epic3: national evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England

National evidence-based guidelines for preventing healthcare-associated infections (HCAI) in National Health Service (NHS) hospitals in England were originally commissioned by the Department of Health and developed during 1998-2000 by a nurse-led multi-professional team of researchers and specialist clinicians. Following extensive consultation, they were first published in January 2001(1) and updated in 2007.(2) A cardinal feature of evidence-based guidelines is that they are subject to timely review in order that new research evidence and technological advances can be identified, appraised and, if shown to be effective for the prevention of HCAI, incorporated into amended guidelines. Periodically updating the evidence base and guideline recommendations is essential in order to maintain their validity and authority. The Department of Health commissioned a review of new evidence and we have updated the evidence base for making infection prevention and control recommendations. A critical assessment of the updated evidence indicated that the epic2 guidelines published in 2007 remain robust, relevant and appropriate, but some guideline recommendations required adjustments to enhance clarity and a number of new recommendations were required. These have been clearly identified in the text. In addition, the synopses of evidence underpinning the guideline recommendations have been updated. These guidelines (epic3) provide comprehensive recommendations for preventing HCAI in hospital and other acute care settings based on the best currently available evidence. National evidence-based guidelines are broad principles of best practice that need to be integrated into local practice guidelines and audited to reduce variation in practice and maintain patient safety. Clinically effective infection prevention and control practice is an essential feature of patient protection. By incorporating these guidelines into routine daily clinical practice, patient safety can be enhanced and the risk of patients acquiring an infection during episodes of health care in NHS hospitals in England can be minimised.

A physical map of 30,000 human genes

A map of 30,181 human gene-based markers was assembled and integrated with the current genetic map by radiation hybrid mapping. The new gene map contains nearly twice as many genes as the previous release, includes most genes that encode proteins of known function, and is twofold to threefold more accurate than the previous version. A redesigned, more informative and functional World Wide Web site (www.ncbi.nlm.nih.gov/genemap) provides the mapping information and associated data and annotations. This resource constitutes an important infrastructure and tool for the study of complex genetic traits, the positional cloning of disease genes, the cross-referencing of mammalian genomes, and validated human transcribed sequences for large-scale studies of gene expression.

Identification of a major susceptibility locus on chromosome 6p and evidence for further disease loci revealed by a two stage genome-wide search in psoriasis

Psoriasis is a common chronic inflammatory disorder of the skin. To further understand the pathogenesis of psoriasis we have chosen to investigate the molecular genetic basis of the disorder. We have used a two-stage approach to search the human genome for the location of genes conferring susceptibility to psoriasis, using a total of 106 affected sibling pairs identified from 68 independent families. As over a third of the extended kindreds included affected relatives besides siblings, in addition to an analysis of allele sharing between affected sibling pairs, a novel linkage strategy was applied that extracts full non-parametric information. Four principal regions of possible linkage were identified on chromosomes 2, 8, 20 (p <0.005) and markers from the MHC region at 6p21 (p <0.0000006) for which significant evidence of linkage disequilibrium was also observed (p <0.00002). Whilst data from limited case control associations exist to implicate the MHC, the results of this genome wide analysis demonstrate that, at least in the population studied, a gene or genes located within the MHC and close to the class 1 HLA loci, represent the major determinant of the genetic basis of psoriasis.

Pharmacokinetics of novel erythropoiesis stimulating protein compared with epoetin alfa in dialysis patients

Novel erythropoiesis stimulating protein (NESP) is a hyperglycosylated analogue of recombinant human erythropoietin (Epoetin) which has an increased terminal half-life in animal models. The aim of this study was to extend these observations to humans. Using a double-blind, randomized, cross-over design, the single-dose pharmacokinetics of Epoetin alfa (100 U/kg) and an equivalent peptide mass of NESP were compared following intravenous bolus in 11 stable peritoneal dialysis patients. This was followed by an open-label study to determine the single-dose pharmacokinetics of an equivalent peptide mass of NESP by subcutaneous injection in six of these patients. The mean terminal half-life for intravenous NESP was threefold longer than for intravenous Epoetin (25.3 versus 8.5 h), a difference of 16.8 h (95% confidence interval, 9.4 to 24.2 h, P = 0.0008). The area under the serum concentration-time curve was significantly greater for NESP (291.0 +/- 7.6 ng x h per ml versus 131.9 +/- 8.3 ng x h per ml; mean +/- SEM; P < 0.0005), and clearance was significantly lower (1.6 +/- 0.3 ml/h per kg versus 4.0 +/- 0.3 ml/h per kg; mean +/- SEM; P < 0.0005). The volume of distribution was similar for NESP and Epoetin (52.4 +/- 2.0 ml/kg versus 48.7 +/-2.1 ml/kg; mean +/-SEM). The mean terminal half-life for subcutaneous NESP was 48.8 h. The peak concentration of subcutaneous NESP was approximately 10% of that following intravenous administration, and bioavailability was approximately 37% by the subcutaneous route. The longer half-life of NESP is likely to confer a clinical advantage over Epoetin by allowing less frequent dosing in patients treated for anemia.

