Diagnostic laparoscopy for suspected appendicitis: only useful in young women.

The clinical diagnosis of acute appendicitis is inaccurate and can be associated with a negative appendicectomy rate in excess of 40%. The latter has an attendant, albeit low, potential for increased morbidity and mortality, particularly related to infection. In this two year prospective audit of 282 patients presenting with the symptoms and signs of acute appendicitis, preliminary diagnostic laparoscopy (PDL) was performed on 145 patients with the remainder (137) proceeding directly to open appendicectomy. In the PDL group, appendicectomy was undertaken when there was clear clinical evidence of inflammation or when the appendix was not visualised. The negative appendicectomy rate was similar in both groups (21.6% vs. 21.2%) with a male predominance in the PDL group. Whereas women of childbearing age obtained most benefit from PDL with avoidance of unnecessary open operation, the results of our audit showed little benefit for men.

Effects of volume control, pressure control, and pressure-regulated volume control on cardiopulmonary parameters in a normal rat lung.

The purpose of this study was to investigate the differences in diaphragm shortening and cardiopulmonary parameters at varying tidal volumes during volume control (VC), pressure control (PC), and pressure-regulated volume control (PRVC). A miniaturized ultrasonic sensor attached to the inferior surface of the upper costal surface of the right hemidiaphragm of 16 Sprague-Dawley rats provided a direct assessment of diaphragm shortening. Within each control mode of mechanical ventilation, the tidal volume was increased from 3 to 12 ml in increments of 3 ml. There were no differences in cardiac output, mean arterial pressure, central venous pressure, peak inspiratory pressure, or end-tidal CO2 among the three modes of mechanical ventilation. At equivalent tidal volumes, diaphragm shortening was less during PRVC than during VC or PC. This finding suggests that differences in diaphragm shortening may be caused by shorter resting (end-expiratory) diaphragm muscle length. The cardiopulmonary data obtained in this study provide new information for clinicians to consider when using various modes of ventilation, particularly PRVC.

The day treatment program: meeting rehabilitation needs for SCI in the changing climate of health care reform.

Life expectancy for persons with spinal cord injury (SCI) is somewhat below normal but continues to increase (Devivo & Stover, 1994). Therefore, rehabilitation nurses must develop a way to provide interventions over an entire lifespan for the person with SCI. One setting in which to implement care is the day treatment program, and rehabilitation nurses can be a part of this new care delivery model (Stevens, 1994). Because of increasing regulations with reimbursement and the need for early discharge planning, the Rehabilitation Nursing Department at Spain Rehabilitation Center developed a day treatment program. Patients now have the opportunity to continue their rehabilitation program and become more functional if maximum potential is not reached during their inpatient rehabilitation stay. A nurse serves as the case manager to plan, coordinate, and monitor patient programs and patient care. The expectation of this author is that nurses may facilitate comparable programs in the agencies where they practice.

Serosal imprint cytology in colonic cancer: a simple staging technique.

Accurate staging of colonic cancer is essential in defining the rational use of adjuvant treatments. Recent studies have shown that prognostic accuracy can be significantly improved by recognition of primary tumour extension to the free serosal surface. This study compares the technical results of serosal imprint cytology with the results of histology in assessing serosal involvement. When analysed in terms of the modified Dukes' staging the results of cytology imprints taken from the peritoneum overlying the colonic primary were positive for tumour cells in 4/13 Dukes' B, 7/14 Dukes' C, and 5/9 metastatic cancers. Imprint cytology was positive in 6/7 Dukes' B and C cases with histological serosal invasion and was suspicious in the remaining case. However, a further 5/20 cases without identified invasion on routine histology also had positive cytology. Imprint cytology is an adjunct to routine histology which is easily performed and allows more precise staging of serosal involvement in Dukes' B and C colonic cancers. Final evaluation of this technique requires long-term follow-up of patients.

A six year prospective study of fibrinogen and other risk factors associated with mortality in stable claudicants.

A total of 333 patients with stable intermittent claudication at recruitment were followed up for 6 years to determine risk factors associated with subsequent mortality. Cardiovascular diseases were the underlying cause of death in 78% of the 114 patients who died. The strongest independent predictor of death during the follow-up period was the plasma fibrinogen level, an increase of 1 milligram being associated with a nearly two-fold increase in the probability of death within the next 6 years. Age, low ankle/brachial pressure index and a past history of myocardial infarction also increased the probability of death during the study period. The plasma fibrinogen level is a valuable index of those patients with stable intermittent claudication at high risk of early mortality. The results also provide further evidence for the involvement of fibrinogen in the pathogenesis of arterial disease.

