Community-acquired pneumonia in primary care: clinical assessment and the usability of chest radiography.

OBJECTIVES: To investigate the diagnostic value of different clinical and laboratory findings in pneumonia and to explore the association between the doctor's degree of suspicion and chest X-ray (CXR) result and to evaluate whether or not CXR should be used routinely in primary care, when available. DESIGN: A three-year prospective study was conducted between September 2011 and December 2014. SETTING: Two primary care settings in Linköping, Sweden. SUBJECTS: A total of 103 adult patients with suspected pneumonia in primary care. MAIN OUTCOME MEASURES: The physicians recorded results of a standardized medical physical examination, including laboratory results, and rated their suspicion into three degrees. The outcome of the diagnostic variables and the degree of suspicion was compared with the result of CXR. RESULTS: Radiographic pneumonia was reported in 45% of patients. When the physicians were sure of the diagnosis radiographic pneumonia was found in 88% of cases (p < 0.001), when quite sure the frequency of positive CXR was 45%, and when not sure 28%. Elevated levels of C-reactive protein (CRP) ≥ 50mg/L were associated with the presence of radiographic pneumonia when the diagnosis was suspected (p < 0.001). CONCLUSION: This study indicates that CXR can be useful if the physician is not sure of the diagnosis, but when sure one can rely on one's judgement without ordering CXR. KEY POINTS: There are different guidelines but no consensus on how to manage community-acquired pneumonia in primary care. When the physician is sure of the diagnosis the judgement is reliable without chest X-ray and antibiotics can be safely prescribed. Chest X-ray can be useful in the assessment of pneumonia in primary care, when the physician is not sure of the diagnosis.

Laparoscopically assisted or open enterolithotomy for gallstone ileus.

BACKGROUND: Gallstone ileus is associated with high morbidity and mortality rates. Enterolithotomy as a single procedure is recommended to minimize complications. The trauma could potentially be reduced further by using a laparoscopic technique. METHODS: Thirty-two consecutive patients with gallstone ileus operated by a laparoscopic or open approach between 1992 and 2004 were studied retrospectively. Demographic data, preoperative and postoperative hospital stay, duration of operation, complications and deaths were recorded. Median follow-up after surgery was 36 months. RESULTS: Nineteen laparoscopic procedures, with two conversions, and 13 open operations were performed. The median duration of operation was 60 min in the laparoscopic group and 58 min in the open group (P = 0.675). The median hospital stay was 7 and 10 days, respectively (P = 0.383). There were five minor and one major complications in the laparoscopic group, compared with one and four, respectively, in the open group. There were no deaths within 30 days. CONCLUSION: The overall morbidity rate was low after both laparoscopic and open enterolithotomy for gallstone ileus, especially in terms of major complications in the laparoscopic group. Laparoscopically assisted enterolithotomy can be recommended for both diagnosis and treatment.

An open access technique to create pneumoperitoneum in laparoscopic surgery.

BACKGROUND: An open access technique might reduce severe vascular and visceral injuries. An open access technique through the umbilical cicatrix tube has been developed as a routine method with the goal to be easy, safe and used by all surgeons in patients without a previous midline incision. AIM: To evaluate the open technique in a prospective study in 100 consecutive laparoscopic operations regarding time for entrance, surgeons experience and BMI of the patients. METHODS: A midline incision from the linea alba up into the inverted umbilicus was performed in the cicatrix tube and the peritoneum was penetrated allowing air to flow into the abdominal cavity followed by a blunt trocar insertion. RESULTS: Time for access was median 93 seconds. Entrance time in patients with BMI >30 (n=18) was 100 sec and with BMI <30 it was 90 sec (p = 0.71). The median time for consultants was 88 sec and for residents 120 sec (p = 0.003). No gas leakage was seen. Prolonged time for access was seen in three patients; two equipment failures and one obese patent. CONCLUSION: The open access technique is applicable in all patients without a former midline incision. It is fast, easy to learn with very few associated problems.