A radiation hybrid map of the rat genome containing 5,255 markers

A whole-genome radiation hybrid (RH) panel was used to construct a high-resolution map of the rat genome based on microsatellite and gene markers. These include 3,019 new microsatellite markers described here for the first time and 1,714 microsatellite markers with known genetic locations, allowing comparison and integration of maps from different sources. A robust RH framework map containing 1,030 positions ordered with odds of at least 1,000:1 has been defined as a tool for mapping these markers, and for future RH mapping in the rat. More than 500 genes which have been mapped in mouse and/or human were localized with respect to the rat RH framework, allowing the construction of detailed rat-mouse and rat-human comparative maps and illustrating the power of the RH approach for comparative mapping.

A row-action alternative to the EM algorithm for maximizing likelihood in emission tomography

The maximum likelihood (ML) approach to estimating the radioactive distribution in the body cross section has become very popular among researchers in emission computed tomography (ECT) since it has been shown to provide very good images compared to those produced with the conventional filtered backprojection (FBP) algorithm. The expectation maximization (EM) algorithm is an often-used iterative approach for maximizing the Poisson likelihood in ECT because of its attractive theoretical and practical properties. Its major disadvantage is that, due to its slow rate of convergence, a large amount of computation is often required to achieve an acceptable image. Here, the authors present a row-action maximum likelihood algorithm (RAMLA) as an alternative to the EM algorithm for maximizing the Poisson likelihood in ECT. The authors deduce the convergence properties of this algorithm and demonstrate by way of computer simulations that the early iterates of RAMLA increase the Poisson likelihood in ECT at an order of magnitude faster that the standard EM algorithm. Specifically, the authors show that, from the point of view of measuring total radionuclide uptake in simulated brain phantoms, iterations 1, 2, 3, and 4 of RAMLA perform at least as well as iterations 45, 60, 70, and 80, respectively, of EM. Moreover, the authors show that iterations 1, 2, 3, and 4 of RAMLA achieve comparable likelihood values as iterations 45, 60, 70, and 80, respectively, of EM. The authors also present a modified version of a recent fast ordered subsets EM (OS-EM) algorithm and show that RAMLA is a special case of this modified OS-EM. Furthermore, the authors show that their modification converges to a ML solution whereas the standard OS-EM does not.

Association between healthcare water systems and Pseudomonas aeruginosa infections: a rapid systematic review

BACKGROUND

Pseudomonas aeruginosa is an opportunistic pathogen with a particular propensity to cause disease in the immunocompromised. Water systems have been reported to contribute to P. aeruginosa transmission in healthcare settings.

AIM

To systematically assess the evidence that healthcare water systems are associated with P. aeruginosa infection; to review aspects of design that can increase their potential to act as a reservoir; and to compare the efficacy of strategies for eradicating contamination and preventing infection.

METHODS

A rapid review methodology with a three-step search strategy was used to identify published studies. Scientific advisors were used to identify unpublished studies.

FINDINGS

Twenty-five relevant studies were included. There was plausible evidence of transmission of P. aeruginosa from water systems to patients and vice versa, although no direct evidence to explain the exact mode of transfer. Two studies provided plausible evidence for effective interventions: point-of-use filters and increasing chlorine disinfection. Non-touch taps and aspects of water system design were identified as probable risk factors for P. aeruginosa biofilm formation and subsequent transmission to patients. Poor hand hygiene or compliance with contact precautions were identified as potential contributory factors; plausible evidence to confirm this was not available.

CONCLUSIONS

Water systems can act as a source of P. aeruginosa infection in healthcare settings, although the route of transmission is unclear. Contamination appears to be confined to the distal ends of a water system and can persist for prolonged periods. Further studies are required to establish effective methods of preventing transmission and eradicating P. aeruginosa from plumbing systems.

