Appendicectomy deferred to a CEPOD list: the patients' opinion

AIMS: Implementation of NCEPOD guidelines to avoid out-of-hours operating, Junior doctors' 'New Deal' and EWTD have significantly altered surgical practice. Patients admitted 'out of hours', who need an emergency procedure, are often deferred until the next day. We have attempted to assess patients' opinions of this management plan. METHODS: Consecutive patients admitted with uncomplicated appendicitis and operation deferred to the next day according to NCEPOD guidelines were studied. A surgeon, other than the one carrying out the initial assessment, performed the operation on a scheduled morning emergency list. A full explanation was given to patients regarding reasons for deferring operation, and they found out that a different surgeon would be performing their operation. Patients completed a questionnaire post-operatively. RESULTS: 42 patients were studied; median age 24 years (range 17-69); 32 men, 10 women. Thirty presented after 6 p.m. and eight after midnight. The remaining four were admitted during the day. Only one third of the patients recalled reasons for deferred operation with seven not remembering being given an explanation. Two thirds (n=27) of the patients slept poorly pre-operatively, principally due to pain (17) and ward noise (10). Operation on the same night as their admission was the preferred option in 24 patients. All of these slept poorly. Some 22 patients would have preferred the admitting surgeon to have performed their operation; 16 expressed no preference. Only four patients preferred a 'new' surgeon the following day. Of the 42 patients, 28 did not know who had performed their operation. CONCLUSION: Despite being told why their operation was delayed most patients would prefer not to have their procedure delayed. Lack of sleep pre-operatively is a major determinant of patient opinion. Few patients wanted a 'new' surgeon to perform their operation.     

A modification of the urine osmolal gap: an improved method for estimating urine ammonium

A modification of the urine osmolal gap was evaluated as an estimate of urine [NH4+]. We proposed that: Urine [NH4+] = Urine osmolality - [2(Na+ + K+) + urea + glucose]/2 Spot urine samples were collected from normal volunteers and from individuals with ketonuria; the modified urine osmolal gap as well as two other previously described estimates of urine [NH4+] were compared with measured urine [NH4+]. There was a significant positive linear correlation between the urine [NH4+] and the modified urine osmolal gap in normal volunteers (r = 0.81; p less than 0.01) and in individuals with ketonuria (r = 0.93; p less than 0.001). The originally described urine osmolal gap greatly overestimated the urine [NH4+] but also showed a significant correlation. The urine anion gap was not a valid estimate of urine [NH4+] within the range of values measured in our subjects. The modified urine osmolal gap is an improvement over previously described estimates of urine [NH4+] and can be used as a single calculation in place of the other two.     

Green urine: an association with metoclopramide

Sir, Green urine is a distinctly unusual and intriguing finding inclinical medicine. A healthy 28-year-old man presented to theemergency department with abdominal pain, nausea and vomitingof 1 day's duration. He did not take any medications, supplementsor any unusually coloured food items. The patient was afebrilebut had evidence of volume depletion     

Renal response to boxing: an investigation of changes in the urine in amateur boxers

It has been well established that self-limited, benign changes frequently occur in the urine following exercise. This study was undertaken to evaluate potential changes in the urine of amateur boxers. Demographic data, a boxing history, a complete medical history, and a physical examination were obtained for each subject. Prefight and postfight urine specimens were examined for comparison. The data were subjected to statistical analysis in order to evaluate the significance of mean changes by using an independent one-way analysis of variance. The authors used the least significant difference test designed by Fisher. Results of this study revealed no clinically significant effect on urine variables other than changes normally associated with comparable strenuous exercise of other types. However, the long-term effect of boxing on renal function was not explored. Therefore, the authors recommend that all boxers undergo a urine evaluation as a routine part of their ongoing physical examinations.     

地塞米松防治皮瓣缺血-再灌注损伤及其机制

目的研究地塞米松对中性粒细胞凋亡与坏死的调控,阐明地塞米松防治皮瓣缺血-再灌注损伤的机制. 方法 30只Wistar大鼠腹部制备3 cm×6 cm 岛状皮瓣,分成3组(n＝10).A组正常皮瓣组;B组阻断静脉8 h,腹腔注射生理盐水作为对照组;C组阻断静脉8 h,腹腔注射地塞米松5 mg/kg,作为治疗组.术后7 d观察皮瓣成活面积;以Annexin V及Propidium双标记,流式细胞仪检测全血中性粒细胞凋亡、坏死水平;电镜观察凋亡、坏死中性粒细胞的形态.并于术后1 d,从各组大鼠皮瓣中央取材,电镜观察吞噬细胞吞噬凋亡中性粒细胞形态.阻断血管前,再灌注损伤后0、 3、6、12 及 24 h,以双夹心ELISA法测量血浆肿瘤坏死因子α(tumor necrosis factor α,TNF-α)及白细胞介素10(interleukin 10,IL-10)浓度. 结果皮瓣成活面积A、C组大于B组(P<0.05),A、C组差异无统计学意义(P＞0.05).术后1、3 d,B组全血中性粒细胞凋亡含量明显低于A、C组, 6 d高于A、C组.术后1、3、6 d,中性粒细胞坏死水平B组高于A、C组.术后1 d,皮瓣中吞噬细胞吞噬凋亡中性粒细胞的数量C组明显高于B组(P<0.05).B组血浆TNF-α于再灌注1 h达到高峰,IL-10于再灌注3 h达到最低.C组TNF-α峰值明显低于B组,6 h即明显下降;IL-10再灌注1h达最低,3 h时明显上升,其浓度明显高于B组. 结论地塞米松防治皮瓣缺血再灌注损伤的机制在于调理了中性粒细胞的凋亡水平,减少了中性粒细胞的坏死数量,平衡了中性粒细胞分泌细胞因子.