Patients' attitudes towards "do not attempt resuscitation" status.

INTRODUCTION: The decision of "do not attempt resuscitation" (DNAR) in the event of cardiopulmonary arrest is usually made when the patients are critically ill and cannot make an informed choice. Although, various professional bodies have published guidelines, little is know about the patients' own views regarding DNAR discussion. AIM: The aim of this study was to determine patients' attitudes regarding discussing DNAR before they are critically ill. METHODS: A prospective study was performed in a general out patients department. A questionnaire was distributed to consecutive outpatients along with an explanatory leaflet in the adult outpatient clinic. RESULTS: 364 patients completed the questionnaire (response rate 77%). 90% of respondents wanted all patients to be asked regarding DNAR decision at some point during a hospital admission. The majority would not find a DNAR discussion distressing. Only 10% would find it upsetting, however, 48% of these still wanted a discussion. 37% of respondents wanted to discuss DNAR decisions on admission; 32% in outpatients; 17% at consent for surgery, 14% when they are critically ill. 87% of respondents would not object to their relatives being involved in making decisions about their resuscitation status. However, only 12% of the subjects in the study had been involved in discussing the resuscitation status of a relative and 21% would not be comfortable to discuss a relative's resuscitation status. Although 33% of patients preferred their resuscitation status to simply be documented within their clinical notes, 77% wanted it to be more easily accessible. CONCLUSIONS: This study suggests that contrary to current practice most patients want to discuss their DNAR status prior to becoming critically ill. This includes half of the small number that find it distressing to discuss. Although most patients are comfortable with relatives being involved in discussing DNAR, a significant proportion do not want their relatives to be asked. Furthermore, once a decision has been made, the majority of patients want it to be more accessible than current practice allows.

Patients' perception of surgical services in a district general hospital.

BACKGROUND: In addition to studying the outcomes of surgery in terms of mortality and morbidity rates and performance, it is also important to consider how patients perceive the delivery of the service given to them. METHODS: A patient satisfaction survey was carried out by the Surgical Epidemiology and Audit Unit of the Royal College of Surgeons of England, on patients undergoing surgical procedures by the Department of Surgery at Wrexham Maelor Hospital. No day cases were included in the study. Two hospitals in southern England (undergoing the same survey) designated X and Y were used for comparison. RESULTS: Some 2000 questionnaires were sent out twice; 1666 subjects (83 per cent) responded to the first questionnaire and 1445 (87 per cent) of these responded to a second questionnaire 6 weeks later (overall response 72 per cent). A total of 35 per cent of patients were older than 65 years of age. Some 76 per cent of patients with a malignant condition were seen within 4 weeks of referral compared with 38 per cent of those with a benign condition (P < 0.0001). A total of 78 per cent of patients with cancer were admitted within 4 weeks compared with 84 and 88 per cent in hospitals X and Y. Some 23 per cent of patients were admitted as an emergency. Eighteen per cent of patients did not know who presented a consent form to them before surgery compared with 13 and 17 per cent in hospitals X and Y (P < 0.0001). Some 26 per cent of patients perceived that they had complications after surgery compared with 27 and 25 per cent for hospitals X and Y. A total of 35 per cent of patients did not receive a follow-up appointment and 20 per cent of these patients were unhappy about this. Two areas of major concern revealed by the responses were the lack of written information and the overall poor scores generally attained by the emergency admission ward. However, 94 per cent of patients said that they would return to the same consultant. CONCLUSION: Patients were generally happy with their surgical care and there was little difference between the three hospitals studied. Lower scores were given when patients were admitted to emergency admission wards. Higher scores were given when patients received printed information.

The influence of total knee arthroplasty on lower limb blood flow.

Ischaemic complications of total knee arthroplasty (TKA) are unusual and tend to occur in patients with peripheral vascular disease (PVD). A prospective study was undertaken to investigate the effect of TKA on blood flow in patients without clinical evidence of PVD. Ankle brachial index (ABI) did not alter post-operatively and no changes in arterial waveforms were found. Unless there is clinical evidence of PVD, TKA under tourniquet control is therefore very unlikely to cause ischaemic complications.

Assessment of peritonism in appendicitis.

