Improving patient outcomes with inguinal hernioplasty-local anaesthesia versus local anaesthesia and conscious sedation: a randomized controlled trial.

PURPOSE: Conscious sedation is regularly used in ambulatory surgery to improve patient outcomes, in particular patient satisfaction. We hypothesized that the addition of conscious sedation would provide greater patient satisfaction with inguinal hernioplasty compared to local anesthesia alone. METHODS: This trial was a single-centre, randomized, placebo-controlled, double-blinded trial where patients undergoing inguinal hernioplasty using local anaesthesia were randomized to receive local anaesthesia alone versus local anaesthesia and conscious sedation. The primary outcome of patient satisfaction was assessed using the Iowa Satisfaction with Anesthesia Scale (ISAS). The study was powered to detect a significant difference in ISAS scores between groups. Comparisons were made using T test and Chi square tests. A p value of less than 0.05 was considered significant. RESULTS: There were 149 patients randomized: 78 to the local anesthesia (LA) group and 71 to the local anaesthesia and conscious sedation (LACS) group. For the primary outcome measure of patient satisfaction, the mean ISAS score was significantly greater in the LACS group (p = 0.009). The experience of pain and pain severity was greater in the LA group (p = 0.016; p = 0.0162 respectively). No statistically significant difference was found between groups with respect to operative time, time to discharge or postoperative complications. CONCLUSION: The use of conscious sedation with local anesthesia for inguinal hernioplasty is safe, results in less pain experience and severity and is associated with better patient satisfaction. The use of conscious sedation does not delay patient discharge.

Indications for Red Cell Transfusion in the Intensive Care Unit at the University Hospital of the West Indies.

OBJECTIVE: To determine current red cell transfusion practices, transfusion indications and their relationship to patient outcome in intensive care unit (ICU) patients at the University Hospital of the West Indies (UHWI). METHOD: An observational study was conducted over seven months in the two ICUs at the UHWI, on all patients over 16 years who had been admitted for more than 24 hours. Patient demographics, indication(s) for transfusion, haemoglobin level at the time of transfusion, details of ICU admission and patient outcome were recorded. Data analysis was done using Stata v12. RESULTS: Of the 203 patients included in the study, 79 were transfused (39%). A low haemoglobin level was the most common indication for transfusion, with a mean of 7.3 ± 1.5 g/dL. Patients who were transfused had higher phlebotomy volumes [61.9 versus 126.1 mL, p < 0.001], were more likely to require mechanical ventilation (p = 0.002) and inotropic support (p = 0.007). Most were surgical patients (p = 0.01) and were post-open heart/thoracic surgery (66% transfusion rate). Patient outcome was correlated with transfusion, as transfused patients had longer ICU stays (13.0 versus 6.7 days, p < 0.001) and increased mortality rates (32.9% compared to 20.2%, p = 0.04). Most transfusions occurred within the first week of admission (83.5%). CONCLUSION: The mean haemoglobin for transfusion at the ICU, UHWI, is 7.3 g/dL, just above the recommended trigger of 7.0 g/dL in a restrictive transfusion practice. Transfusion policies are needed to better allocate a scarce commodity and minimize complications associated with blood transfusion.

Blood use in neurosurgical cases at the university hospital of the west indies.

