Evaluation of the modified Alvarado score in the diagnosis of acute appendicitis: a prospective study.

The Alvarado score was assessed as to its accuracy in the preoperative diagnosis of acute appendicitis. A series of 49 consecutive patients was studied prospectively over a period of 9 months in two hospitals (Gateshead and Sunderland). The presence of a high score was found to be an easy and satisfactory aid to early diagnosis of appendicitis in children and men. However, the false-positive rate for appendicitis in women was unacceptably high.

Comparison of saphenous versus jugular veins for central venous access in children with malignancy.

A retrospective analysis was carried out to compare the performance and complications of central catheters inserted into either the saphenous (27) or jugular (52) veins. The saphenous route may be preferred in certain circumstances including extensive mediastinal pathology, prior neck surgery, previous catheter(s), and cosmetic reasons. There was no difference in complications (local or systemic catheter-related infections, catheter occlusions, or venous thrombosis). The incidence of catheter removal due to complications was also not different between sites. Hence, the saphenous route can provide an additional portal of vascular access in selected patients.

Five years' experience with long saphenous catheterisation for chronic venous access.

The five-year experience by one surgical team of the implantation of 419 chronic venous access catheters in 368 adults and children is reported. The majority of the catheters were required for the management of malignant disease but some were used for long-term home parenteral nutrition. The inferior vena cava was cannulated through the long saphenous vein in 181 cases and the superior vena cava by the jugular or cephalic veins in 238. Mean catheter lives of over one year, with individual lives of more than three years were achieved by both routes. The overall infection rate was 18%. No excess of thrombotic or infective complications was observed in patients with long saphenous vein catheters. It is suggested that the long saphenous vein is an appropriate route for chronic venous access for chemotherapy in most patients.

The impact of an endoscopic laser service on gastroenterological practice.

During the 18 months following the introduction of a neodymium yttrium aluminium garnet laser in Newcastle upon Tyne 48 patients were treated, 23 for haemorrhage from peptic ulcers or vascular anomalies of the gut and 25 for palliation of inoperable tumours of the oesophagus, stomach and rectum. The treatment was tolerated well and was effective both for the arrest of haemorrhage and relief of dysphagia. Laser treatment has now entered the realms of routine clinical practice but its high cost and the operator expertise required suggest that its availability should be limited to designated centres.

Nutritional status in cancer.

A decline in nutritional status is seen in many, but not all cancer patients. The factors leading to this decline are complex and include anorexia, malabsorption and alterations in energy expenditure. The end result of this decline is cachexia, but it is questionable whether this syndrome differs materially from that seen in severe undernutrition arising from other causes. Of the measurable changes in body composition taking place in cancer patients those of most importance are losses of lean tissue, which result in a reduced functional capacity for organ systems. Such losses are difficult to detect because accumulated water may mask many of the early changes in composition and make conventional assessment of nutritional status unreliable. Nutritional support should be provided for undernourished patients, irrespective of the primary cause of their poor nutrition, but there is no convincing evidence that the treatment of nutritional deficiencies alone improves the outcome in cancer patients.

Digital vascular imaging of neck veins for the insertion of chronic venous access catheters.

A new technique using standard radiological methods, non-ionic contrast material coupled with digital subtraction angiography, has allowed reliable imaging of the external jugular veins, with high patient acceptability and no complications. This has enabled easier surgical insertion of chronic venous access catheters.

Cancer cachexia--a clinical entity?

A number of metabolic abnormalities associated with cancer may interfere with normal starvation-adaption to alter the pattern of tissue loss in individuals with cancer. The cachexia thus produced is said to differ from simple under-nutrition and may therefore be detectable using simple clinical methods. Seven measurements commonly used for nutritional assessment were made before treatment in 72 patients with cancer and 89 patients who were undernourished but cancer-free. Body weight as a percentage of ideal weight, arm muscle circumference, triceps skinfold thickness, plasma protein, albumin and transferrin and the peripheral blood lymphocyte count did not differ significantly between the groups. If body composition in cancer cachexia differs from that found in comparable simple undernutrition then such variations are not detectable by a standard nutritional assessment.

A programable calculator system for the estimation of nutritional intake of hospital patients.

The estimation of nutritional intake of hospital patients is made laborious because of the multiplicity of proprietary feeding products. A programable calculator-based system to estimate intake from oral, enteral, and intravenous sources is described. The system is portable, accurate, and rapid and can be used easily by nondietary personnel. A retrospective study using the system found that actual nutritional intake was 20% or more below the prescribed intake for over half of 14 patients under the care of a Nutritional Support Team. It is suggested that frequent and rapid assessment of actual daily nutritional intakes using a system such as this can improve nutritional care and allow more efficient utilization of Nutritional Support Service personnel.

Comparison of proprietary elemental and whole-protein diets in unconscious patients with head injury.

Forty men who had sustained head injury were randomly assigned to one of five groups to receive 0.2 g nitrogen/kg body weight/day as either an elemental or a whole-protein diet. Three proprietary elemental and two whole-protein diets were compared. The mean daily nitrogen intake was below 0.2 g/kg in all groups, and was significantly lower in the groups receiving elemental compared with whole-protein diets. Energy intake was significantly different only between one group receiving an elemental and one receiving a whole-protein diet. Mean daily urinary nitrogen excretion was significantly lower in the groups receiving elemental diets, and mean daily nitrogen balance was negative in all groups except one receiving a whole-protein diet. Reduced nitrogen intakes occurred particularly with the elemental diets, which often provoked reflex vomiting or gastric stasis. The need to introduce diets at reduced strength made a negative balance almost inevitable, but nutritional balance seemed to be more readily achieved with the whole-protein diets. More work is needed to assess the relative merits of these proprietary diets compared with tube feeds prepared in hospitals.

A pocket calculator program for intravenous requirements.

A program to calculate the 24-h intravenous requirements of water, nitrogen, energy and six electrolytes on a card-programmable pocket calculator is described. Comparison of calculator-generated requirements with intravenous feeding regimens prescribed by junior clinicians for 8 ill patients suggests that the clinicians provide too much water and too little nitrogen and energy. Certain program modifications are necessary to widen the useful clinical application of the calculator, but in general it is a useful bedside tool capable of further application to suitable medical tasks.

Ketosis and nitrogen excretion in undernourished surgical patients.

Hormonal and substrate profiles and urinary nitrogen and urea excretion were measured in 78 underweight patients admitted for surgical investigation, who were placed into either a normo- or a hyperketonemic group, depending upon their levels of acetoacetate and beta-hydroxybutyrate. The two groups were otherwise similar in terms of weight loss, arm muscle circumference, triceps skinfold thickness, and serum protein levels. Before surgery only one-quarter of them were hyperketonemic displaying mean glucose, insulin, and glucagon levels characteristic of starvation-adaption, and excreted significantly less urinary nitrogen than in normoketonemic group. Those patients who underwent surgery tended to retain their presurgery hormonal and substrate profile. The normoketonemic group excreted significantly greater amounts of urinary nitrogen, depleted body protein to a greater extent as evidenced by larger changes in arm muscle circumference and serum protein levels, and mortality was greater. Interference with insulin-glucagon balance by sepsis and disease is suggested as a possible explanation for the failure of three-quarters of the patients to become starvation-adapted. The implications of this finding on the parenteral feeding of undernourished patients are discussed.