Insertion of a new gene of viral origin into bone marrow cells of mice

DNA containing the herpes simplex virus thymidine kinase (HSVtk) gene was used to transform wild-type tk+ mouse L cells to a tk++ status in vitro using methotrexate as a selective agent. HSVtk DNA was also used to transform mouse bone marrow cells in vitro. Transformed marrow cells injected into irradiated and methotrexate-treated recipient mice gave rise to proliferating cells which in some cases dominated the marrow population and which contained HSVtk gene sequences.

A meta-analysis of variables that predict significant intracranial injury in minor head trauma

BACKGROUND

Previous studies have presented conflicting results regarding the predictive effect of various clinical symptoms, signs, and plain imaging for intracranial pathology in children with minor head injury.

AIMS

To perform a meta-analysis of the literature in order to assess the significance of these factors and intracranial haemorrhage (ICH) in the paediatric population.

METHODS

The literature was searched using Medline, Embase, Experts, and the grey literature. Reference lists of major guidelines were crosschecked. Control or nested case-control studies of children with head injury who had skull radiography, recording of common symptoms and signs, and head computed tomography (CT) were selected.

OUTCOME VARIABLE

CT presence or absence of ICH.

RESULTS

Sixteen papers were identified as satisfying criteria for inclusion in the meta-analysis, although not every paper contained data on every correlate. Available evidence gave pooled patient numbers from 1136 to 22 420. Skull fracture gave a relative risk ratio of 6.13 (95% CI 3.35 to 11.2), headache 1.02 (95% CI 0.62 to 1.69), vomiting 0.88 (95% CI 0.67 to 1.15), focal neurology 9.43 (2.89 to 30.8), seizures 2.82 (95% CI 0.89 to 9.00), LOC 2.23 (95% CI 1.20 to 4.16), and Glasgow Coma Scale (GCS) <15 of 5.51 (95% CI 1.59 to 19.0).

CONCLUSIONS

There was a statistically significant correlation between intracranial haemorrhage and skull fracture, focal neurology, loss of consciousness, and GCS abnormality. Headache and vomiting were not found to be predictive and there was great variability in the predictive ability of seizures. More information is required about the current predictor variables so that more refined guidelines can be developed. Further research is currently underway by three large study groups.

Waste management models and their application to sustainable waste management

The purpose of this paper is to review the types of models that are currently being used in the area of municipal waste management and to highlight some major shortcomings of these models. Most of the municipal waste models identified in the literature are decision support models and for the purposes of this research, are divided into three categories-those based on cost benefit analysis, those based on life cycle assessment and those based on multicriteria decision making. Shortcomings of current waste management models include that they are concerned with refinements of the evaluation steps (e.g. stage four of AHP or the improvement of weight allocations in ELECTRE) rather than addressing the decision making process itself. In addition, while many models recognise that for a waste management model to be sustainable, it must consider environmental, economic and social aspects, no model examined considered all three aspects together in the application of the model.

Divergent mechanisms of cis 9, trans 11 ‐ and trans 10 , cis 12 ‐ conjugated linoleic acid affecting insulin resistance and inflammation in apolipoprotein E knockout mice: a proteomics approach

Conjugated linoleic acids (CLA) affect atherogenesis, but mechanisms are not well understood. We explored how two isomers of CLA, cis9, trans11-CLA and trans10, cis12-CLA, affected lipid and glucose metabolism, as well as hepatic protein expression, in apolipoprotein E knockout mice. After 12 wk of intervention, plasma triglyceride, NEFA, and glucose concentrations were significantly higher in the trans10, cis12-CLA group, whereas plasma triglyceride, NEFA, glucose, and insulin concentrations were significantly lower in the cis9, trans11-CLA group, compared with control mice consuming linoleic acid. Proteomics identified significant up- or down-regulation of 113 liver cytosolic proteins by either CLA isomer. Principal component analysis revealed that the treatment effect of cis9, trans11-CLA was mainly explained by the up-regulation of different posttranslational forms of heat shock protein 70 kD. In contrast, the treatment effect of trans10, cis12-CLA was mainly explained by up-regulation of key enzymes in the gluconeogenic, beta-oxidation, and ketogenesic pathways. Correlation analysis again emphasized the divergent effects of both CLA isomers on different pathways, but also revealed a linkage between insulin resistance and increased levels of hepatic serotransferrin. Thus, our systems biology approach provided novel insights into the mechanisms by which individual CLA isomers differentially affect pathways related to atherogenesis, such as insulin resistance and inflammation.

