Caecal volvulus: high index of suspicion is the key to early diagnosis.

Caecal volvulus represents an uncommon acute surgical presentation of bowel obstruction. Familiarity with particular long-term symptoms and pre-disposing factors can help a clinician identify caecal volvulus as a possible diagnosis. There has been a changing vogue of radiological investigation and surgical interventions. We present a summary of these options.

Comparison of appendicectomy outcomes: acute surgical versus traditional pathway.

INTRODUCTION: The acute surgical unit (ASU) is an evolving novel concept introduced to address the challenge of maintaining key performance indicators (KPIs) in the face of an increasing acute workload. METHODS: The aim of this retrospective study was to compare the performance of the ASU (from June 2008 to December 2010) at Auckland City Hospital with the traditional model (from January 2006 to May 2008) and benchmark the results against other similar published studies. The analysis was on the basis of KPIs for 1857 appendicectomies, which form a large volume of acute surgical presentations. RESULTS: Our results show significant improvement in length of stay (2.8 days, 2.6 days, P = 0.0001) and proportion of daytime operations (59.4%, 65.8%, P = 0.004), in keeping with other studies on benchmarking. CONCLUSION: The introduction of ASU has led to significant improvements in some KPIs for appendicectomy outcomes in the face of an increasing workload.

Antithrombotic therapy in atrial fibrillation: an assessment of compliance with guidelines.

AIM: To assess physician compliance (at South Auckland's Middlemore Hospital) with two international guidelines on the prevention of thromboembolic complications of atrial fibrillation (AF). The two guidelines are The American College of Cardiology/American Heart Association/European Society of Cardiology consensus group (ACC/AHA/ESC guidelines-2001) and the American College of Chest Physicians guidelines (ACCP guidelines-2001). METHOD: A retrospective review of patients who presented to the emergency department with AF between 1 December 2001 and 28 February 2002. Antithrombotic treatment was compared with that recommended by the above stated international guidelines. It was hypothesised that 20% variance from guideline recommended treatment was clinically significant. The incidence of stroke in the study group was followed over a 12-month period. RESULTS: Eighty patients were included in the study. The proportion of patients managed in accordance with the ACC/AHA/ESC and ACCP guidelines was 47.5% (95% CI 36.2-59.0) and 31.2% (95% CI 21.3-42.6) respectively. This was significantly different from that hypothesised (p<0.0001). Only 47.4% (95% CI 34.0-61.0) and 47.3% (95% CI 33.6-61.2) of eligible patients, according to ACC/AHA/ESC and ACCP guidelines respectively, received warfarin. This was also less than hypothesised; p<0.0001. High-risk patients were less likely to be given warfarin if they were older (p<0.03). Four patients had a stroke at follow-up. These patients were not on warfarin, although recommended by the guidelines. CONCLUSION: Warfarin is significantly underutilised in patients with AF at our institution.

Reduced glutathione: Importance of specimen collection.

Glutathione, the dominant intracellular thiol, plays an important protective role against oxidative stress. The accidental findings of increased reduced glutathione level postprandially as compared to post absorptive level prompted the design of present study. Reduced Glutathione levels were estimated in 50 healthy individuals in post absorptive and postprandial phase by taking whole blood in ACD bulb. Mean postprandial reduced Glutathione (9.60±3.39 µmole/gm of Hb) is significantly increased than mean postabsorptive level (5.53±0.88 µmole/gm of Hb; p<0.001). It also shows positive correlation (r=0.65) between these two GSH levels. So present study suggests that post absorptive specimen collection is preferable over random or postprandial as the former reflects the true basal level of reduced glutathione.

Serum calcium measurement: Total versus free (ionized) calcium.

Measurement of serum free (ionized) calcium (Ca(++)) reflects true calcium status of the body in health and disease. Present study evaluates efficacy of Ca(++) over total calcium (CaT) in serum for calcium status. 52 subjects were enrolled for study. Anaerobic fasting blood sample for Ca(++) measurement and autoclaved plain bulb for estimation of CaT, Total protein (TP) and Albumin was used. CaT, Corrected CaT, Ca(++), Calculated Ca(++) were measured and correlated. Corrected CaT and calculated Ca(++) were derived from the measured parameters. Study group showed significant difference between CaT and corrected CaT (p<0.006), Ca(++) and calculated Ca(++) (p<0.001). Negligible correlation was observed between Ca(++) and serum protein. Positive correlation was observed between CaT and calculated Ca(++), TP and albumin. Findings indicate that Ca(++) levels are independent of serum protein status. With scrupulous sampling, Ca(++) may be a better parameter than presently used CaT for assessing calcium status in serum.