OBJECTIVE: Many neurosurgical cases are done without the need for blood transfusion, yet blood is unnecessarily cross-matched, resulting in wasted resources. This study was undertaken to document and compare the number of units of blood components requested, cross-matched and transfused in neurosurgical cases at the University Hospital of the West Indies (UHWI). METHODS: A prospective, observational study was undertaken over one year. Data collected for each patient included demographic information, relevant perioperative data, and blood banking data including blood components requested, cross-matched and transfused. Data were analysed using SPSS version 16. RESULTS: Data were analysed on 152 patients, 71 females (46.7%) and 81 males (53.3%). The mean age was 48.7 ± 19.6 years and 100 of the procedures were done electively (65.8%). Blood components were ordered in 114 (75%) cases, red cells more commonly in 113 (74.3%) patients, and plasma in 19 (12.5%) patients. Overall, 20 patients (13.2%) were transfused. Most patients (90.9%) needed one to two units of blood. Of the 236 units of blood components that were cross-matched or prepared, only 62 were transfused. The cross-match/preparation to transfusion ratio (CTR/PTR) was 6.00 for red cells and 1.31 for plasma. Preoperative haemoglobin ≤ 10.0 g/dL (p = 0.001), estimated blood loss of ≥ 1 litre (p < 0.001), higher American Society of Anesthesiologists (ASA) physical status score (p < 0.03) and a resident as lead surgeon (p < 0.05), were significant predictors of blood transfusion. CONCLUSION: The transfusion rate was low with a high cross-match to transfusion ratio, suggesting that less cross-matching is needed. A new approach to blood ordering for neurosurgical cases is recommended.

Blood use in neurosurgical cases at the University Hospital of the West Indies / El uso de la sangre en los casos de neurocirugía en el Hospital Universitario de West Indies

OBJECTIVE: Many neurosurgical cases are done without the need for blood transfusion, yet blood is unnecessarily cross-matched, resulting in wasted resources. This study was undertaken to document and compare the number of units of blood components requested, cross-matched and transfused in neurosurgical cases at the University Hospital of the West Indies (UHWI). METHODS: A prospective, observational study was undertaken over one year. Data collected for each patient included demographic information, relevant perioperative data, and blood banking data including blood components requested, cross-matched and transfused. Data were analysed using SPSS version 16. RESULTS: Data were analysed on 152 patients, 71 females (46.7%) and 81 males (53.3%). The mean age was 48.7 ± 19.6 years and 100 of the procedures were done electively (65.8%). Blood components were ordered in 114 (75%) cases, red cells more commonly in 113 (74.3%) patients, and plasma in 19 (12.5%) patients. Overall, 20 patients (13.2%) were transfused. Most patients (90.9%) needed one to two units of blood. Of the 236 units of blood components that were cross-matched or prepared, only 62 were transfused. The cross-match/preparation to transfusion ratio (CTR/PTR) was 6.00 for red cells and 1.31 for plasma. Preoperative haemoglobin < 10.0 g/dL (p = 0.001), estimated blood loss of > 1 litre (p < 0.001), higher American Society of Anesthesiologists (ASA) physical status score (p < 0.03) and a resident as lead surgeon (p < 0.05), were significant predictors of blood transfusion. CONCLUSION: The transfusion rate was low with a high cross-match to transfusion ratio, suggesting that less cross-matching is needed. A new approach to blood ordering for neurosurgical cases is recommended.

OBJETIVO: Muchos casos neuroquirurgicos se realizan sin necesidad de transfusion de sangre. Sin embargo, la sangre es innecesariamente sometida a pruebas cruzadas, lo cual resulta en un malgasto de recursos. Este estudio fue emprendido con el proposito de documentar y comparar el numero de unidades de los componentes sanguineos requeridos, cotejados, y transfundidos en los casos de neurocirugia en el Hospital Universitario de West Indies (HUWI). MÉTODOS: Se realizo un estudio prospectivo observacional por espacio de mas de un ano. Los datos recopilados de cada paciente incluian informacion demografica, datos relevantes perioperatorios, y datos de bancos de sangre, incluyendo los componentes sanguineos solicitados, cotejados, y transfundidos. Los datos fueron analizados utilizando SPSS version 16. RESULTADOS: Los datos se analizaron en 152 pacientes: 71 mujeres (46.7%) y 81 varones (53.3%). La edad promedio fue de 48.7 ± 19.6 anos y 100 de los procedimientos se realizaron de manera electiva (65.8%). Se ordenaron componentes de la sangre en 114 casos (75%), siendo los globulos rojos los mas comunmente requeridos en 113 pacientes (74,3%) y el plasma en 19 pacientes (12.5%). En general, 20 pacientes (13.2%) fueron transfundidos. La mayoria de los pacientes (90.9%) necesito una o dos unidades de sangre. De las 236 unidades de componentes sanguineos que fueron preparados o sometidos a pruebas cruzadas, solo 62 fueron transfundidos. La proporcion de la preparacion/prueba cruzada en relacion con la transfusion (CTR/PTR por sus siglas en ingles) fue 6.00 para los globulos rojos y 1.31 para el plasma. La hemoglobina preoperatoria < 10.0 g/dL (p = 0.001), la perdida estimada de sangre de > 1 litro (p < 0.001), la mayor puntuacion del estado fisico (p < 0.03) segun los criterios de la Sociedad Americana de Anestesiologos (ASA), y un residente como principal cirujano (p < 0.05), fueron predictores significativos de la transfusion de sangre. CONCLUSIÓN: La tasa de transfusion fue baja, con una alta proporcion de la prueba cruzada frente a la transfusion, sugiriendo que se necesitan menos pruebas cruzadas. Se recomienda un nuevo enfoque a la hora de hacer pedidos de sangre para los casos neuroquirurgicos.