Facet joint injection: a rare form cause of epidural abscess formation

The posterior zygo-apophyseal joints (facet joints) may be a significant source of back pain. Invasive treatment typically consists of injecting the joints with local anaesthetic and steroid or by radiofrequency ablation of the nerve supply to the joint. Facet joint injection is generally considered to be a very safe procedure with few significant side effects reported. Epidural abscess is a rare but potentially very serious occurrence. Most cases occur spontaneously but the condition may complicate epidural anaesthesia, spinal anaesthesia or epidural steroid injection. We report a case in which facet joint injections resulted in epidural abscess formation. To our knowledge this has not previously been reported.

Factors associated with the health status of internally displaced persons in northern Uganda

BACKGROUND

Globally, there are over 24 million internally displaced persons (IDPs) who have fled their homes due to violence and insecurity but who remain within their own country. There have been up to 2 million IDPs in northern Uganda alone. The objective of this study was to investigate factors associated with mental and physical health status of IDPs in northern Uganda.

METHODS

A cross-sectional survey was conducted in November 2006 in IDP camps in the Gulu and Amuru districts of northern Uganda. The study outcome of physical and mental health was measured using the SF-8 instrument, which produces physical (PCS) and mental (MCS) component summary measures. Independent demographic, socio-economic, and trauma exposure (using the Harvard Trauma Questionnaire) variables were also measured. Multivariate regression linear regression analysis was conducted to investigate associations of the independent variables on the PCS and MCS outcomes.

RESULTS

1206 interviews were completed. The respective mean PCS and MCS scores were 42.2 (95% CI 41.32 to 43.10) and 39.3 (95% CI 38.42 to 40.13), well below the instrument norm of 50, indicating poor health. Variables with negative associations with physical or mental health included gender, age, marital status, income, distance of camp from home areas, food security, soap availability, and sense of safety in the camp. A number of individual trauma variables and the frequency of trauma exposure also had negative associations with physical and mental health.

CONCLUSIONS

This study provides evidence on the impact on health of deprivation of basic goods and services, traumatic events, and fear and uncertainty amongst displaced and crisis affected populations.

Topical amethocaine (Ametop) is superior to EMLA for intravenous cannulation. Eutectic mixture of local anesthetics

PURPOSE

A eutectic mixture of local anesthetics (EMLA) is commonly used to provide topical anesthesia for intravenous (i.v.) cannulation. One of its side effects is vasoconstriction, which may render cannulation more difficult. A gel formulation of amethocaine (Ametop) is now commercially available. The aim of this study was to compare EMLA and Ametop with regard to the degree of topical anesthesia afforded, the incidence of vasoconstriction and the ease of i.v. cannulation.

METHODS

Thirty two ASA I adult volunteers had a #16 gauge i.v. cannula inserted on two separate occasions using EMLA and Ametop applied in a double blind fashion for topical anesthesia. Parameters that were recorded after each cannulation included visual analogue pain scores (VAPS), the presence of vasoconstriction and the ease of cannulation, graded as: 1 = easy, 2 = moderately difficult, 3 = difficult and 4 = failed.

RESULTS

The mean VAPS +/- SD after cannulation with Ametop M was 12+/-9.9 and with EMLA was 25.3+/-16.6 (P = 0.002). Vasoconstriction occurred after EMLA application on 17 occasions and twice after Ametop (P = 0.001). The grade of difficulty of cannulation was 1.44+/-0.88 following EMLA and 1.06+/-0.25 with Ametop (P = 0.023).

CONCLUSIONS

Intravenous cannulation was less painful following application of Ametop than EMLA. In addition, Ametop caused less vasoconstriction and facilitated easier cannulation. Its use as a topical anesthetic agent is recommended, especially when i.v. access may be problematic.

Characterization of the murine A1 adenosine receptor promoter, potent regulation by GATA-4 and Nkx2.5

Adenosine acts via A1 adenosine receptors (A1ARs) in the heart and brain to potently influence mammalian physiology. A1ARs are expressed very early in embryonic development, and A1ARs are among the earliest expressed G protein coupled receptors in the heart and brain. To understand the biologic basis of A1AR expression, a genomic fragment containing the murine A1AR promoter was cloned. Reporter assay studies using DDT1 MF2 cells that express A1ARs revealed that 500 base pairs of the proximal A1AR promoter contained essential elements for A1AR gene expression. Transgenic mice with A1AR proximal promoter coupled with the beta-galactosidase reporter gene had heavy labeling of the brain and atria, consistent with normal patterns of A1AR expression. Within the proximal A1AR promoter, putative binding sites for cardiac transcription factors GATA and Nkx2.5 were identified. Co-expression studies revealed that GATA-4 and Nkx2.5 could individually drive A1AR promoter activity and act synergistically to activate A1AR expression. These observations suggest that embryonic A1AR expression involves activation of the A1AR promoter by GATA-4 and Nkx2.5.

