The use of mobile telephones in a district general hospital.

Advances in technology have led to the increased availability of mobile telephones, but their use in an NHS hospital has not previously been reported. Junior doctors require easy access to a telephone, but ward telephones are frequently busy and not readily accessible when urgently needed. A one-year retrospective study was carried out on the use of mobile telephones in a small district general hospital.

A drip is unnecessary after cholecystectomy.

A randomized controlled study of 93 patients undergoing a cholecystectomy was performed to examine the need for intravenous fluids in the postoperative period. Forty-five patients were randomized to have only oral fluid, and these patients suffered significantly less in the way of haemodilution as measured by changes in packed cell volume (P = 0.0001), haemoglobin (P = 0.0001) and urea (P = 0.036) than those who routinely received intravenous fluids. Although questionnaires at the time of discharge showed that patients themselves did not object to an intravenous infusion, recent studies linking deep vein thromboses to haemodilution, coupled with the findings presented here, provide an argument against their routine and often unconsidered use.

The effect of infrarenal aortic reconstruction on glomerular filtration rate and effective renal plasma flow.

Compromised patients with aortic disease are vulnerable to various complications from aortic reconstruction. These complications are related to changes in systemic haemodynamics during aortic cross-clamping, which leads to cardiac stress and alteration in regional blood flow to different organs. One of the most important postoperative complications is renal failure which is associated with a high mortality rate. Circulatory alterations within the kidney must play a role in the pathogenesis of renal dysfunction that may follow infrarenal aortic cross-clamping and reconstruction. To study the effects of abdominal aortic reconstruction on renal function and perfusion, we measured prospectively the glomerular filtration rate (GFR, n = 59), effective renal plasma flow (ERPF, n = 38) and left ventricular ejection fraction (LVEF, n = 38) in patients undergoing elective infrarenal aortic reconstruction. Radionuclide techniques were used. The three parameters were measured at three time points: preoperatively, postoperatively and 6 months after surgery. The LVEF was measured in order to reflect the patient's cardiac status and pre-renal perfusion. We also measured the three parameters in two control groups of patients: a group of patients undergoing major colonic surgery and a group of patients with arterial disease under conservative management. Six months after surgery the GFR had decreased in 67% of aortic reconstruction patients. Overall GFR in the aortic reconstruction group decreased by a mean of 9 ml min-1 (p = 0.007). This was associated with a decrease in the ERPF in 48.5% of patients. The mean decrease in ERPF in the aortic reconstruction group was 74 ml min-1 (p = 0.05). The LVEF was unchanged.(ABSTRACT TRUNCATED AT 250 WORDS)

Technical and operative factors in infrarenal aortic reconstruction and their effect on the glomerular filtration rate in the immediate postoperative period and 6 months later.

Renal failure is an important cause of postoperative morbidity and mortality in infrarenal aortic reconstruction. Several mechanisms for this postoperative renal dysfunction have been suggested. However, biochemical testing of renal function is insensitive since it shows only gross renal changes. This study examined prospectively the effects of the technical and operative factors on renal function using radionuclide tests. The authors measured the total Glomerular Filtration Rate (GFR) using 51Cr-EDTA clearance in 59 patients undergoing elective infrarenal aortic reconstruction. We also examined the individual kidneys using 99mTc-DTPA renography and 99mTc-DMSA renal scanning. Renal scanning gives the percentage of function of each kidney, while renography gives a graphic assessment of individual renal perfusion and clearance. All tests were carried out preoperatively, 2 weeks postoperatively and 6 months later. Twelve technical factors including aortic cross clamping time, type of aortic anastomosis, forced diuresis, division of left renal vein and various others were recorded to study their effect on the GFR and the individual kidney function. The effect on renal function of these operative factors has not previously been described. GFR showed no change in the immediate postoperative period. Six months later GFR decreased, the mean decrease was 9 ml/min. (P = 0.007 Wilcoxon rank). Some of our patients showed an increased GFR, a phenomenon that was recognised recently. None of the factors studied, except division of the left renal vein, had any effect on the changes in the GFR in the immediate postoperative period or 6 months later.

The incidence of congenitally absent foot pulses.

The pedal pulses of 547 young healthy subjects were examined using digital palpation and a Doppler probe to determine the incidence of congenitally absent foot pulses. The posterior tibial (PT) pulse was absent in only one subject (0.18%), while the dorsalis pedis (DP) pulse was bilaterally absent in nine subjects (1.8%) and unilaterally absent in a further six subjects. The low incidence of congenital absence makes the clinical finding of an absent pedal pulse in later life a more significant marker of peripheral vascular disease than current surgical texts would have us believe.

A prospective study of bladder function following aortic surgery.

