Primary malignant fibrous histiocytoma of spleen.

We report a case of primary malignant fibrous histiocytoma of spleen, which also emphasizes the difficulties in diagnosing such a rare condition.

Correlation of acute cocaine-induced changes in local cerebral blood flow with subjective effects.

The authors administered 48 mg of intravenous cocaine or placebo to eight abstinent cocaine users in a double-blind, crossover design and examined blood flow using single photon emission computed tomography. Cocaine produced significant decreases in frontal cortical and basal ganglia blood flow; these latter correlated negatively with increases in self-ratings of "rush" and "high." The authors conclude that these local effects are compatible with dopaminergic system involvement.

Surgical audit: variations in wound infection rates according to definition.

A prospective study of 702 postoperative surgical patients was undertaken to determine whether clinicians showed consistency in their interpretation of signs of infection in wounds. In the 62 cases where symptoms suggestive of such infection were noted, clinical signs were recorded, as were the clinicians' subjective impressions. The application of different criteria would have resulted in a substantial variation in the apparent rates of infection, which raises questions about the need for an agreed definition of the term 'wound infection'. The lack of a specific definition has implications for surgical audit.

Wound infection: the surgeon's responsibility.

Surgical audit has two main purposes: the pursuit of efficiency through the review of clinical workload and the pursuit of quality by reviewing clinical outcomes. In-house quality control is an important aspect of surgical practice. This prospective study aimed to determine the incidence of infection, describe the time distribution of presentation and identify contributory factors. There were 1 242 consecutive patients in the survey (1 086 inpatients and 156 day cases), of whom 83 became infected (79 in-patients and four day cases) - an overall infection rate of 6.7%. Over 55% presented during the first week and 89% within the first two weeks. Of 23 specific aetiological variables studied, four - age, preoperative stay, shaving and the surgeon - were shown to have a statistically significant association with the development of wound infection. A strong association between the surgeon and the development of wound infection was demonstrated. In addition to obvious strong resource implications, it supports the need for routine audit supervision and training of junior staff and peer review for senior clinicians.

Assessing adequacy of collateral circulation during balloon test occlusion of the internal carotid artery with 99mTc-HMPAO SPECT.

A balloon test occlusion of the internal carotid artery was performed in 11 patients with internal carotid artery aneurysms. Tolerance by patients was assessed by a combination of clinical examination; angiography; electroencephalography; 99mTc-hexamethylpropyleneamine oxime (99mTc-HMPAO) single-photon emission computed tomography (SPECT) with relative quantification; and, in four patients, 99mTc-HMPAO SPECT with absolute quantification of cerebral blood flow. During test occlusion, angiography showed a patent circle of Willis in all patients. No patient developed new clinical findings or electroencephalographic changes. The SPECT studies of five patients in whom 99mTc-HMPAO was injected during test occlusion demonstrated changes from their baseline SPECT studies. The internal carotid artery was permanently occluded in two of these patients, neither of whom became symptomatic because of the occlusion. Three patients who demonstrated no changes between baseline and test occlusion SPECT studies underwent permanent occlusion of the internal carotid artery without incident, and postoperative SPECT images were unchanged from baseline. Our preliminary results suggest that patients who have no changes between baseline and test occlusion 99mTc-HMPAO SPECT studies should have adequate collateral circulation to sustain cerebral blood flow after occlusion of the internal carotid artery if no thromboembolic episodes occur. In contrast, a patient's tolerance of permanent occlusion cannot be consistently and reliably predicted if there are changes between baseline and test occlusion SPECT studies. In these patients, absolute quantitation of cerebral blood flow is important. Greater numbers of patients are required to confirm these initial results.

Mapping the distribution of amobarbital sodium in the intracarotid Wada test by use of Tc-99m HMPAO with SPECT.

The intracarotid amobarbital sodium, or Wada, test has been used to localize speech and memory function prior to surgical treatment of temporal lobe seizures. The authors mixed technetium-99m hexamethyl-propyleneamine oxime (HMPAO) with amobarbital sodium and injected the mixture in 25 patients with epilepsy. Single photon emission computed tomography (SPECT) of the brain was then performed to determine intracerebral distribution of the amobarbital sodium. Results of SPECT were compared with those of conventional and digital subtraction angiography (DSA). The distribution of Tc-99m HMPAO and, presumably, amobarbital sodium varied from patient to patient. SPECT revealed a statistically different distribution from that predicted with conventional angiography. The distribution also often differed from that of DSA, although the difference was not significant. SPECT revealed infrequent delivery to mesial temporal lobe structures. This emphasizes the need for caution in the use of the intracarotid amobarbital sodium test to predict the outcome of removal of these areas.

Factors affecting the incidence of postoperative wound infection.