Primary access-related complications with laparoscopy: comparison of blind and open techniques.

BACKGROUND: Severe or fatal complications attributable to gas embolus, major vascular injury, or visceral injury are rare but have been reported after blind access to the abdominal cavity in laparoscopy. The open access technique has been introduced with the aim to reduce these injuries. This report evaluates access-related complications with both blind and open access techniques in a teaching hospital using standardized techniques for both methods. METHODS: Two groups of patients at different times from a prospective database were compared. A retrospective analysis of 2,297 patients treated using blind access between 1992 and 1996 were compared with 2,066 patients treated using open step-by-step access between 1999 and 2001 regarding access-related complications. An accreditation program for both techniques was mandatory for the 67 surgeons involved. RESULTS: No case of gas embolus or major vascular injury was seen in either group. Four cases of visceral injuries (0.17%) in the blind access group and one case (0.05%) in the open group were seen (p = 0.337). All the injuries were recognized and repaired intraoperatively with no further postoperative complications. CONCLUSION: Our educational efforts to make both techniques as safe as possible were successful, as evidenced by a minimum of access-related complications. Because no evidence exists to show that the blind access technique is superior in any aspect, the open technique is recommended for access to the abdominal cavity in laparoscopy.

Randomized clinical trial of laparoscopic versus open appendicectomy for confirmed appendicitis.

BACKGROUND: Laparoscopy is safe for diagnostic and therapeutic purposes in patients with suspected acute appendicitis. This study compared recovery after laparoscopic (LA) and open appendicectomy (OA) for confirmed appendicitis, carried out by experienced surgeons in an educational setting. METHODS: One hundred and sixty-three patients with laparoscopically confirmed appendicitis suitable for LA were randomized prospectively to either LA or OA in a blinded fashion. The primary endpoint was time to full recovery. Secondary endpoints were operating time, complications, hospital stay and functional status. RESULTS: There was no significant difference between LA and OA in time to full recovery (9 and 11 days respectively; P = 0.225). Operating time was 55 min in the LA group and 60 min in the OA group (P = 0.416). The complication rate was 8.6 and 11.0 per cent respectively (P = 0.696), and median hospital stay was 2 days in both groups (P = 0.192). Functional status was significantly better in the LA group 7-10 days after operation (P = 0.045). CONCLUSION: There was no difference in time to full recovery after LA and OA in patients with laparoscopically confirmed appendicitis. A trend towards better physical activity was noted after the laparoscopic procedure.

Introducing diagnostic laparoscopy for patients with suspected acute appendicitis.

BACKGROUND: The diagnostic accuracy in patients with suspected acute appendicitis varies from 60% to 90% depending on age and gender. The aim of this study was to evaluate the use of diagnostic laparoscopy for diagnostic purposes in patients with suspected acute appendicitis to prevent unnecessary laparotomy and to leave a macroscopically normal appendix in place. METHODS: For this study, 500 consecutive patients with suspected acute appendicitis admitted between January 1994 and October 1996 were included prospectively in a surgical training program set to provide diagnostic laparoscopy on a 24-h-a-day basis. Primary open operation was performed when no laparoscopically trained surgeon was available. Short-term outcome measurements were recorded, and a retrospective long-term follow-up evaluation was performed. RESULTS: We succeeded in performing a diagnostic laparoscopy in 376 patients and a primary open operation in 124 patients. The overall appendicitis rate was 78%. A diagnostic laparoscopy alone was performed in 66 patients (56 of which were fertile women), with a median operating time of 36 min and a complication rate of 0%. The overall complication rate was 8.0%. During a median follow-up period of 19 months one patient returned on a later occasion with appendicitis. At completion of the study, 85% of the surgeons were skilled in diagnostic laparoscopy. CONCLUSIONS: Substantial education effort is needed to introduce diagnostic laparoscopy on a 24-h-a-day basis. Diagnostic laparoscopy has a high rate of accuracy, short operating time, and low associated morbidity, and prevents unnecessary laparotomy. It is possible to leave a macroscopically normal-appearing appendix in place.

