Mastalgia: a 3 year Australian study.

Mastalgia is a common but often poorly understood condition with little Australian data available on the subject. Details are presented of 170 patients who have attended a specific mastalgia clinic at the Princess Alexandra Hospital, Brisbane, Queensland, over a 3 year period. The aims and management protocol of the clinic are outlined. The mastalgia sufferer in this study had an average age of 42 years and 87% were multiparous. Cyclical pain occurred in 59% as determined by a daily pain record chart. Unilateral pain occurred in 38%. Lack of previous breast feeding and low levels of regular physical exercise were identified as two significant factors in the history of those attending the clinic. The responses to treatments are outlined. Response rates of 18 and 26% to two commonly used 'natural products', Vitamin B6 and Evening Primrose Oil, respectively, are considered little better than placebo effect. A complete response was achieved in 67% of women who took low dose danazol with minimal side effects. The overall response rate to all treatments was 65% with a mean follow up of 15.5 months for those women who continued to attend the clinic. For women with mastalgia, a systematic approach can achieve relief of pain.

Incarcerated sigmoid bottle.

A 67-year-old man presented to Casualty approximately 12 hours after the insertion of a bottle into his rectum. An attempt was made to deliver the bottle through the rectum but because of perirectal oedema and a coat-hanger wire around the internal end of the bottle, this proved impossible. Laparotomy was performed and the bottle was removed through a longitudinal colotomy.

Remote arterial injury. Another cause of spurious arterial spasm.

The need for urgent diagnosis and treatment of arterial injury is fully accepted but surgical exposure of the injured vessel is often preferred to pre-operative diagnosis by arteriography. Exposure of the artery at the site of limb injury may reveal spasm or thrombosis without evidence of direct trauma to the vessel. In that case, traction injury of the artery remote from the surgical field is likely. Commonly this affects a proximal segment of the artery but it can occur at a distal fixed point also. Attempts at thrombectomy risk further disruption of the vessel and diagnostic arteriography is required for satisfactory management. An illustrative case is presented.

Solitary thyroid nodule: audit shows improved care requires cytological diagnosis.

An audit was conducted of all patients undergoing thyroid surgery in a district general hospital over the 8-year period during which fine needle aspiration cytology (FNAC) was introduced. Of the 252 patients, 32 (14%) were toxic and 92 (36%) had large multinodular goitres, but 118 (46%) had a solitary thyroid nodule removed to exclude neoplasm. However, only 12.7% of such resected nodules were found to be carcinomas. Where FNAC was used, the accuracy for preoperative diagnosis was 82.6% and the sensitivity for prediction of carcinoma was 87.5%. Cytology correctly predicted 81% of the colloid nodules and these may have been managed without surgery if the patient was agreeable. It is suggested that one-half of the patients with solitary thyroid nodules could have been spared operation. Analysis of the operative procedure shows that one-fifth of the neoplasms may have been more accurately dealt with had FNAC been used, and four patients could have avoided the trauma and risks of a second operation. The study suggests that FNAC and increased specialisation will improve the quality of thyroid surgery in a district general hospital.

Diverticulosis of the vermiform appendix.

A case of appendicitis that was associated with a rare congenital diverticulum of the appendix is presented, along with the results of a retrospective study of diverticulosis of the appendix over a 10-year period. The incidence of the condition in this series (0.65%) is similar to other published series; however, two cases involved rare congenital diverticula--only 43 of such cases have been previously recorded in the medical literature world-wide. The average age of patients who present with acute appendicitis with acquired diverticula (37.8 years) is greater than that of patients without the condition. The perforation rate of an inflamed appendix when diverticula were present (27%) was higher than when no diverticula existed (6.6%). Because of the earlier and higher perforation rate, it is proposed that appendicectomy be performed if an appendix with diverticula is found during the course of a laparotomy for some other condition.

Splenorrhaphy in the management of splenic injury.

A retrospective study of 301 adult splenic injuries presenting to the Princess Alexandra Hospital during a 15 year period, from 1970 to 1984, was conducted. Particular attention was paid to the last 5 years during which 25% of the ruptured spleens were preserved. The details of the preserved spleens are discussed. Respiratory infections were the only complications in this same selected group of patients; the complication rate being higher in the splenectomy group (15.8%) than the splenorrhaphy group (6.25%). None of the cases of splenorrhaphy required re-operation for continued haemorrhage. Twenty-five per cent of all cases of splenic injury had associated intra-abdominal injury which, of its own nature, would require laparotomy. A policy of operative management for splenic injury in adults with major trauma is therefore proposed because of the rate of associated intra-abdominal injuries. When laparotomy is performed, splenorrhaphy should be considered because of the now widely acknowledged risks of diminished immunological competence and overwhelming sepsis in asplenic individuals.