneumatosis intestinalis (PI) occurring in association with cryptosporidiosis in a patient documented as being HIV-seropositive. Chest and abdominal radiographs taken 2 months previously were normal and the patient did not have any evidence of gastrointestinal infection at that time. The case was complicated by cyst rupture resulting in a pneumoretroperitoneum and pneumomediastinum. The association of pneumatosis and cryptosporidiosis has not been previously reported.

Need to measure outcome after discharge in surgical audit

OBJECTIVE

To assess the accuracy of outcome data on appendicectomy routinely collected as part of a surgical audit and to investigate outcome in the non-audited period after discharge.

DESIGN

Retrospective analysis of audit data recorded by the Medical Data Index (MDI) computer system for all patients undergoing emergency appendicectomy in one year; subsequent analysis of their hospital notes and notes held by their general practitioners for patients identified by a questionnaire who had consulted their general practitioner for a wound complication.

SETTING

One district general hospital with four consultant general surgeons serving a population of 250,000.

PATIENTS

230 patients undergoing emergency appendicectomy during 1989.

MAIN MEASURES

Comparison of postoperative complications recorded in hospital notes with those recorded by the MDI system and with those recorded by patients' general practitioners after discharge.

RESULTS

Of the 230 patients, 29 (13%) had a postoperative complication recorded in their hospital notes, but only 14 (6%) patients had these recorded by the MDI system. 189 (82%) of the patients completed the outcome questionnaire after discharge. The number of wound infections as recorded by the MDI system, the hospital notes, and notes held by targeted patients' general practitioners were three (1%), eight (3%), and 18 (8%) respectively. None of 12 readmissions with complications identified by the hospital notes were identified by the MDI system.

CONCLUSIONS

Accurate audit of postoperative complications must be extended to the period after discharge. Computerised audit systems must be able to relate readmissions to specific previous admissions.

Percutaneous needle biopsy of lung nodules following failed bronchoscopic biopsy

Though transthoracic needle biopsy (TNAB) is a well established method for obtaining pathologic diagnosis in lung masses, very often the procedure is only performed after a previous negative bronchoscopic biopsy (BB) attempt. In this study we analyzed the results of TNAB in 129 consecutive patients where one or more inconclusive BB had been performed. TNAB was diagnostic in 115 of 129 lesions (89%) and the yield was not significantly affected by size, cell type or tumour location. In 97 patients who underwent thoracotomy, cytologic specimens obtained by TNAB accurately reflected histologic tumour type in all cases. A false negative rate for malignancy on TNAB was 5%. Awaiting inconclusive BB results caused an average delay of three in-hospital days before TNAB. In those patients in whom a biopsy is warranted, TNAB is most useful as an initial diagnostic procedure in masses that are peripheral and in pleural based tumours, in mediastinal adenopathy associated with a lung mass and instead of a repeat, previously failed bronchoscopy.

Radical external beam radiotherapy for localised carcinoma of the prostate using a hypofractionation technique

The survival of 232 patients with apparently localized carcinoma of the prostate is reported, who were treated between October 1964 and October 1984 by a radical course of external beam radiotherapy using a hypofractionation technique. Assessment was made in a retrospective analysis, noting influence of age, stage of disease at presentation, initial histology, dose of radiotherapy given and any subsequent treatment required, recorded up to October 1986. From this it will be seen that the development of a six fraction regime, given over a period of three weeks leads to comparable results to other reported series, whether assessed as a local response or by survival curves, and to the economical use of scarce resources, but even more important, is less wearing for patients than daily fractionation, with early and late morbidity being within acceptable limits.

The role of discography in lumbar disc disease: a comparative study of magnetic resonance imaging and discography

This study reviews prospectively a series of 29 patients who were examined by magnetic resonance imaging (MRI) and discography for degenerative disc disease. All had persistent low-back pain and non-diagnostic initial investigations, including plain films, myelography and/or computed tomography (CT). The imaging characteristics for degenerative disc disease correlated in 65 out of 73 intervertebral levels. All symptomatic discs were degenerate on both MRI and discography. Features of degenerative disc disease on MRI were assessed retrospectively, with a view to identifying the symptomatic level as defined by discography. MRI could not reliably detect this level, particularly in those with multi-level degenerative disc disease. Positive reproduction of symptoms at discography was the criteria used for surgery. All 12 patients in this group had posterior spinal fusion performed. Nine improved and three were unchanged. Of the ancillary features associated with disc degeneration, only a bulging annulus fibrosis proved to be of any value on MRI. Nonetheless, MRI should be used as the primary investigation in this patient group as it can lead to a marked reduction in the number of disc levels requiring injection.

Caseload or workload? Scoring complexity of operative procedures as a means of analysing workload

OBJECTIVE

To present a more realistic assessment of surgical workload than that provided by a case count.

DESIGN

Prospective study of all the operative procedures performed in one year, classified according to the British United Provident Association's schedule of procedures and scored by the "intermediate equivalent" value (taking the recommended fee value of an intermediate operation as 1.0) compared with the number of operations performed.

