Life-threatening stridor presenting in a patient with rheumatoid involvement of the larynx.

A case of a female patient with extensive rheumatoid arthritis who presented to the Accident and Emergency Department with life-threatening stridor is described. Although clinical involvement of the larynx is found in over a third of patients with severe rheumatoid arthritis, acute airways obstruction is fortunately a very rare complication. Stridor is probably precipitated in the acute situation in such patients as a result of upper respiratory tract infection.

Computer-unaided diagnosis of acute abdominal pain in an accident and emergency department.

The initial accident and emergency and final in-patient diagnoses of 200 patients with acute abdominal pain made without computer aid or structured data sheet were compared. Sixty-five per cent were correctly diagnosed and 5% had normal laparotomies. These results compare favourably with those obtained using computer aid and structured history-taking forms. It is suggested that the spotlight should be on the training and experience of doctors making the initial diagnosis rather than on computer aid.

Fournier's gangrene.

Over a 5-year period 43 men with severe classic Fournier's gangrene of the scrotum and perineum and in some cases of the abdominal wall were treated at King Edward VIII Hospital, Durban. There were 8 deaths, an overall mortality rate of 18,6%. The mortality rate was high (33%) when associated with diabetes mellitus and lower (14,7%) among non-diabetic patients. There was also an increased mortality rate when there was a delay in presentation (of over 6 days in the case of all the patients who later died). We have adopted a policy of aggressive surgical debridement and frequent revision, coupled with the use of broad-spectrum antibiotics.

Prevention of septic complications in massive pelvic-perineal injuries. Case reports.

If they do not immediately lead to death, severe injuries of the pelvis and perineum are frequently complicated by serious invasive infection. This results in a considerable number of late deaths. Adherence to a strict treatment protocol aimed at the prevention of septic complications has undoubtedly reduced the mortality rate related to these injuries. The different aspects of our treatment protocol are outlined, and comprise: (i) antibiotic prophylaxis; (ii) assessment under general anaesthesia; (iii) radical surgical debridement; (iv) diversion of the faecal stream; (v) conservative management of urethral injuries; and (vi)frequent revision of the wounds at 24 - 48-hour intervals. Eight consecutive patients in whom septic complications were successfully prevented are reported on.

Behaviour of synthetic absorbable sutures with and without synergistic enteric infection.

The behaviour of synthetic absorbable sutures, polyglycolic acid (PGA) and polydioxanone (PDS), has been tested in an experimental guinea pig model utilising synergistic enteric bacteria. Braided PDS gave a wound sepsis rate of 42%, monofilament PDS 36%, and PGA 26%, while sepsis rate in the controls was 30%. The dissolution characteristics of PGA and monofilament PDS appeared to be unaffected by the presence of infection, while that of braided PDS was significantly increased. Braided PDS also showed more rapid dissolution characteristics than PGA.

An experimental study of the relationship between synergistic wound sepsis and suture materials.

In wounds on the back of guinea-pigs an inoculum of 6 x 10(5) of Escherichia coli and of Bacteroides fragilis produced a frank infection rate of 27 per cent. Addition of a catgut or a braided nylon tie statistically significantly increased the rate to 56 and 48 per cent respectively. Prolene and silk produced much smaller, non-significant rises. The rate with polyglycolic acid was 18 per cent which, though not statistically significant, suggests the possibility that this material produces conditions unfavourable to multiplication of bacteria that produce this type of infection.

Intraoperative irrigation of the colon to permit primary anastomosis.

A technique is described which permits intraoperative application of antegrade bowel irrigation to clear the obstructed or loaded colon of faeces with minimal risk of contamination. The procedure extends the indications for safe primary anastomosis in surgery of the left colon.