Physicians' Knowledge of Cardiopulmonary Resuscitation Guidelines and Current Certification Status at the University Hospital of the West Indies, Jamaica.

OBJECTIVE: To determine physicians' knowledge of cardiopulmonary resuscitation (CPR) guidelines at the University Hospital of the West Indies (UHWI), Jamaica, and their current certification status in basic life support (BLS), advanced cardiac life support (ACLS), paediatric advanced life support (PALS) and advanced trauma life support (ATLS). METHODS: This was a cross-sectional study. A 23-item self-administered questionnaire was used to assess physicians practising at the UHWI, from the Departments of Anaesthesia, Surgery, Internal Medicine, Accident and Emergency, Obstetrics and Gynaecology and Oncology. RESULTS: One hundred and forty-three (65%) of the targeted 220 physicians responded. There were 77 (55%) females and 41% of respondents were between ages 26 and 30 years. Knowledge of CPR guidelines was inadequate, as the median score obtained was 4.0 (interquartile range [IQR] 2-5) out of a possible eight. Physician seniority was inversely related to knowledge scores (p < 0.01). While 86% of all respondent physicians had been trained in BLS, only 46% were certified at the time of the study. Fewer (52%) were trained in ACLS with only 36% currently certified. Only 65% had been trained in the use of a defibrillator. Most knew the correct compression rate (78%), but only 46% knew the compressions to breaths ratio for both single and two-rescuer CPR. Only 42% of anaesthetists and 27% of emergency physicians were currently ACLS certified. CONCLUSION: Physician knowledge of CPR protocols was suboptimal and current certification levels were low. Increased training and recertification is necessary to improve physician knowledge which is expected to result in improved performance of CPR.

The aetiology of head injury in admitted patients in Jamaica.

This cross-sectional, descriptive study identified 857 head-injured patients who were admitted to the University Hospital of the West Indies (UHWI) over a four-year period. Their median age (IQR) was 28 (16, 45) years and 629 (73.5%) were males. Median length of hospital stay (IQR) was 2 (1, 6) days. Median ICU stay in the intensive care unit (IQR) was 6 (2, 12) days for the 59 (6.9%) patients admitted there. Most patients (73.3%) were admitted with unintentional injuries resulting from road traffic accidents (48.9%), of which passengers were the most commonly affected, and from falls which occurred in 24.4%. Intentional injuries accounted for 26.7% of those admitted, consisting mainly of assaults with blunt objects in 18.0% (154/857). Penetrating injuries were less common, accounting for 67 (7.8%) injuries. Among these, there were 23 gunshot wounds of the head (2.7%). Head injury in admitted patients is mainly due to road traffic accidents, falls and interpersonal violence. Prevention and interventional strategies including education, law enforcement, physical and social engineering must focus on these aetiologies. Current measures are clearly insufficient and more effective strategies are urgently warranted.

