The development of multiple cutaneous inverted papilloma following ovariohysterectomy in a dog.

CASE HISTORY: Ovariohysterectomy was performed on an adult Cavalier King Charles Spaniel. The skin that had been clipped for surgery was noticed to be erythematous 8 days later. CLINICAL AND PATHOLOGICAL FINDINGS: Poorly defined patches containing multiple papules were visible bilaterally within the clipped skin. These became larger over the following 2 weeks, and samples were collected for histology. Seven days later, the lesions were multiple raised masses, up to 5 cm in diameter. Histology revealed numerous cup-shaped epidermal proliferations extending into the dermis. The presence of keratinocytes with increased quantities of blue-grey cytoplasm, and koilocytosis suggested papillomaviral infection; Canis familiaris papillomavirus (CfPV-2) DNA was amplified from two separate samples. Complete regression was observed 8 weeks after the lesions had been initially observed. DIAGNOSIS: Multiple inverted papilloma confined to skin that had been clipped for surgery. CLINICAL RELEVANCE: This is the first time that the development of canine cutaneous papillomas has been associated with surgery. The nature of the association between surgery and development of the papillomas is uncertain. However, it is possible that damage to superficial skin could promote the formation of papillomas. This is the first identification of CfPV-2 in New Zealand.

Head injuries: a prospective observational study evaluating the potential impact of the Galasko report on Accident and Emergency departments.

In June 1999, the Galasko report of the Royal College of Surgeons of England recommended that in the next 5 years, the Accident and Emergency (A&E) departments should admit and supervise head-injured patients for up to 48 h. A prospective observational study was carried out for a 6 weeks period at the A&E department of Birmingham Heartland's Hospital to identify the potential impact of implementation of the Galasko report. The cost implications of this perceived additional workload were considered.Of the 786 head-injured patients seen during study period, 665 (85%) were discharged home directly from the A&E department. Of the remaining 121 patients, who were hospitalized, 76 (63%) were admitted to the A&E observation ward (AEOW) and 19 (16%) patients were admitted to a paediatric ward. All of these patients were discharged home within 24 h. The remaining 21% patients were admitted to other specialities and had prolonged stays in hospital. All of the 9% of the patients admitted under orthopaedics would have been admitted to the AEOW if the Galasko recommendations were implemented leading to an extra 22 bed days over the 6 weeks study period. The estimated annual cost of admission alone for these patients would be pound 38,200. Our study has demonstrated an expected additional workload and cost implications on a single A&E department.

Accident and emergency medicine--still a useful 'apprenticeship'?

The objective of this study was to compare the expressed confidence of senior house officers (SHOs) at performing practical medical procedures before and after working in an accident and emergency (A&E) post. The extent of formal teaching of these skills and opportunity for independent performance of them was also assessed. A postal questionnaire was sent to all SHOs completing an A&E post in the Trent region of the United Kingdom. Doctors were asked to grade their subjective confidence at performing listed practical skills before and after working in A&E. Eighty-four replies from 120 questionnaires were received (70% response rate). There was a significant improvement in confidence ( <0.0001) for all the skills studied after working in A&E. The proportion of doctors who received instruction varied for each of the skills. The expressed confidence of SHOs in performing practical procedures improved dramatically after working in A&E. Although remaining a valuable 'apprenticeship' for junior doctors, structured training is inadequate in the accident and emergency SHO post.

Difficult airway management of a child impaled through the neck.

We report the difficult airway management of a child impaled through the neck by a wooden plant support. The various options are discussed and the involvement of experienced personnel together with a clear preformulated plan of action is stressed.

Combined brachial plexus and vascular injury in the absence of bony injury.

Neurovascular injury to the axillary vessels is well described in association with fracture or dislocation involving the shoulder joint or the humerus. Such injury however can also occur in the absence of bony injury. A case is presented of damage to the axillary artery and brachial plexus following blunt trauma. This case demonstrates that complex neurovascular damage can occur in the absence of fracture or dislocation. The importance of a thorough clinical assessment is highlighted and priorities with regard to diagnosis and management are discussed.

Patient radiation dose during lithotripsy.

Measurements were made of the radiation dose to patients undergoing lithotripsy. Two groups were studied; patients undergoing ultrasound localization of calculi, and patients undergoing fluoroscopic localization. Dose area product (DAP) measurements were obtained using a Diamentor ionization chamber. Ultrasound localization produced a mean DAP of 137 cGy cm2 equivalent to a mean effective dose of 0.24 mSv. Fluoroscopy localization produced a mean DAP of 552 cGy cm2 equivalent to a mean effective dose of 1.2 mSv. There was no correlation between stone size and fluoroscopy time. We recommend the use of ultrasound localization as a first option whilst restricting the use of fluoroscopy (preferably pulsed) for ureteric and difficult renal calculi.