Twenty-four patients undergoing aortic surgery for aneurysmal or occlusive aortic disease were studied prospectively to assess the effect on bladder function. Thirteen patients completed the study with post-operative follow-up at 3 months. Aortic surgery was found to be unlikely to cause damage to the parasympathetic nerves. There was no change in the detrusor stability/instability status in five of seven patients undergoing surgery for occlusive disease. Fifty-seven per cent of patients undergoing surgery for aneurysmal disease and 83% of those undergoing surgery for occlusive disease noted improved urinary flow with decreased maximal urethral pressure following surgery, suggesting damage to the sympathetic nerve supply to the lower urinary tract. The improvement in urinary flow did not relate either to the assessed extent of damage to the sympathetic nerves at operation or to the type of operation or vascular anastomosis. It is concluded that aortic surgery damages the sympathetic rather than the parasympathetic nerves and that any effect on bladder function is of no serious significance.

Identification of accessory bile ducts at cholecystectomy.

The presence of accessory channels between the liver and extrahepatic bile ducts has long been recognised by anatomists and the division of such ducts may be a cause of bile leakage following cholecystectomy. However, visualisation of accessory bile ducts at operation is difficult as they are often small and sometimes less than 1 mm in diameter. Cholangiography has been used to help in the identification of accessory ducts in 50 patients included in a prospective trial. X-rays were taken after dissection of the gall bladder from its bed and extravasation of contrast was seen on five occasions (10%) suggesting leakage from divided accessory ducts. The identification of damage to accessory bile ducts in 10% of patients suggests that this may occur more frequently than previously supposed.

Peroperative cephradine concentrations in the gall bladder wall and bile.

Cephradine levels were assayed in serum, gall bladder wall and bile sampled from the gall bladder and common bile duct in 24 patients undergoing elective cholecystectomy. Cephradine was administered either as 1 g given intravenously at the time of anaesthetic induction, or as three 6-hourly doses of 0.5 g taken orally during the pre-operation day followed by 1 g intramuscularly with the premedication. Adequate antibacterial levels of cephradine were achieved in all serum samples, 8 of 9 samples of choledochal bile, 6 of 12 samples of cholecystic bile and all 12 samples of gall bladder wall in the group receiving a single intravenous dose, compared to only 4 of 12 serum samples, 6 of 11 choledochal bile samples, 6 of 10 cholecystic bile samples, and only 3 of 12 samples of gall bladder wall in the group receiving oral cephradine. Therefore, cephradine given as a 1 g bolus intravenously with anaesthetic induction provides satisfactory concentrations for antibacterial prophylaxis during gall bladder surgery but a regimen of oral and intramuscular dosage was found to be unsatisfactory.

Tissue levels of cephradine in ischaemic limbs following a single intravenous injection.

A single dose of 2g cephradine was administered intravenously at the time of anaesthetic induction to 20 patients with occlusive arterial disease. Concentrations of cephradine were measured in serum, subcutaneous fat from the groins of 10 patients underdoing arterial reconstruction and in the subcutaneous fat and skeletal muscle of 10 legs amputated for severe arterial ischaemia. Concentrations of cephradine were adequate for antibacterial prophylaxis at the time of operation in all serum samples, 9 out of 10 samples of subcutaneous fat from reconstruction cases, all muscle and 8 of 10 fat samples from the level of section of amputated limbs, and in 8 of 10 muscle and fat samples from the distal parts of amputated limbs. These results confirm that a single intravenous dose of 2 g cephradine given with anaesthetic provides adequate serum and tissue concentrations for antibacterial prophylaxis during vascular surgery.

Evaluation of tissue levels of cefamandole in severely ischaemic lower limbs using two regimens of dosage.

Cefamandole levels were measured in peripheral blood, and in skeletal muscle and subcutaneous fat samples taken from 20 patients during amputation of the leg for severe ischemia. Tissue samples were taken from both proximal and distal levels in the amputated limb. Cefamandole was administered as either a 2 g intravenous bolus given with induction of anaesthesia, or a combination of 1 g intramuscularly with the premedication plus 1 g intravenously with anaesthetic induction. Levels of cefamandole in serum and proximal muscle and fat samples were well above the minimum inhibitory concentrations required for most Gram-positive and Gram-negative organisms. Cefamandole levels in more distal samples were somewhat lower but still achieved therapeutic levels in most cases. Higher tissue levels of cefamandole were achieved when 2 g were given intravenously as a bolus.

Cancer markers in patients receiving chemotherapy for colorectal cancer: a preliminary report.

The combination of CEA, hepatic function marker enzymes, and four acute phase reactant proteins (haptoglobin, alpha 1 antitrypsin, alpha 1 acid glycoprotein, and prealbumin) has been used to monitor patients with colorectal cancer receiving chemotherapy. In 18 patients with advanced lesions who survived at least 3 months treatment the markers predicted progression in 92% of 25 incidents of progression; the mean lead time was 2.8 months. A rising CEA was only present in 28%, but in these patients it gave a mean lead time of 4 months. In the group of 14 patients with minimal residual disease progression to clinically detectable disease has occurred in 9 of them. In these cases the markers predicted progression with a mean lead time of 6 months; in a further six patients the markers have indicated progression, but as yet their disease is not detectable, the mean lead time being at least 8.6 months. CEA and the liver enzyme markers are the most sensitive indicators of progression of the minimal residual disease group.