Unnecessary admissions of head-injured patients at the University Hospital of the West Indies.

The prospectively collected data in the Jamaica National Trauma Registry operated by the Section of Surgery identified 88 patients who were admitted with head injury to the University Hospital of the West Indies over a one-year period. There were 67 males (76.1%), the mean (SD) age of the entire group being 35.02 (+/- 18.45) years. Intentional injuries occurred in 47.2%. The Injury Severity Score was greater than 15 in 19.3%, severe head injuries occurred in 19% and overall mortality was 16%. Care in the Intensive Care Unit (ICU) was extended to only half of those with the severe injuries. The Scottish Intercollegiate Guidelines Network (SIGN) method was used to assess the appropriateness of admission to hospital. Sixteen (18%) of the 88 patients were inappropriately admitted according to SIGN guidelines. Increased efficiency may result from standardization of admission criteria for head-injured patients and consistent implementation of the SIGN guidelines for admission without increased risk to patients. This may be expected to minimize unnecessary admissions and result in considerable cost savings.

Surgical and intensive care needs of head-injured patients transferred to the University Hospital of the West Indies.

A cross-sectional, descriptive study utilizing data collected in the 'Trauma Registry' of the Department of Surgery, Radiology, Anaesthesia and Intensive Care at the University Hospital of the West Indies (UHWI) was undertaken to document injury severity, surgical requirements and intensive care needs of head-injured patients transferred to the UHWI over a three-year period Of 144 patients studied, the majority (71%) were young males. Overall, injury tended to be mild Twenty-three patients (16.0%) had severe head injury and 27 patients (18.8%) were admitted to the intensive care unit. Concussion with (33%) or without (36%) skull fracture was the commonest neurological admission diagnosis. Associated non-neurological injuries in 33% were primarily fractures. Fifty-six patients (39%) required surgical intervention. Craniotomies and open reduction and internal fixation of fractures were the commonest procedures. The majority of patients (79.2%) were discharged home; 56 (39%) made a good Glasgow outcome score recovery. Seventeen patients (11.8%) died in hospital. As most of the transferred patients with head injuries in this study had only mild injury, most commonly concussions, and their prognosis was good, we recommend that appropriate educational and training programmes and transfer policies be implemented to minimize inappropriate transfers.

The aetiology of head injury in admitted patients in Jamaica / Aspectos etiológicos de la lesión cefálica en pacientes ingresados en Jamaica

This cross-sectional, descriptive study identified 857 head-injured patients who were admitted to the University Hospital of the West Indies (UHWI) over a four-year period. Their median age (IQR) was 28 (16, 45) years and 629 (73.5%) were males. Median length of hospital stay (IQR) was 2 (1, 6) days. Median ICU stay in the intensive care unit (IQR) was 6 (2, 12) days for the 59 (6.9%) patients admitted there. Most patients (73.3%) were admitted with unintentional injuries resulting from road traffic accidents (48.9%), of which passengers were the most commonly affected, and from falls which occurred in 24.4%. Intentional injuries accounted for 26.7% of those admitted, consisting mainly of assaults with blunt objects in 18.0% (154/857). Penetrating injuries were less common, accounting for 67 (7.8%) injuries. Among these, there were 23 gunshot wounds of the head (2.7%). Head injury in admitted patients is mainly due to road traffic accidents, falls and interpersonal violence. Prevention and interventional strategies including education, law enforcement, physical and social engineering must focus on these aetiologies. Current measures are clearly insufficient and more effective strategies are urgently warranted.