The experience and training of British general surgeons in trauma surgery for the abdomen, thorax and major vessels

BACKGROUND

The report Better Carefor the Severely Injured [London: The Royal College of Surgeons of England and the British Orthopaedic Association; 2000] states that an experienced general surgeon trained in the techniques required to perform life-saving emergency surgery is vital in the management of major trauma. The experience and training of general surgeons in the UK in the management of trauma to the abdomen, thorax and major vessels has never been assessed.

METHOD

Postal questionnaire sent to UK general surgical consultants and Higher Surgical Trainees (HSTs).

RESULTS

A total of 854 (48%) questionnaires were completed. Of respondents, 85% believe that major trauma should be directed to hospitals that provide a dedicated trauma service. Of non-vascular specialists, 43% felt their training was adequate to manage vascular trauma and only one-third of general surgical consultants felt adequately prepared to manage acute cardiothoracic injuries. The median number of trauma laparotomies undertaken annually was 2 for blunt injury and 1 for penetrating injury. Of HSTs, 21% had not performed a splenectomy for trauma and 44% had no experience of packing for liver injuries.

CONCLUSIONS

There is limited experience and training in the surgical management of torso trauma in the UK. Implementation of the recommendations from Better Care for the Severely Injured will be hampered unless steps are taken to maximise experience and improve training.

A guide to policy analysis as a research method

Policy analysis provides a way for understanding how and why governments enact certain policies, and their effects. Public health policy research is limited and lacks theoretical underpinnings. This article aims to describe and critique different approaches to policy analysis thus providing direction for undertaking policy analysis in the field of health promotion. Through the use of an illustrative example in nutrition it aims to illustrate the different approaches. Three broad orientations to policy analysis are outlined: (i) Traditional approaches aim to identify the 'best' solution, through undertaking objective analyses of possible solutions. (ii) Mainstream approaches focus on the interaction of policy actors in policymaking. (iii) Interpretive approaches examine the framing and representation of problems and how policies reflect the social construction of 'problems'. Policy analysis may assist understanding of how and why policies to improve nutrition are enacted (or rejected) and may inform practitioners in their advocacy. As such, policy analysis provides researchers with a powerful tool to understand the use of research evidence in policymaking and generate a heightened understanding of the values, interests and political contexts underpinning policy decisions. Such methods may enable more effective advocacy for policies that can lead to improvements in health.

Neuroendocrine effects of intravenous clomipramine in depressed patients and healthy subjects

OBJECTIVE

Neuroendocrine challenge paradigms have been used to asses serotonergic systems in depression, but limitations in the specificity of many of these tests have been noted. In this study, the neuroendocrine responses to acute intravenous administration of the serotonin (5-HT) reuptake inhibitor clomipramine were assessed in depressed patients and matched control subjects.

METHODS

Thirty hospitalized patients who met DSM-III-R criteria for major depression, and 30 healthy control subjects who were matched for age, sex, and season of year for the time of study, received 12.5 mg of intravenously administered clomipramine.

RESULTS

The depressed patients demonstrated significant blunting of prolactin responses to clomipramine, as well as trends toward blunted ACTH and cortisol responses. There was no difference between the patient and control groups in growth hormone responses, plasma clomipramine levels, or self-reports of side effects.

CONCLUSIONS

These data support the hypothesis that depressed patients have abnormal neuroendocrine responses to the intravenous administration of the 5-HT reuptake inhibitor clomipramine. Further study is required to delineate the mechanisms responsible for the abnormal response to intravenously administered clomipramine in depression.

A profile of the clients of male sex workers in three Australian cities

OBJECTIVE

This paper describes the profile of clients as reported by 186 male sex workers in three Australian cities.

METHOD

The data were collected using a diary which was completed after each commercial sexual encounter with a male client over a two-week period. The data reported in this study are based on reports from 2,088 sex encounters and a profile of 1,776 clients.