Acetabulum-head index measured on arthrograms in children with Legg-Calvé-Perthes disease.

The acetabulum-head index (AHI), which can be used to assess the lateral displacement of the femoral head, was measured on both plain radiographs and arthrograms in 37 children with unilateral Legg-Calvé-Perthes disease. For the identification of the outermost part of the acetabulum on the arthrograms, two measuring points were used: A. the lateral border of the bony acetabulum (arthrogram I) and B. the lateral border of the labrum (arthrogram II). The reproducibility of the measurements, evaluated by duplicate calculations of the AHI on arthrogram II, which was obtained from the unaffected hips, was high; the root mean square error of the AHI was 3.3. On the plain radiographs, an AHI of 80 or less could be used as a 'guideline' to reveal early subluxation of the femoral head. The corresponding figures on arthrograms I and 11 were 70 and 85, respectively.

Acetabulum-head index in children with normal hips: a radiographic study of 154 hips.

The acetabulum-head index (AHI), which is used to assess femoral head coverage on plain radiographs, was measured in 77 children (154 hips) with normal hips aged 2 to 14 years. The mean AHI value was 94 (range, 79-114). Both the intraobserver and the interobserver reproducibility of the measurements was high. The AHI values tended to decrease with increasing age. The mean AHI minus 2 standard deviations, which was used to define the border value for subluxation of the femoral head, was 80. The authors propose that an AHI < or = 80 can be used as a guideline to reveal abnormal lateral displacement of the femoral head in children.

[Laparoscopy in acute abdomen as diagnostic and surgical aid]. / Laparoskopi vid akut buk diagnostiskt och operativt hjälpmedel.

In cases of acute abdomen, the preoperative diagnostic options are limited. Diagnostic laparoscopy offers a superior overview of the abdominal cavity with minimal trauma to the patient. If further surgery is needed, it may take the form of either laparoscopic procedures or conversion to open surgery, the incision being guided by laparoscopy findings. Complications associated to laparoscopy are few and can be minimized further by using minilaparotomy techniques. Intensive educational programmes for all categories of staff are required to make a 24-hours-a-day laparoscopy service available.

Diagnostic laparoscopy in 1043 patients with suspected acute appendicitis.

OBJECTIVE: To evaluate the efficacy of diagnostic laparoscopy in patients with suspected acute appendicitis, the number of complications associated with the laparoscopic technique, and the effect of leaving a macroscopically normal-looking appendix in place. DESIGN: Three prospective protocols. SETTING: Three departments of surgery, one in Norway and two in Sweden. SUBJECTS: 1043 patients aged 15 years or over. INTERVENTIONS: Diagnostic laparoscopy in patients with signs and symptoms of acute appendicitis who were to be operated on. MAIN OUTCOME MEASURES: Morbidity, mortality, and histological appearance of removed appendices, and outcome whether or not the patient was operated on. RESULTS: 819 patients had appendectomies (61% laparoscopically and 39% by conversion to open operation) with a total complication rate of 10%. In 211 patients a diagnostic laparoscopy was done as a single procedure. There were 181 women in this group and 86 of them had gynaecological disorders. The complication rate was 2% among these 211 patients and after a follow up of two years no patients had been readmitted for appendicectomy. 13 patients were subjected to other open procedures. The overall mortality was 0.4%. CONCLUSION: Diagnostic laparoscopy is safe and can be recommended in patients with suspected acute appendicitis, particularly in women. A macroscopically normal-looking appendix can be left in place.

[Legg-Calve-Perthes disease--a mysterious hip joint disease in children. Diagnosis, investigation and treatment]. / Legg-Calvé-Perthes sjukdom--gåtfull barnhöftsjukdom. Diagnostik, utredning och behandling.