Episodic intermittent claudication associated with a Baker's cyst.

Baker first described synovial cysts in the leg in connection with diseases of the knee joint. Whilst the majority are asymptomatic, some present as a localised swelling behind the knee, and others either compress the popliteal vein or rupture and can be misdiagnosed as deep vein thrombosis; transmitted pulsation through the cyst can suggest the presence of a popliteal aneurysm. This paper documents a case of intermittent claudication of the lower limb secondary to compression of the popliteal artery by a Baker's cyst.

Idiopathic scrotal calcinosis: a possible aetiology reaffirmed.

Idiopathic scrotal calcinosis is characterised by the presence of multiple firm scrotal nodules of unknown or disputed aetiology. Only 55 cases have been reported in the literature since the first description by Lewinski (1883). We report an additional five patients. We have reviewed the literature exhaustively and our findings support the suggestion that the lesions of "idiopathic" scrotal calcinosis result simply from dystrophic calcification of epidermal cysts.

Bacterial colonisation of leg ulcers and its effect on the success rate of skin grafting.

There is little information on the immediate and long-term results of skin grafting to chronic lower limb ulcers. Our experience in their management had led us to analyse, retrospectively, the results of split thickness skin grafts applied to lower limb ulcers in 88 consecutive patients. Graft take has been related to bacterial growth from ulcer swabs taken on admission, preoperatively and postoperatively. Follow-up was for a median of 18 months. Initial graft take varied from 20% to 100% (median 85%). Bacterial flora grown from the ulcer swabs varied with the duration of the ulcer and the treatment. Analysis by bacterial type has shown that Staphylococcus aurcus and Pseudomonas significantly reduced skin graft healing. Overall, 90% of these ulcers had healed with a median of 6 weeks' in-patient treatment. Examination of the swab results from the 8 ulcers that were slow to heal postoperatively and the 8 ulcers that recurred 6 days to 8 months after discharge from hospital revealed that 15 out of 16 (94%) grew S. aurcus; none had Pseudomonas isolated from them. After eighteen months 8% of these ulcers remain active. Aetiology appears important as this figure is 6% for limbs affected by venous disease only, 13.3% for limbs with arterial disease only and 13.6% for limbs with both venous and arterial disease.

The effects of ethionine administration and choline deficiency on protein carboxymethylase activity in mouse pancreas.

Protein carboxymethylase of mouse pancreas is both soluble (70%) and particulate (30%). The Km for S-adenosylmethionine is 7.5 x 10(-7) M and the Ki for S-adenosylethionine is 1.3 . 10(-5) M. Administration of an ethionine containing diet results in a decrease in protein carboxymethylase activity. Ethionine ingestion also increases pancreatic amylase content by interfering with digestive enzyme discharge. The reciprocal changes in amylase content and protein carboxymethylase activity can be detected within 12 h of commencing the ethionine administration and are enhanced by simultaneous choline deficiency. These studies support the hypothesis that protein carboxymethylase plays an important role in secretion of exportable material. Inhibition of pancreatic protein carboxymethylase activity in vivo may be one important mechanism by which ethionine interferes with digestive enzyme discharge.

Parallel secretion of enzymes by the rabbit pancreas.

1. The purpose of this study was to determine whether or not the secretion of pancreatic enzymes by the rabbit remained proportional (parallel) after acute stimulation. 2. Hourly samples of pancreatic juice were collected from anaesthetized rabbits, each sample being analysed for volume, protein, amylase, trypsinogen and chymotrypsinogen. 3. Four groups of animals were studied for 2 hr before and 2 hr after stimulation with either saline (controls), methacholine, sincalide (C-terminal active octa-peptide of CCK-PZ) or CCK-PZ. 4. Despite a rise in protein output of more than 100% in the hour after stimulation in all experimental groups, there was no change in the specific activity (u./mg protein) of the three enzymes monitored, and the ratios of these enzymes to each other remained constant. 5. These results in the in vivo rabbit confirm our previous observation of parallel secretion in the in vitro rabbit pancreas; they are at variance with other studies in the rabbit (predominantly in vitro but also in vivo) which showed non-parallel secretion after CCK-PZ stimulation. 6. Our results tend to support the theory of mass transport and parallel secretion of pancreatic enzymes though no firm deductions on intracellular events can be made from juice analysis alone.