The aim of this study was to evaluate the accuracy of different methods of demonstrating right iliac fossa peritonism in appendicitis. The methods used were cat's eye symptom (pain on going over a bump in the road), cough sign, right iliac fossa tenderness, percussion tenderness, rebound tenderness and guarding. A series of 100 consecutive patients with a median age of 25 years (range 4-81 years), presenting with right iliac fossa pain were studied prospectively; the male:female ratio was 39:61. In all, 58 patients underwent operation, 44 had appendicitis confirmed on histology. Fourteen patients had a normal appendix removed; 11 were women aged between 16 and 45 years. Cat's eye symptom and cough sign were sensitive indicators of appendicitis (sensitivity 0.80 and 0.82, respectively), but were not specific (specificity 0.52 and 0.50, respectively) and therefore inaccurate (accuracy 64%). Percussion tenderness was less sensitive (sensitivity 0.57) but more specific (specificity 0.86). Rebound tenderness proved to be sensitive (sensitivity 0.82), specific (specificity 0.89) and accurate (accuracy 86%). Thus, rebound tenderness had a positive predictive value of 86% compared with 56% and 57% for cough sign and cat's eye symptom, respectively. In the difficult diagnostic group of young women, the positive predictive value of rebound tenderness was 88% compared with 58% and 56% for cat's eye symptom and cough sign. Appendicitis remains a difficult diagnosis, particularly in young women. Rebound tenderness still has an important role to play in clinical assessment.

Vascular trauma in civilian practice.

Vascular trauma is associated with major morbidity and mortality, but little is known about its incidence or nature in Britain. A retrospective study of 36 patients requiring operative intervention for vascular trauma under one vascular surgeon over a 6-year period was undertaken. Twenty-four patients suffered iatrogenic trauma (median age 61 years); including cardiological intervention (19), radiological intervention (2), varicose vein surgery (1), umbilical vein catherisation (1) and isolated hyperthermic limb perfusion (1). There were 23 arterial and three venous injuries. Twelve patients had accidental trauma (median age 23 years). Three of the ten patients with blunt trauma were referred for vascular assessment before orthopaedic intervention, two after an on-table angiogram and five only after an initial orthopaedic procedure (range of delay 6 h to 10 days). Injuries were arterial in nine, venous in two and combined in one. Angiography was obtained in six patients, and in two patients with multiple upper limb fractures identified the site of injury when clinical localisation was difficult. A variety of vascular techniques were used to treat the injuries. Two patients died postoperatively and one underwent major limb amputation. Thirty-two (89%) remain free of vascular sequelae after a median follow-up of 48 months (range 3-72 months). Vascular trauma is uncommon in the United Kingdom. To repair the injuries a limited repertoire of vascular surgery techniques is needed. Therefore, vascular surgical assessment should be sought at an early stage to prevent major limb loss.

The use and impact of a daily general surgical emergency operating list in a district general hospital: a prospective study.

Daytime emergency operating lists (EOL) have been shown to reduce out-of-hours operating but problems with their introduction have been reported. A six-month prospective study of EOL and unscheduled operations (USO) was undertaken. Two firms use their EOL differently--one including mostly emergencies, the other including a number of urgent elective cases. After the introduction of EOL only 9 per cent of emergency operations were performed after midnight. Including urgent elective cases on the EOL allowed full use of available theatre time but meant that proportionately more emergency operations were unscheduled. A senior surgeon was involved with 75 per cent of EOL and 36 per cent of USO operations, and a senior anaesthetist with 52 per cent of EOL and 14 per cent of USO. Senior anaesthetic involvement would have been greater if there were more senior staff. There had been a marked increase in the number of USO over the four years previous to this study. EOL do reduce out-of-hours operating and allow excellent supervision and therefore training opportunities. Care must be taken with the case mix to balance full use of theatre time with reduction in out-of-hours operating.

The importance of pubic pain following childbirth: a clinical and ultrasonographic study of diastasis of the pubic symphysis.

This study aimed to investigate the diagnosis and consequences of pubic symphysis diastasis postpartum, in particular the use of ultrasonography to measure interpubic gap. It was a prospective follow-up study, which included an ultrasonographic comparison between symptomatic mothers and controls, set in Morriston Hospital, Swansea. Nine women presenting with unusual pubic pain post-partum were included: there were no exclusion criteria. Forty-two controls were also studied: the only exclusion criterion was unusual pubic pain. Interpubic gap was measured with ultrasonography. Follow up was undertaken for a median of 37 months (range 2-57). An abnormal interpubic gap was found in all symptomatic women. The incidence of diastasis was found to be at least one in 800 deliveries and significant long-term disability was found in three women. Diastasis is commoner than generally acknowledged and its consequences may be severe. Interpubic gap confirms diagnosis but does not appear to predict outcome. Ultrasonography aids diagnosis and follow up.

Plasma cholesterol ester fatty acids: a new biochemical abnormality in obstructive jaundice.

Changes in fatty acid patterns may explain many of the observed abnormalities found in obstructive jaundice. This study looked at fatty acids in plasma cholesterol esters, in a group of patients with obstructive jaundice and a matched group of controls. Significant abnormalities were demonstrated, most importantly a fall in essential fatty acids, in the jaundiced group. Overall the saturation of this fraction, as assessed by double bond index, rose. The essential fatty acids are important as factors in membrane function and as precursors of eicosanoids. The abnormalities found in this study provide further evidence of the significance of EFA in patients with obstructive jaundice.

