Psoas abscess - not as rare as we think?

OBJECTIVE: Iliopsoas abscess (IPA) is a rare condition with a reported worldwide incidence of 12 new cases per year with primary abscesses now predominating. The presentation is often vague and the diagnosis not considered. METHOD: The medical records of 15 consecutive patients presenting to our hospital in a 3-year period with IPA were reviewed. Demographic data, presenting features, predisposing factors and the investigations performed were recorded. Abscesses were classified as primary or secondary and the treatment provided and eventual outcomes were analysed. RESULTS: Fifteen patients (eight males) were included. Nine patients were pyrexial on admission, 14 were anaemic and all had raised inflammatory markers. Only five patients presented with the classical triad of pain, fever and limp. The median time to diagnosis was 3 days with a median hospital stay of 27 days (range 7-243 days). Fourteen patients were diagnosed by computed tomographic scan. Three patients were treated with antibiotics alone whilst 11 received percutaneous drainage (PCD) as well. Of these, five had recurrence following initial drainage, needing further PCD procedures but none needed open drainage. Only one patient underwent open drainage initially. The mortality rate was 20%. CONCLUSION: The incidence of IPA is probably under-reported. The vague presentation leads to delays in diagnosis and increases morbidity and a high index of suspicion is the key to early diagnosis. Percutaneous drainage with antibiotics is the first line of treatment although recurrence rate is high. Open drainage allows simultaneous treatment of underlying pathology in secondary abscesses.

A family tradition of Scottish medicine.

In the late nineteenth and early twentieth centuries, Edinburgh was among the most popular of all destinations for South Africans seeking a medical education. Scotland was thus the fountainhead of much of the knowledge and skill that subsequently led to the development of a high standard of medical education in South Africa. This article describes how four members of a South African family received their medical education at the University and Royal Colleges of Physicians and Surgeons of Edinburgh and a fifth family member obtained the Membership of the Royal College of Physicians and was later elected to Fellowship. This is the story of a relationship spanning three generations between a family in which medicine had almost become a hereditary trait and the best of Scottish medical education.

Constipation in elderly patients attending a polyclinic.

OBJECTIVE: To determine the prevalence of and risk factors for constipation in the elderly. Differences between the white and black elderly populations in this regard were examined. DESIGN: Cross-section hospital-based study. SETTING: The family medicine clinics at National and Pelonomi hospitals in greater Bloemfontein. PARTICIPANTS: 179 white and 188 black patients, born before 1930, visiting the clinics during December and January 1994/95 and seen by one doctor. MAIN OUTCOME MEASURES: Constipation. RESULTS: In both the black and white population groups 29% of the participants were constipated according to the definition used in this study. Depression was a risk factor for constipation in both population groups. Age over 80 years was a risk factor in the black participants. The fibre and fluid contents of participants' diets were not found to be associated with constipation. Pain during defaecation was positively associated with constipation. Forty-three per cent of the white and 76.6% of the black participants used laxatives. Of the white and black laxative users 14.3% and 21.5%, respectively, used more than one laxative at a time. CONCLUSION: The prevalence of constipation was high in both groups. Laxative use and abuse are very common in the black elderly population.

The pharmacokinetics and UK usage of heparin in vascular intervention.

Intravascular heparin is used routinely during peripheral and visceral angioplasty, although usage and dose vary widely. The aims of this prospective study were to: (1) Determine the pattern of Heparin usage by Vascular/Interventional Radiologists in the UK. (2) Determine the optimum doses of Heparin for vascular intervention on the basis of its pharmacokinetic profile. A questionnaire was sent to Consultant Radiologists who were also members of the British Society of Interventional Radiology (BSIR), regarding their use of heparin during peripheral angioplasty. This included heparin doses in flushing solution, timing and amounts of heparin used as a bolus dose and monitoring of clotting times. Seventy-three percent returned completed forms. A wide variation in practice was shown. Apart from the variety of individual protocols in use, significant findings were that more than 75% of the respondents were giving heparin as a bolus only after the lesion had been crossed with a guide-wire. None of the respondents were monitoring clotting times, even in prolonged and complicated procedures. The pharmacokinetic profiles of two separate bolus doses of heparin in two groups of 30 and 25 patients each were then evaluated. Our results showed that a 3000 IU bolus of heparin maintained the plasma APTT in the therapeutic range (at least twice the normal value), for at least 30 min in the majority of patients. A 5000 IU bolus maintained the APTT in the therapeutic range for 45 min in the vast majority of patients. Apart from minor bruising at the compression site and slightly increased compression times in a small number of patients, no significant immediate complication was noted. We conclude that in the context of peripheral angioplasty, there is a wide variation in the use of heparin as an adjunct to the procedure. In the light of our own experience we recommend a 3000 IU intra-arterial bolus of unfractionated heparin to be given once arterial access has been achieved. This would cover short, uncomplicated procedures. The larger 5000 IU dose would be more appropriate for longer and more complicated procedures. We also recommend monitoring APTT values in prolonged procedures, with administration of further bolus doses of heparin if required.

Computed tomographic scanning of L3/4 in suspected disc prolapse: is it necessary?

Computed tomography (CT) scanning is an accepted first line investigation for suspected lumbar prolapsed intervertebral disc disease (PID). However, it does involve ionizing radiation and any possible reduction in the dose is desirable. A questionnaire was sent to a random selection of 60 CT centres in the UK to confirm that a routine scan of the three lower lumbar levels is current practice in a majority of centres, regardless of symptomatic presentation. All orthopaedic CT referrals over 2 years for suspected lumbar disc disease in Sheffield were studied retrospectively. Of 486 cases, 99 (20%) were shown to have disc disease, of which 16 (3.3%) had disease at the L3/4 level. Of these 16 cases, 11 were suspected clinically. Analysis of the long-term outcome of the five unsuspected cases showed that in none did the CT findings make any significant contribution to this outcome. These results have altered our practice. Two-level scanning is now performed routinely and three-level scanning is only performed when specified clinical or radiological indications are present.

Cervical intra-epithelial neoplasia and invasive cervical cancer in black and white patients.

The relative incidences of cervical intra-epithelial neoplasia (CIN) and invasive cervical cancer were studied in black and white patients at the academic hospitals of the University of the Orange Free State. A statistically highly significant difference was found between black and white patients, with a higher incidence of invasive cervical cancer than stage III CIN (CIN III) in black patients and a higher incidence of CIN III than invasive cervical cancer in white patients (P = 0.000092; 95% confidence interval -0.355-(-)0.128). The time interval between the peak incidence of CIN III and that of invasive cervical cancer was found to be shorter in black than in white patients. These distressing findings emphasise the urgent need for a national cervical cytological screening programme to decrease the incidence of invasive cervical cancer. This serious yet preventable disease is still very prevalent in South Africa, especially among black women.

The effect of radiology guidelines for general practitioners in Plymouth.

The impact of introducing guidelines to General Practitioners using the radiodiagnostic services in the Plymouth Health District has been analysed. The guidelines were advisory and issued to all General Practitioners in the area served by the Plymouth group of hospitals. There was no vetting of requests from Practitioners following their introduction. Three 6 month periods were considered; two before the guidelines were introduced and one after. An overall reduction of 23% in referrals was achieved. An analysis by examination showed that only those examinations specifically targeted in the guidelines showed a significant reduction. In the case of targeted examinations, a reduction of 28% (P less than 0.001) was demonstrated.