Este estudio transversal descriptivo identificó 857 pacientes con lesiones cefálicas, ingresados en el Hospital Universitario de West Indies (UHWI) por un periodo de cuatro años. Su edad mediana (IQR) fue 28 (16, 45) años y 629 (73.5%) eran varones. La longitud mediana de estancia hospitalaria (IQR) fue de 2 (1, 6) días. La estancia mediana en la unidad de cuidados intensivos fue de (IQR) 6 (2, 12) días para los 59 (6.9%) pacientes ingresados allí. La mayoría de los pacientes (73.3%) fueron ingresados con lesiones involuntarias a consecuencia de accidentes de tráfico (48.9%) ­ de los cuales los pasajeros fueron comúnmente los más afectados ­ y de caídas ocurridas en 24.4%. Las lesiones intencionales constituyeron el 26.7% de los casos ingresados, siendo el 18.0% (154/857) producidas principalmente por ataques con objetos contundentes. Las lesiones penetrantes fueron menos comunes, representadas por 67 (7.8%) de las lesiones. De estas, 23 fueron heridas de bala en la cabeza (2.7%). Las lesiones en la cabeza en los pacientes ingresados se debieron principalmente a accidentes de tráfico, caídas y violencia interpersonal. Las estrategias de prevención e intervención ­ incluyendo la educación, la imposición del cumplimiento de la ley, la ingeniería física y social ­ deben centrar su atención en estas etiologías. Las medidas actuales son a las claras insuficientes y se requiere con urgencia estrategias más efectivas

Surgical and intensive care needs of head-injured patients transferred to the University Hospital of the West Indies / Necesidades quirúrgicas y de cuidados intensivos de los pacientes con lesiones cefálicas transferidos al hospital universitario de west indies

A cross-sectional, descriptive study utilizing data collected in the 'Trauma Registry' of the Department of Surgery, Radiology, Anaesthesia and Intensive Care at the University Hospital of the West Indies (UHWI) was undertaken to document injury severity, surgical requirements and intensive care needs of head-injured patients transferred to the UHWI over a three-year period Of 144 patients studied, the majority (71%) were young males. Overall, injury tended to be mild Twenty-three patients (16.0%) had severe head injury and 27 patients (18.8%) were admitted to the intensive care unit. Concussion with (33%) or without (36%) skull fracture was the commonest neurological admission diagnosis. Associated non-neurological injuries in 33% were primarily fractures. Fifty-six patients (39%) required surgical intervention. Craniotomies and open reduction and internal fixation of fractures were the commonest procedures. The majority of patients (79.2%) were discharged home; 56 (39%) made a good Glasgow outcome score recovery. Seventeen patients (11.8%) died in hospital. As most of the transferred patients with head injuries in this study had only mild injury, most commonly concussions, and their prognosis was good, we recommend that appropriate educational and training programmes and transfer policies be implemented to minimize inappropriate transfers

Se llevó a cabo un estudio transversal descriptivo utilizando datos tomados del "Registro de traumas" del Departamento de Cirugía, Radiología, Anestesia y Cuidados Intensivos en el Hospital Universitario de West Indies (HUWI), a fin de documentar la severidad de la lesión, los requerimientos quirúrgicos y las necesidades de cuidado intensivo de pacientes con lesiones cefálicas transferidos al HUWI durante un período de más de tres años. De 144 pacientes estudiados, la mayor parte (71%) eran varones jóvenes. En general, las lesiones tendían a ser leves. Veintitrés pacientes (16.0%) tuvieron lesiones cefálicas severas, y 27 pacientes (18.8%) fueron ingresados a la unidad de cuidados intensivos. Concusión con fractura del cráneo (33%) o sin fractura del cráneo (36%) fue el diagnóstico neurológico más común para el ingreso. Las lesiones no neurológicas asociadas en 33% fueron principalmente fracturas. Cincuenta y seis pacientes (39%) necesitaron intervención quirúrgica. Las craniotomías así como la reducción abierta y la fijación interna de fracturas, fueron los procedimientos más comunes. La mayoría de los pacientes (79.2%) fueron dados de alta; 56 (39%) tuvo una buena recuperación según la puntuación de la escala de Glasgow para la evolución clínica. Diecisiete pacientes (11.8%) murieron en el hospital. Como que la mayor parte de los pacientes transferidos con lesiones de cabeza en este estudio tuvieron solo lesiones leves ­ por lo general concusiones ­ y puesto que su prognosis era buena, recomendamos que se implementen programas adecuados de educación y entrenamiento, así como políticas de transferencia apropiadas, a fin de minimizar las transferencias inadecuadas