RESULTS

The findings reveal, for example, that the most common source used for recruiting clients was advertisements, followed by escort agencies, although there were differences between the three cities; the majority of the clients were in their 40s but clients of street workers were younger; clients were most often classified as 'middle class', with differences by source of client recruitment; less than half the clients were identified as being gay and a significant number were identified as bisexual or straight; alcohol and drug use took place in a small percentage of the encounters; most workers had some information about their clients, such as occupation and home number; violence was infrequent; and unsafe sex was requested in a minority of the encounters.

CONCLUSION

Overall, the results reveal that clients of male sex workers are a highly heterogeneous group.

IMPLICATIONS

The paper highlights a number of issues which can further promote safety and public accountability in male sex work.

Use of participatory research and photo-voice to support urban Aboriginal healthy eating

The aim of this research was to work collaboratively with an urban Aboriginal community to understand meanings of food and food insecurity and strengthen responses to this issue. The project took place at the Wathaurong Aboriginal Cooperative in Geelong, South Eastern Australia in 2009-2010. Photo-voice research methods were used to explore meanings of food and food insecurity. This identified that food selections were influenced by family harmony, collectivism and satiation of hunger with cheap high carbohydrate and fat foods. People were also proud of their hunter-gatherer heritage and saw the Wathaurong Aboriginal Cooperative as leaders in healthy food provision. Action research cycles were used to develop responses including plates depicting healthy food portions, social cooking opportunities, development of a cooking television series and a specialised cook-book. The partnership required researchers to listen carefully to respond to needs of the Wathaurong Aboriginal Cooperative, and this meant adapting research plans to suit the local environment and community partner needs. There is potential for Aboriginal organisations to provide further leadership for healthy eating and food security through workplace food policies and partnerships with food security agencies. Use of Aboriginal nutrition knowledge to provide nutrition education may be useful in health promotion approaches.

Location of the first genetic locus, PKDr1, controlling autosomal dominant polycystic kidney disease in Han:SPRD cy/+ rat

The Han:SPRD cy/+ strain develops a form of slowly progressive disease that appears similar in many respects to that seen in the autosomal dominant polycystic kidney disease (ADPKD) in humans. We have performed a total genome scan in an experimental backcross population derived from affected Han:SPRD cy/+ rat (PKD) and non-affected Wistar Ottawa Karlsburg rat (WOK) using 117 microsatellite markers. The genetic dissection of PKD allowed us to map on rat chromosome 5, a quantitative trait locus (QTL) controlling PKD, kidney mass and plasma urea concentration. The homology region is likely to reside on human chromosome 8. The gene responsible for PKD in Han:SPRD cy/+ rat is neither PKD1, localised on human chromosome 16, nor PKD2, localised on human chromosome 4. Therefore, we propose that this new locus be denoted PKDr1. The detection of the PKDr1 locus and associated QTL should accelerate research into the genetic causes of ADPKD.

Pneumomediastinum, pneumothorax and subcutaneous emphysema complicating MIS herniorrhaphy

PURPOSE

Videoscopic herniorrhaphy is being performed more frequently with advantages claimed over the conventional open approach. This clinical report describes a pneumothorax, pneumomediastinum and subcutaneous emphysema occurring at the end of an extraperitoneal videoscopic herniorrhaphy.

CLINICAL FEATURES

A 25 yr old ASA I man presented for elective extraperitoneal videoscopic hernia repair. Following intravenous induction with fentanyl, midazolam and propofol a balanced anesthetic technique using enflurane in N2O and O2 was used. Apart from a prolonged operating time (195 min), the procedure and anesthetic was uneventful. At the conclusion of the operation, prior to reversal of neuromuscular blockade extensive subcutaneous emphysema was noted on removal of the surgical drapes. Chest radiography revealed a pneumomediastinum and pneumothorax. A 25 FG intercostal tube was inserted and connected to an underwater seal drain. Sedation and positive pressure ventilation was maintained overnight to permit resolution and avoid airway compromise. The clinical and radiological features had resolved by the next morning and the patient's trachea was extubated. His subsequent recovery was uneventful.

CONCLUSION

Pneumothorax and pneumomediastinum are well recognised complications of laparoscopic techniques but have not been described following extraperitoneal herniorrhaphy. In this report we postulate possible mechanisms which may have contributed to their development, including inadvertent breach of the peritoneum and leakage of gas around the diaphragmatic herniae or tracking of gas retroperitoneally. The case alerts us to the possibility of this complication occurring in patients undergoing videoscopic herniorrhaphy.