Computed tomography of the head by the accident and emergency department--why 24 hour access is vital.

OBJECTIVE: To examine the use made of 24 hour access to computed tomography from an accident and emergency (A&E) department and to assess whether clear benefits for patients could be identified by having such a service. METHODS: Retrospective review of 176 cases where computed tomography was ordered by A&E staff of a large teaching hospital over a one year period. RESULTS: 53% of scans were done "out of hours"; 97% of scans performed (171/176) were studies of the brain. Three examinations were of the cervical spine and two were of the chest. 54% of head scans (93/171) were performed for either confirmed or suspected trauma with 46% (78/171) done for medical indications. Only 16% (11/71) of patients who had a head scan for acute trauma required transfer to the regional neurosurgical unit after consultation. Computed tomography was 100% sensitive in the diagnosis of sub-arachnoid haemorrhage. In cases where computed tomography was performed for coma of undetermined origin the pathology causing coma was identified on computed tomography in 50% of cases. CONCLUSIONS: Computed tomography facilities allow comprehensive initial evaluation of the head injured patient and minimise hazardous and expensive transfer of these seriously ill patients. Experience shows that it is a vital tool in the initial differential diagnosis of the comatose patient and therefore must be available for use by senior and middle grade A&E staff on a 24 hour basis.

"Not so immediate" hypersensitivity--the danger of biphasic anaphylactic reactions.

OBJECTIVE: To assess how commonly clinically significant biphasic anaphylactic reactions occur after apparently successful treatment of an anaphylactic reaction. Cases were analysed to determine whether there were any markers that would allow early identification of patients who would subsequently develop a biphasic response. METHOD: Retrospective review of case notes of 34 patients admitted for observation after an anaphylactic reaction that had required treatment with adrenaline. RESULTS: Six patients (18%) had biphasic reactions. No clinical features on initial presentation identified those likely to have a biphasic response. These patients however required significantly more adrenaline to ameliorate their initial symptoms (p = 0.03) compared with those having a simple uniphasic reaction. CONCLUSIONS: Biphasic anaphylactic reactions occur frequently. There are no clinical features that allow identification of patients likely to have a biphasic response. These patients require higher doses of adrenaline to control their initial symptoms and this should be considered a marker for patients who may develop a biphasic response. These results confirm that all patients being discharged after treatment for an acute anaphylactic reaction must be made aware of the risk of a second phase response after apparent clinical resolution.

Dermatobia hominis in the accident and emergency department: "I've got you under my skin".

An unusual form of larval infestation from South America is presented which, in view of increasing tourism to South america's tropical areas, may present to any accident and emergency department. Infestation with Dermatobia hominis is reviewed in terms of clinical recognition and life cycle. Techniques of removal are described.

The changing profile of poisoning and its management.

To identify changes in treatment methods and types of drugs taken in overdoses over a 10-year period we conducted a retrospective study in the accident and emergency department of a large teaching hospital. The influence of a protocol to direct medical management was also studied. Results were compared with those of a 1984 survey at the same institution. 409 cases of accidental and deliberate poisoning were reviewed. In deliberate poisoning 52% of drugs taken were prescription drugs, 41.6% over-the-counter medications and the remaining 6.4% illicit drugs. Only 13% of patients had a stomach emptying procedure compared with 75.2% of patients in the previous survey. Charcoal was administered or offered in over 95% of cases. Medical management of overdoses in this centre changed drastically over 10 years. A department protocol had been adhered to in the great majority of cases, and we recommend that all accident and emergency departments as well as medical and paediatric teams establish similar protocols. Over-the-counter drugs are increasingly troublesome, especially paracetamol, which accounts for 28.8% of drugs taken in deliberate overdose.

The use of CT scanning by accident and emergency departments in the UK: past, present and future.

To determine the access to and use of computed tomography (CT) scanning by Accident and Emergency (A&E) departments a questionnaire was sent to all major A&E departments in the UK. Although CT scanners were present in over 80 per cent of the 225 responding hospitals, many centres (including 15.8 per cent of those with a CT scanner on site) did not have 24 h scanning facilities for emergency cases. Few departments (26 per cent) have agreed protocols with their radiology departments with regard to CT scanning and some departments transferred cases for emergency CT scans at another hospital. There are deficiencies in access to CT scanning in a significant number of hospitals. This results in some patients undergoing hazardous and in our view unnecessary transfer for scanning. Little use is made of agreed protocols between A&E and Radiology departments to simplify and speed up the process of arranging CT scans. We feel that the deficiencies identified need to be addressed particularly in the assessment of head injury.

Near asphyxiation with a child's dummy.

A case is reported of near asphyxiation in a child caused by impaction of a dummy in the upper airway. Previous similar cases are described and recommendations made for changes in the design of children's dummies to improve their safety profile.