SETTING

General surgical unit of Taunton and Somerset Hospital, comparing four consultant surgeons and their teams.

PATIENTS

Inpatients and day patients admitted under the care of general surgeons during 1989.

MAIN OUTCOME MEASURE

Difference between the apparent workload represented by simple case counting (caseload) and the actual workload represented by calculation of the total "intermediate equivalent" value.

RESULTS

The workload assessed in terms of intermediate equivalent values was greater than that suggested by case counting for complex operations (12% v 4%), operations at the district hospital (82% v 74%), and operations performed by consultants (53% v 35%) and was lower for minor operations (20% v 42%), operations at the community hospitals (18% v 26%), and operations performed by surgeons in training grades and clinical assistants (47% v 66%).

CONCLUSIONS

The use of the intermediate equivalent values as an indicator of complexity allows a more realistic assessment of the operative workload than a simple case count of the number of different operations and is recommended for comparing workload in different hospitals and departments.

Carcinoma of prostate treated by radical external beam radiotherapy using hypofractionation. Twenty-two years' experience (1962-1984)

The survival of 209 patients with apparently localized carcinoma of the prostate treated by radical external beam radiotherapy is reported, noting the influence of age, stage of the disease at presentation, initial histology, previous surgery, and dose of radiotherapy given. From this it is seen that the development of a six-fraction regimen given over a period of three weeks leads to excellent results whether assessed as a local response or by survival curves and to the economical use of scarce resources, but, even more important, is less wearing for patients than conventional daily fractionation and with no major early or late morbidity recorded up to October 1986.

Model workload agreement for DGH general surgeon: discussion paper

A guideline programme for a Consultant General Surgeon includes three operating lists, and two outpatient sessions per week. A General Surgical Consultant working with a 'standard' surgical team should expect to see approximately 1,000 new patients per year, and undertake an elective operative workload of 15 'hernia equivalent' procedures per week. A model workload such as this might assist surgical service planners to estimate the need for surgical staff in their Districts.

Treatment of acromegaly by external irradiation

Despite the place of hypophysectomy as the primary treatment in acromegaly, external radiotherapy maintains a role as a relatively slow but effective therapy for inadequately treated patients or those unsuitable for operation. Over the last 25 years our radiotherapy regimen has differed from the published series in that we give a larger dose per fraction, with fewer treatments. We have analysed the efficacy and side-effects of this regimen in 27 subjects with acromegaly. Growth hormone levels have fallen by, on average, 27% per year in the first five years, 83% of subjects achieving a basal growth hormone of less than 10 mU/l. The acute and chronic side-effects of irradiation are discussed, including the relevance of estimates of biological potency, for example the Time Dose Fraction (TDF). One patient suffered visual loss that was most likely to be secondary to the radiotherapy. We also report the histological appearances of the pituitary fossa in five subjects previously treated with radiotherapy.

Assay of anti-cancer drugs in tissue culture: relationship of relapse free interval (RFI) and in vitro chemosensitivity in patients with malignant cerebral glioma

One hundred and seventeen patients with cerebral glioma (Kernohan grades III and IV) were treated with adjuvant chemotherapy using procarbazine (PCB), CCNU and vincristine (VCR) following whole head irradiation. Cell cultures were prepared from 40 patients in this series and their sensitivity to each cytotoxic drug was assessed in a mictotitration assay with 35 S-methionine incorporation as the end point. Twenty-two of forty (55%) patients responded to PCB and/or CCNU in vitro, and sensitivity to these drugs was linked with increased RFI, whilst sensitivity to VCR was not. The RFI of patients who had responded to PCB or CCNU in vitro was significantly longer than the RFI of patients whose tumours failed to respond in vitro or patients who had not been tested. There was no difference in sex ratio, extent of operation, radiation dose and degree of steroid cover between responders, non-responders and untested groups. Grade III tumours tended to be more sensitive in vitro than grade IV tumours. The age of patients also influenced in vitro chemosensitivity. Patients with chemosensitive tumours in vitro tended to be younger than patients with insensitive tumours in vitro. Further statistical analysis, taking into account these prognostic factors, indicated an association between chemosensitivity in vitro and RFI.

Attitudes to follow-up after uncomplicated surgery--hospital out-patients or general practitioner?

The attitude of 216 patients, 10 hospital doctors and 80 general practitioners (GPs) to hospital follow-up after uncomplicated surgery for non-malignant disease was assessed. Hospital doctors felt that most patients (86%) could have been satisfactorily followed-up by their GP and in most cases (89%), the GP was willing to provide the service. However, 183 patients (85%) found their visit to hospital out-patients worthwhile and only 41 patients (19%) would have preferred to have visited their GP instead. In fact, 157 patients (73%) had already seen their GP before their return to surgical out-patients. In most cases, hospital follow-up appears to be unnecessary. In this series, if suitable post-operative patients were followed-up by their GP, there would be a reduction of 20% in the number of old patients returning to out-patients.

Abdominal drainage following cholecystectomy: high, low, or no suction?