Unnecessary admissions of head-injured patients at the University Hospital of the West Indies / Ingresos unnecesarios de pacientes con lesiones cefálicas en el hospital universitario de west indies

The prospectively collected data in the Jamaica National Trauma Registry operated by the Section of Surgery identified 88 patients who were admitted with head injury to the University Hospital of the West Indies over a one-year period. There were 67 males (76.1%), the mean (SD) age of the entire group being 35.02 (+/- 18.45) years. Intentional injuries occurred in 47.2%. The Injury Severity Score was greater than 15 in 19.3%, severe head injuries occurred in 19% and overall mortality was 16%. Care in the Intensive Care Unit (ICU) was extended to only half of those with the severe injuries. The Scottish Intercollegiate Guidelines Network (SIGN) method was used to assess the appropriateness of admission to hospital. Sixteen (18%) of the 88 patients were inappropriately admitted according to SIGN guidelines. Increased efficiency may result from standardization of admission criteria for head-injured patients and consistent implementation of the SIGN guidelines for admission without increased risk to patients. This may be expected to minimize unnecessary admissions and result in considerable cost savings.

En los datos recopilados prospectivamente en el Registro Nacional Jamaicano de Traumas (Jamaica National Trauma Registry), operado por la Sección de Cirugía, se identificaron 88 pacientes que habían ingresado con lesiones cefálicas al Hospital Universitario de West Indies, por un período de más de un año. Había 67 varones (76.1%), y la edad mediana (SD) del grupo en su totalidad fue 35.02 (± 18.45) años. En el 47% ocurrieron heridas intencionales. La Puntuación de Severidad de la Lesión fue mayor de 15 en 19.3%; las lesiones cefálicas severas ocurrieron en 19%, y la mortalidad general fue 16%. El cuidado en UCI se extendió sólo a la mitad de las lesiones severas. El método conocido como Scottish Intercollegiate Guidelines Network (SIGN), se usó para evaluar hasta que punto el ingreso al hospital era adecuado. Dieciséis (18%) de los 88 pacientes fueron ingresados inadecuadamente según los lineamientos de SIGN. Puede producirse un aumento de la eficiencia a partir de la estandardización de los criterios de admisión para los pacientes con lesiones cefálicas y la implementación sistemática de los lineamientos de SIGN para los ingresos, sin aumento de riesgo para los pacientes. Hay razón para esperar que esto minimice los ingresos innecesarios y traiga consigo un ahorro considerable de los costos

Tetanus: a recurring intensive care problem.

A fifteen-year retrospective study of 108 cases of tetanus admitted to the Intensive Care Unit (ICU) at the University Hospital of the West Indies is presented. Males predominated (70%), with peak incidence occurring amongst the young and the elderly. In 57% the disease was severe enough to require neuromuscular blockade and controlled ventilation. Respiratory complications occurred most commonly (80%), predominantly as a result of infection. Dysautonomia, exhibited by 55% of patients, presented the greatest difficulty in management. Mortality was high (20%), with sudden cardiac arrest being the most common cause of death. The average duration of stay in the ICU was long (27 days). As Jamaica is a Third World country with limited resources, the continued occurrence of this preventable disease represents a drain on existing intensive care funds. This must be brought to the attention of institutions responsible for planning health care programmes for developing countries.

Prevention of postoperative deep venous thrombosis and pulmonary emboli with combined modalities.

