Symptoms, diagnosis and endoscopic management of common bile duct stones

Symptomatic BDS commonly cause significant morbidity and attempt at stone removal should be attempted if possible. Complications of CBDS include biliary colic, jaundice, cholangitis and pancreatitis. Investigations aimed to predict the presence of stones within the bile duct include serum bilirubin, AST, ALP, common bile duct diameter and age as independent predictors of choledocholithiasis. TUS is a sensitive test in detecting bile duct dilatation but the sensitivity is reduced in its ability to detect choledocholithiasis. A NIH consensus statement found that ERC, MRC and EUS were comparable in their sensitivities, specificities and accuracy rates for detection of choledocholithiasis. ERC and stone removal using a balloon or basket is often performed following EST. EBD may be performed if patients have uncorrected coagulopathies but the risk of pancreatitis is higher than for EST (although the risk of bleeding complications is lower for EBD). ML is often required in difficult to remove CBDS and using this device, CBDS can be removed in 90–95% of cases. Other forms of lithotripsy including laser lithotripsy and EHL are confined to specialised centres and the evidence for their use is based on small studies. ESWL may clear stones from the bile duct in up to 93% of patients but frequently ERC and stone fragment removal is required post ESWL. The role of medical therapy in difficult to remove CBDS (or in CBDS in patients with severe co-morbid illness preventing ERC + stone removal) is still currently uncertain due to a lack of large randomised control trials.     

A Latex Finger Strip and Nylon Zip-Tie Combo as a Tunable Digital Tourniquet

BACKGROUND: Surgery on digit and nail requires a clear bloodless field that is often achieved by a tourniquet. OBJECTIVE: The objective is to present a simple, effective, and safe tourniquet for digital surgery. MATERIALS AND METHODS: A latex glove and a nylon zip-tie were used. A long strip is cut from the little finger tube of a latex glove. This is used for wrapping around the digit for exsanguination. The pressure is then maintained with a household nylon zip-tie. The finger strip is then cut to expose the operative field ready for surgery. The tourniquet pressure can be adjusted by tightening or loosening of the nylon zip-tie. RESULTS: Exsanguination and a bloodless field can be effectively achieved. The long tail of the nylon zip-tie reminds the operator to remove it at end of the surgery. CONCLUSION: A latex strip and nylon zip-tie combo serves as a simple, effective, and safe tourniquet for digital surgery.     

HYPOKALEMIA IN THE ELDERLY: IS IT ALWAYS DIURETIC-INDUCED?

SUMMARY Serum potassium was measured within 24 hours in 156 patients (48 male, 108 female) with an average age of 81.9 years admitted to the unit with acute illness. Of the 156 patients, 88 (56.4%) were taking diuretics (none was on ACE inhibitors); 20 patients (12.8%) were also on digoxin therapy. In all, 24 patients (16%) had hypokalaemia and 3 (2%) hyperkalaemia. Hypokalaemia was seen in patients associated with acute illness. There was no significant difference between the diuretic and non-diuretic groups. Monitoring of serum potassium is not routinely indicated to detect hypokalaemia in patients on diuretic therapy except in those with severe hepatic or renal impairment or those on digoxin.     

Building a relationship: communications and relationships between staff and stroke patients on a rehabilitation ward

Communications among staff and patients on a stroke rehabilitation ward form the focus of this article, which reports on some aspects of a larger study using a grounded theory approach. Tape-recorded interviews were transcribed and analysed concurrently according to recommendations for the approach. A main theme entitled building a relationship was identified, and this process was found to occur in a context varying from participative at one end of a continuum to hierarchical at the other. Building a relationship was found to be influenced by role, personal qualities and organizational context. Appropriate relationships between role-holders were subject to negotiation, leading to a resulting congruence or incongruence between participants' expectations of each other and their roles. Personal qualities were brought into play in the process, with patients' views of staff and staff views of patients both being influential. Some of these views seemed to parallel what has been described in earlier literature as ‘the sick role’ and the labelling of patients as ‘good’ or ‘bad’. Responses to personal qualities led to nurses ascribing meaning to patients' behaviour in terms of adjustment to their stroke, giving time to them to help them to adjust, and withdrawal and handing over to other staff if this strategy failed. Organizational context also had an influence on building a relationship, with time constraints being identified particularly by nurses, and the need to fit in the most essential aspects of care. Place was also important, in that nurses were confined to the ward as a work location, whereas other therapists and doctors worked in other places and sometimes had the facility to take patients off the ward to concentrate on therapy. The findings are discussed against the background of related literature and the conclusion is drawn that the crucial role of nurses in rehabilitation is not recognized and valued, and that shortages of resources - especially suitably qualified and trained nursing staff- are a negative influence on building the relationships which are vital to successful rehabilitation.     

Evolution of a form of pure alexia without agraphia in a child sustaining occipital lobe infarction at 21/2 years

The progress of cognitive visual dysfunction over an 8-year period of a child who sustained bilateral occipital-lobe infarctions at the age of 21/2 years is described. She survived with normal intelligence and went on to attend mainstream school. She manifested many features of cognitive visual impairment and, in particular, developed a form of pure alexia without agraphia. She achieved some letter-by-letter reading but no sight vocabulary development, including to her own name. She learned to write imaginatively employing phonetically true spelling but cannot read what she has written. Her progress and the difficulties encountered during the management of her condition are discussed in this first case report of the evolution of pure alexia without agraphia in childhood. The features of this syndrome in the developing child who has never developed the capacity to read are contrasted with that seen in affected adults.     

A personal computer database system for head and neck cancer records

The computerized database system described was initially developed in 1986 to facilitate analysis of retrospective head and neck cancer data from the Royal Adelaide Hospital Department of Otolaryngology. This has now been expanded to become an on-going patient information management system. It is based on the dBase-III-Plus database package and is implemented on an IBM XT compatible computer. The system was designed to be used by staff without specialist computer skills and is therefore largely “menu-driven.” The main functions include patient record creation, update, and retrieval, and the production of reports including graphical presentations. There is also a powerful but easy to use query facility. The system has already provided much useful epidemiological material but is now beginning to fulfill an even more important role in patient follow-up and in assisting evaluation of alternative treatment protocols.