A prospective trial to assess the effect of suction in an abdominal drain following cholecystectomy was carried out. Three types of closed drainage system were compared: a simple tube drain, a low negative pressure drain, and a high negative pressure drain: 120 consecutive patients undergoing cholecystectomy were randomly allocated to one of the three drainage groups. There was no significant difference in postoperative pyrexia, wound infection, chest infection, or hospital stay. This study failed to demonstrate any clinically useful difference between high negative pressure, low negative pressure, and static drainage system were compared: a simple tube drain, a low negative used, suction is not necessary and a simple tube drain (greater than 6 mm internal diameter) is the most effective form of drainage.

Comparison of moxalactam with the combination of clindamycin and an aminoglycoside in the treatment of common surgical infections

The efficacy and safety of moxalactam were compared with those of a combination of clindamycin and an aminoglycoside in a randomized study of therapy for 60 patients with the following surgical infections: intraabdominal or pelvic infections (12 patients), abscesses (13 patients), and severe infections of extremities (35 patients). These infections were equally distributed between the two treatment groups, except that, according to the randomization process, a majority of patients with intraabdominal infections received moxalactam therapy. Surgery was used as adjunctive therapy when necessary. One adverse reaction--fever and leukocytosis with eosinophilia--was due to continued administration of moxalactam. No significant adverse reaction was observed in the patients treated with the clindamycin-aminoglycoside combination. Although the number of isolated organisms resistant to the antibiotics was similar within each treatment regimen, an alarmingly high percentage of gram-positive cocci were intermediately sensitive to moxalactam in vitro. Even in the presence of resistant organisms, moxalactam therapy was as effective as the clindamycin-aminoglycoside therapy when surgical debridement or drainage was properly timed and executed.

In vitro activity of N-formimidoyl thienamycin, moxalactam, and other new beta-lactam agents against Bacteroides fragilis: contribution of beta-lactamase to resistance

N-Formimidoyl thienamycin (N-F-thienamycin) and moxalactam were compared with other currently available and investigational antibiotics against 100 clinical isolates of Bacteroides fragilis by an agar dilution method. N-F-thienamycin was the most active among the beta-lactam agents tested, with a minimal inhibitory concentration for 90% of isolates (MIC90) of 0.25 micrograms/ml. Moxalactam was next in activity, with an MIC90 of 4 micrograms/ml. N-F-thienamycin was somewhat more active, and moxalactam was slightly less active, than metronidazole and clindamycin. An increase in inoculum size caused an increase in the MIC of N-F-thienamycin, cefoperazone, and cefotaxime. This inoculum effect could influence the usefulness of these drugs in certain clinical conditions. The minimal bactericidal concentration was less than two times the MIC for most agents and less than four times the MIC for all beta-lactam agents at each inoculum size tested. Investigation of the mechanism of resistance to beta-lactam agents demonstrated a correlation between the level of resistance and beta-lactamase activity in each strain tested. N-F-thienamycin and cefoxitin were not hydrolyzed, and moxalactam was less susceptible to hydrolysis than the other beta-lactam antibiotics. Moxalactam and N-F-thienamycin may prove to be useful against infections with B. fragilis.

The urodynamic assessment of adult enuresis

Urodynamic analysis has revealed a high proportion of uninhibited bladder activity in adult enuresis. There was no associated neurological deficit to explain this abnormality. There was no correlation between the various diurnal symptoms and the presence of uninhibited bladder contractions. Enuresis was associated with obstructive uropathy in only 6 percent of cases. Some evidence has also been presented to support the concepts of ectopic sensory receptors and abnormal sphincter inhibition. A review of the problem of pathogenesis has suggested four main areas of possible abnormality: 1. A sensory lesion producing inadequate or delayed appreciation of bladder activity. 2. Cortical and subcortical dysfunction because of inadequate arousal or defective maturation of subconscious inhibition. 3. A congenital or acquired upper motor neurone lesion causing an uninhibited bladder. 4. A similar or related lesion causing an over-inhibited sphincter. These factors probably always occur in varying combinations. Because of the lack of association between symptoms, signs and objective measurements, there is a strong case for relating diagnosis, prognosis and treatment to urodynamic assessment.

Perforation of a peptic ulcer in duplicated ileum

A case of perforation of a peptic ulcer in a tubular duplication of the ileum is presented with a brief review of the relevant literature.

Intramural cysts of the ileum

A case of intramural cysts of the ileum is described for the first time. The clinical presentation and pathological findings are presented and the possible aetiology is discussed.

Closure of colostomy

In this review of 179 patients in whom colostomy closure was performed the mortality from the operation was 2·2 per cent and the morbidity from faecal fistula was 23 per cent. This operation, there fore, should not be regarded as a minor procedure.

Complications in patients with diverticular disease following colostomy closure are lowest when the operation is carried out 3 months or more after resection. After resection of a carcinoma, complications are lowest if the colostomy closure is carried out after 2 months.

New method of measuring forces in the anal canal

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Force in the anal canal and anal continence

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