Worldwide statistics reveal that 25 to 40 per cent of patients who are over the age of 40 years and operated on for 1 or more hours will develop a deep venous thrombosis (DVT). The studies reviewed in this paper were performed to evaluate several modalities and compare their effectiveness in preventing DVT in postoperative patients. In the first study, five modalities plus a control group were evaluated in 562 patients from five surgical specialties. The incidence of DVT in the control group was 35 per cent. Though most of the pharmacologic agents were effective in reducing the incidence of DVT, the antistasis devices (gradient elastic stockings and intermittent pneumatic compression) were most effective. The purpose of the second study was to evaluate the effectiveness of combining a pharmacologic drug with an antistasis modality. Deep venous thrombosis was virtually eliminated in this group of 328 patients. There was only a 1.5 per cent incidence of DVT in the treated population as compared to a 26.8 per cent incidence in the control group. Thus, it seems that combining one antistasis and one pharmacologic agent greatly reduces the incidence of lower extremity thrombi. I-125 fibrinogen scanning was the most sensitive test in detecting DVT and had an accuracy of 97 per cent.

Postoperative venous thrombosis. Evaluation of five methods of treatment.

Five methods for preventing deep venous thrombosis in postoperative patients were evaluated and compared with a control group. Five hundred patients from five surgical specialties were studied. The incidence of deep venous thrombosis was 37.3 percent in the control group but significantly less within all treatment groups. The minidose heparin group had the highest incidence (26.9 percent) because there were a large number of bilateral thromboses. The antistasis modalities did slightly better than the drugs; the intermittent pneumatic compression group had the fewest thromboses (11.9 percent). The significant risk factors for postoperative deep venous thrombosis are (1) obesity, (2) malignancy, (3) a history of venous disease, major surgery or major fracture, (4) length of surgery greater than 1 hour, and (5) increasing age. Four nonfatal pulmonary emboli occurred in 500 patients. Two were in women with hysterectomies in whom thrombosis had never been detected in an extremity; it is presumed that these clots arose from pelvic veins. It is thus recommended that patients in these high risk groups be treated prophylactically with one of the aforementioned modalities to decrease the risk of postoperative deep venous thrombosis. Of the different methods used to detect deep venous thrombosis, iodine-125 fibrinogen scanning was superior to both impedance plethysmography and venous Doppler ultrasound. One hundred percent of the thrombi were identified with scanning, whereas far fewer were detected with the latter methods. It is recommended that fibrinogen scanning be used clinically in patients in high risk categories who are undergoing major operative procedures.

The prevention and correction of hypocalcemia in the parathyroidectomized rat by portacaval shunt.

Adult rats underwent end-to-side portacaval shunt either 30 days prior to or 12 days following parathyroidectomy. When portacaval shunt was performed initially, the serum calcium failed to decrease following subsequent parathyroidectomy and remained within normal levels up to 110 days. When parathyroidectomy first was done, the significant hypocalcemia was corrected subsequently by portacaval shunt and serum calcium remained close to the normal level up to 75 days. The effect of portacaval shunt depended on the calcium content of the food and was obtained only when rats were fed by a regular diet. Rats on a calcium-deficient diet were hypocalcemic, similar to the parathyroidectomized rats without the portacaval shunt. Prolonged calcium-deficient diet alone, without parathyroidectomy, did not by itself result in hypocalcemia either in the intact rat or in the portacaval shunted rat. The data indicate that portacaval shunt prevents and corrects hypocalcemia in the parathyroidectomized Lewis rat as long as sufficient calcium is available in the diet.

Unsuspected perforated adenocarcinoma of the appendix as a second colonic neoplasm: report of a case.

The case of a patient who had an unsuspected perforated adenocarcinoma of the appendix discovered during operation for a sigmoid carcinoma is presented. The problems in diagnosing carcinoma of the appendix are discussed and the literature is reviewed.

Clinical study of second kidney transplantation.

During the period from November 1972 to February 1975, 39 patients received second renal grafts in our institution. The clinical course of the patients was analyzed and compared with 121 patients who received only one graft during the same period. The graft survival either from living related or cadaveric sources was inferior in the second graft group. However, mortality was not increased by re-transplantation. Major differences were noted in the occurrence of hyperacute or accelerated type rejections. There was a high incidence of this type of rejection in the second graft group, especially in the simultaneous retransplant group.