Experience with a one-stop colorectal clinic.

BACKGROUND AND OBJECTIVE: Colorectal services have traditionally been arranged for the convenience of hospitals rather than patients. This model is not ideal, particularly for minor interventions and diagnostic procedures. In order to address this a one-stop colorectal clinic was set up. PATIENTS AND METHODS: Weekly clinics ran from 6.00 to 9.30 p.m. on Wednesdays for a period of 6 months. Patients with rectal bleeding, altered bowel habit, anorectal symptoms and those requesting screening advice were seen by a consultant or specialist registrar. Patients were asked to fill in a questionnaire at the end of their clinic attendance. RESULTS: 197 patients were seen in 17 clinics; 134 underwent proctoscopy, 72 had a rigid sigmoidoscopy and 85 had a flexible sigmoidoscopy carried out. Twenty-four patients subsequently had a barium enema and 3 were listed for colonoscopy. The main diagnosis was haemorrhoids (n = 104); 14 colorectal neoplasms were discovered (5 cancers and 9 polyps). During the study period the number of patients waiting for lower gastrointestinal endoscopy fell from 119 to 63; 2 months after ending the pilot scheme, the number had risen to 108. CONCLUSION: The clinic was found to have significantly improved patient care. The majority of patients were satisfied with an evening clinic. Flexible sigmoidoscopy without sedation was well tolerated and the ability to perform this at initial assessment had a marked effect on the number of patients awaiting lower gastrointestinal endoscopy.

Core temperature measurement in hypovolemic resuscitation.

STUDY OBJECTIVES: Accurate core temperature measurement in severely hypovolemic patients can be difficult to achieve. We used a dog model to determine both a convenient method of measuring core temperature and the relative accuracy of the multiple sites. DESIGN: Prospective laboratory (animal model) study. SETTING: Operating suites in the Animal Care Department. PARTICIPANTS: Eight adult, anesthetized greyhound dogs. INTERVENTIONS: Continuous temperature monitoring by thermistors placed in the brain, central vein, tympanic membrane, bladder, rectum, esophagus, and subcutaneous tissue. Hemorrhage to 65% initial intravascular volume and autologous transfusion of cooled blood, during which serial temperature measurements were recorded. MEASUREMENTS AND MAIN RESULTS: The readings were analyzed with Pearson's correlation coefficient. Brain temperature correlated very well with tympanic membrane temperature throughout the course (r = .869, P less than .0005). Rectum, bladder, and esophagus also correlated well with brain. Central venous temperature, however, correlated poorly with temperatures at all other sites, reflecting the marked swings in intravascular temperature caused by cold transfusion. These wide variations were damped at the other sites. The best correlation of central venous temperature was with brain and bladder, although tympanic membrane correlation was fair. CONCLUSIONS: Because intravascular hypothermia appears to be the source of the arrhythmias and hemostatic abnormalities often seen during the early resuscitation of hypovolemic patients, our results suggest bladder or tympanic membrane as the initial temperature site. After the initial resuscitation, end organ (eg, brain) temperature is the most important and is most accurately reflected by tympanic membrane temperature.

HIDA scanning in gall-bladder disease.

HIDA labelled with 99Tcm is a new hepatobiliary imaging radiopharmaceutical which is selectively taken up by the liver and excreted into the biliary tree; it has been shown to demonstrate the gall bladder in normal subjects. Using a gamma-camera computer system, dynamic liver scans were performed during the first hour on 97 patients who, on the basis of standard investigations and on the findings at surgery, were divided into six groups as follows. 1. Normal. 2. Hepatocellular disease. 3. Biliary obstruction. 4. Chronic gall-bladder disease. 5. Acute gall-bladder disease. 6. Acute abdomen (not due to gall-bladder disease). Pictures were taken and activity-time curves of "regions of interest" were generated from the computer data. From these the presence or absence of a gall-bladder image was easily determined. The gall bladder was visualized in all normals but in none of the patients with acute gall-bladder disease. In the group with an acute abdomen suggestive of acute gall-bladder disease, but subsequently shown to be otherwise, the gall bladder was visualized in all cases. The gall bladder was not visualized in 42% of hepatocellular disease patients, nor in any of those with biliary obstruction, due to poor uptake or poor secretion of the HIDA. In cases of chronic gall-bladder disease, visualization of the gall bladder corresponded with gall-bladder opacification on the oral cholecystogram; in these cases the HIDA scan offers no advantage over the oral cholecystogram. These results suggest that in cases of "acute abdomen" an absent gall bladder image with a normal hepatogram will strongly support the diagnosis of acute gall-bladder disease, and that visualization of the gall bladder excludes such a diagnosis, making the HIDA scan a useful first-line investigation in these patients.

The plasma protein binding of HIDA.

By using Sephadex gel column chromatography to separate substances into their various components according to molecular weight, we have investigated the effect of incubating several "brands" of HIDA in plasma, in vitro. The results show that such incubation has no effect on either dimethyl HIDA, or diethyl HIDA, but that in the case of para-butyl HIDA, incubation in plasma increases the Rf value to that of HSA (human serum albumin). This indicates that para-butyl HIDA becomes bound to plasma proteins, in contrast to both dimethyl HIDA and diethyl HIDA.

The preparation and composition of HIDA.

The compositions of four "brands" of Tc-HIDA-dimethyl HIDA (Sorin Biomedica), diethyl HIDA (Solco), diethyl HIDA (The Radiochemical Centre), and para-butyl HIDA (Sorin Biomedica)--were investigated at varying times after their preparation from "instant kits", by using Sephadex gel column chromatography. Up to three peaks of activity were seen in each chromatogram, representing free reduced technetium, the monocomplex, and the biscomplex of Tc-HIDA respectively. In all cases the free reduced technetium component diminished to reach a plateau at less than 4% of total activity, by 1 h. In both "brands" of diethyl HIDA there was a transformation from the monocomplex to the biscomplex which took about one hour. The rate of this transformation was increased by raising the temperature of incubation, or by agitation during incubation. In the para-butyl HIDA this transformation was again noted, but was incomplete. In the dimethyl HIDA the monocomplex form was not seen. There was no noticeable disintegration of any Tc-HIDA complex up to 6 h. It is suggested that HIDA should be incubated for 1 h after preparation, before use, to achieve a stable composition.