A prospective study of postoperative wounds was carried out in West Dorset to determine the incidence of infection, describe the time distribution of presentation before and after discharge from hospital and identify possible contributory factors. There were 702 consecutive patients admitted to the study (600 in-patients and 102 day cases). Fifty one became infected (47 in-patients and 4 day cases), corresponding to an overall infection rate of 7.3%. Over 50% of infections presented during the first week after operation, and almost 90% were diagnosed within 2 weeks of surgery Twenty-eight (55%) wounds that became infected presented after hospital discharge. Of 23 specific aetiological variables studied, four (age, preoperative stay, shaving and the surgeon) were shown to have a statistically significant association with the development of wound infection. A strong association between the individual surgeon and the development of a wound infection was demonstrated and this supports the need for routine surgical audit.

The importance of surveillance after discharge from hospital in the diagnosis of postoperative wound infection.

A prospective survey was carried out in West Dorset to determine the incidence of postoperative wound infection. A total of 1242 patients were included in the survey (1086 inpatients and 156 day cases). The overall infection rate was 6.7%. Although the incidence of infection was consistent with that reported by other studies, the infection rate in the 'clean' surgical category was higher than in most other published reports. Careful surveillance after discharge from hospital may have been responsible for identifying cases of wound infection which otherwise might not have come to the attention of the study. Of patients whose wounds became infected, 34 (41%) cases were diagnosed in hospital and 49 (59%) cases were diagnosed in the community. Failure to pursue patients after discharge would have resulted in a substantial underestimation of the true wound infection rate.

Bowel visualization during indium-111-labelled diethylene triamine penta-acetic acid cisternography due to massive cerebrospinal fluid leak. Case report and review of the literature.

We report a case of massive cerebrospinal fluid (CSF) leakage where the tracer injected intra-thecally for radionuclide cisternography was later visualized in the bowel as well as the nasopharynx. We discuss the potential implications of this finding in patients with CSF leaks. A brief review of the diagnosis of CSF leaks is included.

Postanal repair and intersphincteric Ivalon sponge rectopexy for the treatment of rectal prolapse.

Twenty-four consecutive patients (mean age: 74 years) with complete rectal prolapse, fifteen of whom were incontinent of solid stool, have been treated by postanal repair and intersphincteric Ivalon sponge rectopexy. There was no operative mortality, or serious morbidity. There was one recurrence of complete prolapse which occurred 14 days after operation. The other 23 patients have been followed for up to 4 years. All patients who were incontinent of solid stool pre-operatively have been rendered continent. This type of operation may be the treatment of choice in the elderly, where an abdominal procedure is considered unwise and in cases of rectal prolapse associated with faecal incontinence.

The treatment of haemorrhoids by rubber band ligation at St Mark's hospital.

Two hundred and ninety-five patients with symptomatic haemorrhoids were treated by rubber band ligation as out-patients at St Mark's Hospital, London, between April 1972 and December 1975. Follow-up was possible in 260 patients of whom two-thirds were satisfied with the outcome: 69 patients had residual symptoms for which no treatment had been sought. Nineteen patients eventually required a haemorrhoidectomy.

Treatment of haemorrhoids in patients with inflammatory bowel disease.

A retrospective review of outcome was undertaken in forty-two patients with ulcerative colitis and twenty patients with Crohn's disease who were treated for haemorrhoids and the inflammatory bowel disease between 1935 and 1975. Both surgical and conservative treatment of haemorrhoids in patients with ulcerative colitis had low complication-rates (4 complications after 58 courses of treatment). In Crohn's disease the complication-rate was high (11 complications after 26 courses of treatment). One of the forty-two patients with ulcerative colitis and six of the twenty with Crohn's disease required rectal excision for complications apparently dating from the treatment of haemorrhoids. These results suggest that treatment of symptomatic haemorrhoids is usually safe in patients with ulcerative colitis but is contraindicated in those with Crohn's disease.

Calculus disease of the urinary tract at a district hospital.

At a District General Hospital the organization of a clinic for the investigation and treatment of patients with calculus disease of the urinary tract is described. The way in which such a clinic may be orgainzed is discussed and the results presented. In patients with idiopathic hypercalciuria, sodium cellulose phosphate causes a significant reduction in urinary calcium levels when used in such a clinic.

Colo-anal sleeve anastomosis in the treatment of diffuse cavernous haemangioma involving the rectum.

An operative technique, involving a colo-anal sleeve anastomosis, is described for the treatment of cavernous haemangioma of the rectum. All the patients with this condition treated since 1930 at St Mark's Hospital are reviewed, and the presentation and results of treatment in the last 5 patients who have had a resection and colo-anal sleeve anastomosis are discussed.