The major challenge to the attending physician in cases of children with Legg-Calvé-Perthes disease (LCPD) is to prevent the development of degenerative arthritis of the hip joint. In the presence of unfavourable prognostic factors such as lateral subluxation or more than 50 per cent necrosis of the femoral head, the examination should be complemented by MRI (magnetic resonance imaging), and operative treatment be considered. Treatment is commonly based on the principle of containment of the femoral head to prevent its deformity. However, there is no consensus as to the treatment of LCPS, and as the aetiology remains unknown the optimal treatment is similarly unclear.

A comparative study of fixation techniques in the open Bankart operation using either a cannulated screw or suture-anchors.

The purpose of this study was to compare fixation using either Mitek suture-anchors or a cannulated screw technique, both applied extracapsularly, for an open Bankart reconstruction. Fifty-five consecutive patients with recurrent anterior dislocation of the shoulder were operated in two consecutive series. The same surgical technique was applied regardless of group, except for the reattachment method of the capsulolabral complex to the glenoid rim. Patients operated with suture-anchor fixation had better anterior stability, external rotation and functional outcome after a 24-month minimum follow-up. There were no differences between the groups regarding redislocation or subluxation rate.

Results after femoral and innominate osteotomy in Legg-Calvé-Perthes disease.

In a retrospective study of the surgical management of Legg-Calvé-Perthes disease, 16 femoral osteotomies (Group A) and 18 innominate osteotomies (Group B) were compared Smith regard to clinical and radiographic results. All hips were classified preoperatively as Catterall Group 3 or Group 4. The average followup period was 6 years in Group A and 8 years in Group B. The clinical results were the same in the 2 groups and all patients were asymptomatic in the affected hip(s) during daily activity. The radiographic results were also the same in the 2 groups with regard to measurements of the sphericity of the femoral head (Mose's index and epiphyseal quotient) but the coverage of the femoral head by the acetabulum (center edge angle) was better in the innominate osteotomy group.

Appendicitis: laparoscopic versus conventional operation: a study and review of the literature.

A retrospective study was performed after introduction of the laparoscopic technique in patients with suspected appendicitis to validate it in comparison with conventional open appendectomy. A series of 103 patients with suspected acute appendicitis were included. In 51 consecutive patients, a diagnostic laparoscopy was performed, and, if needed, an appendectomy was carried out. Fifty-two consecutive patients underwent conventional appendectomy. The primary intention of the laparoscopy was diagnostic, but if the patient was found to suffer from appendicitis, a laparoscopic appendectomy was performed. Eight (16%) patients in the laparoscopic group had a healthy appendix that was left in place. Eleven (22%) patients in this group were converted to open appendectomy. There was no significant difference between the groups concerning age, sex, or diagnosis at the time of the operation, and there was also no significant difference in the postoperative hospital stay or complication rate between the groups. The postoperative need for analgesia was lower (p < 0.01) and the operation time was longer (p < 0.0001) in the laparoscopic group than the group that underwent open surgery. It can be concluded that the greatest benefits of the laparoscopic technique are that it causes less trauma, the diagnostic accuracy is better, and the cosmetic result is superior to that after a conventional operation. This is all at the price of a longer operation time.

Conventional radiography and bone scintigraphy in the prognostic evaluation of Legg-Calvé-Perthes disease.

PURPOSE: The role of conventional radiography and bone scintigraphy in predicting the outcome of Legg-Calvé-Perthes disease was investigated. MATERIAL AND METHODS: The 75 children reviewed (86 hips) were followed up to the primary healing of the disease. The findings at conventional radiography (obtained at presentation, at the time of maximum capital head involvement, and at the end of the healing process of the disease) were compared to early bone scintigraphy features. RESULTS AND CONCLUSIONS: Bone scintigraphy provided more accurate information concerning the extent of the necrotic process than initial radiographs. Moreover it could determine revascularization and consequently the stage of the disease. The methods was, however, unable to predict the outcome of the disease in some cases, particularly if it was performed late after the onset of symptoms. Conventional radiography provided important information about other parameters such as "head-at-risk" signs which facilitated treatment selection. Of these signs not only lateral subluxation but also metaphyseal changes strongly predispose to severe deformity of the hip joint.