Audit of patients' experiences of cholecystectomy: laparoscopic and open operations compared.

A study was undertaken to compare open cholecystectomy with laparoscopic in terms of patient related variables. This was not a randomized study but compared two groups of patients treated at different times. A number of variables were assessed. The study showed that each method was equally effective in treating symptomatic gall stone disease. Very few significant differences, in terms of the patients' perceptions of the procedures, were found, although the trend appeared to favour the laparoscopic procedure.

Study of plasma and red cell phospholipid fatty acids in extrahepatic cholestatic jaundice.

The poor outcome in patients with extrahepatic cholestatic jaundice seems in some way related to reticuloendothelial dysfunction. Similar dysfunction can be caused by abnormal tissue phospholipid fatty acid patterns. Little is, however, known about such patterns in extrahepatic cholestatic jaundice. The phospholipid fatty acid patterns in 42 controls were compared with 42 patients with extrahepatic cholestatic jaundice. Many abnormalities were found. The general pattern was of a fall in polyunsaturated fatty acids and a rise in monounsaturated fatty acids, with a consequent fall in the double bond index (mean number of double bonds per fatty acid) showing an overall rise in saturation. All three major substrates for eicosanoid production were reduced in the jaundiced group. The changes seemed to be associated with jaundice itself, rather than the cause of the jaundice. The central roles of fatty acids in the determination of membrane function and in the provision of substrates of eicosanoid production, mean that these changes may explain some of the reticuloendothelial dysfunction found in extrahepatic cholestatic jaundice.

An 11-year experience of arterial embolectomy in a district general hospital.

We present a retrospective audit of all arterial embolectomies performed at the East Glamorgan General Hospital over an 11-year period (1980-1990). Eighty-seven patients (47M:40F), mean age 67 years (50-90 years) underwent 95 embolectomies, an incidence consistent with previous studies. There were 17 upper and 71 lower limb emboli with a mean delay before diagnosis of 29 h (range 1-264 h). In 66% of cases the cause was atrial fibrillation; 33% received immediate heparinization and 14% prophylactic antibiotics. Surgery was performed by a consultant in 12 and registrars in 75 cases, and under local anaesthesia in 80% and general anaesthesia in 20%. There was no anaesthetist present in 54% of cases. Few pre- or peroperative arteriograms were performed. The 30-day mortality was 45%, with an amputation rate of 15% and an overall postoperative complication rate of 62% with little improvement in these figures over the last 10 years. Factors increasing mortality were: delay before diagnosis, grade of surgeon performing the operation, and inadequate inflow or outflow at operation. Factors found to affect limb salvage rate adversely were a history of intermittent claudication, although such a history was not recorded in many cases, and lack of immediate preoperative heparinization. Although embolectomy is considered a 'registrar operation', reviewing our results it can be seen that it is an uncommon operation, in our series eight or nine being performed annually. Sometimes inappropriate surgery is performed upon patients in whom severe systemic illness may contraindicate any form of surgical intervention.(ABSTRACT TRUNCATED AT 250 WORDS)

Malignant pancreatic polypeptide secreting tumour of islet cells: a case for aggressive surgical palliation.

A case of a malignant pancreatic polypeptide secreting tumour is reported. The tumour was metastatic at presentation at which time it was excised. Pancreatic duct obstruction occurred 3 years after excision causing severe pain on eating. Major palliative surgery, in the form of a pancreatico-jejunostomy, cured the severe symptoms. The patient survives, largely symptom free, over six years after original excision. This case illustrates the need for aggressive management of symptoms in tumours in which long term survival is possible despite locally advanced or metastatic disease.

Cholecystectomy: a study of patient satisfaction.

A prospective study of 77 patients undergoing open cholecystectomy was undertaken to establish the degree of satisfaction experienced by these patients. Specific symptoms were recorded preoperatively and at one year postoperatively. Two patients died from unrelated diseases during the year of follow-up and were excluded from the analysis. All symptoms inquired about reduced in frequency postoperatively, the best cures being achieved for jaundice, upper abdominal colic, fatty food intolerance and back/shoulder pain. A third of patients developed at least one new symptom during the year of follow-up. Seventy-seven per cent graded themselves either completely or well satisfied. It was not possible to predict from preoperative symptoms those who would be dissatisfied or those who would develop a new symptom. This study refutes recent suggestions that up to 50% of patients are dissatisfied with cholecystectomy and provides data which may be used to counsel patients preoperatively.