Legg-Calvé-Perthes disease. Comparison of conventional radiography, MR imaging, bone scintigraphy and arthrography.

In a prospective study of 22 patients (24 hips) with Legg-Calvé-Perthes disease (LCPD) the findings at conventional radiography, arthrography, bone scintigraphy and MR imaging, obtained at the time of diagnosis, were compared. MR was superior to conventional radiography and bone scintigraphy in the detection of the extent of involvement in the femoral head. Arthrography was as good as or better than MR imaging in determining the shape of the articular surfaces and the occurrence of lateral subluxation. Conventional radiography was less sensitive in identifying the degree of lateral subluxation and the extent of the necrosis in the femoral head. MR imaging provided anatomical and pathophysiological information about the extent and location of head involvement as well as the degree of lateral subluxation. Revascularisation was more clearly demonstrated with MR than with bone scintigraphy, irrespective of symptom duration.

Immediate free ankle motion after surgical repair of acute Achilles tendon ruptures.

We prospectively studied 17 consecutively treated patients (15 men and 2 women) who had surgically treated subcutaneous, complete and acute Achilles tendon ruptures. The patients underwent a new postoperative regimen that allowed free ankle motion in a patellar tendon bearing plaster cast with a protecting frame under the foot making weightbearing possible immediately after surgery. Evaluation was done using a patient questionnaire and a clinical examination recorded at 6 weeks (when the mobile ankle cast was removed), 3 months, and 1 year. Measurements of isokinetic and functional strength compared with the uninjured leg were performed at the final followup. No rerupture or other complications occurred. At 1 year, our patients were graded according to the Arner-Lindholm rating scale and there were 15 (88%) excellent, 2 good, and no poor results. Six patients had an excellent result already at 3 months, and there were no poor results at any evaluation. The patient evaluations showed range of motion, strength, and recovery time comparable with or better than results of previous studies. Early free ankle motion after repair of Achilles tendon ruptures proved safe with very satisfactory clinical results, which justified a randomized, prospective study (now in progress) comparing it with traditional ankle immobilization.

A 6-year follow-up of alcoholics after long-term outpatient treatment.

The predictors of the long-term outcome in alcoholics (n = 50) who had been treated in a 2-year outpatient treatment program were investigated. Previously, the sample had been followed up personally 2 years after the termination of treatment. This study is a repeated, independent follow-up of the same sample over a 4-year period, 3-6 years after termination of treatment. Outcome could be categorized in 38 subjects. Patients with a favorable outcome during at least 2 years of the 4-year follow-up period (n = 21), who were categorized as a positive outcome group, were compared with the other patients (n = 17). There was no significant correlation between initial patient characteristics and outcome 3-6 years after treatment. Drinking outcome during the 1st half-year of treatment had no correlation to positive drinking outcome in years 3-6, whereas there was a positive correlation for later phases of treatment and outcome reaching a significant level during the 2nd and 4th half-year of treatment. A favorable drinking outcome during years 1-2 after treatment had a positive significant correlation to outcome in years 3-6 after treatment [i.e., 80% of the patients with a favorable outcome during the 1st follow-up period also had a positive outcome during the 2nd follow-up period, and 72% of those who had an unfavorable outcome during the 1st follow-up period had an unfavorable outcome also during the 2nd follow-up period (chi 2 test = 10.4, p < 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Magnetic resonance imaging not indicated in healed Perthes' disease. Comparison with radiography in 10 cases.

We examined 10 patients with unilateral healed Perthes' disease with plain radiographs and magnetic resonance imaging (MRI). The mean time between the onset of symptoms and follow-up was 8 (4-10) years. The MRI scans did not contribute more information than the plain radiographs.