APACHE II score and abdominal sepsis. A prospective study

Therapeutic trials for intra-abdominal sepsis require pretreatment stratification; physiologic scoring has been recently proposed for this purpose. We have prospectively tested the validity of one such scoring system, namely, the Acute Physiology and Chronic Health Evaluation (APACHE II). As part of a larger database, we correlated APACHE II scores with mortality in 100 patients hospitalized for generalized peritonitis or abdominal abscess. Use of steroids was recorded because of our suspicion that steroids increase mortality but blunt the physiologic response to sepsis. Thirty-one patients died, including 12 of 19 patients receiving steroids. Stepwise discriminant analysis revealed that the APACHE II score and steroid use were each independently associated with the rate of mortality. We report a prospective validation of pretreatment APACHE II scoring in abdominal sepsis. Steroid use is an independent risk factor.     

C-reactive protein levels predict postoperative septic complications

We studied 108 patients undergoing clean-contaminated and dirty surgical procedures to determine whether daily C-reactive protein (CRP) measurements for 14 days postoperatively could predict the occurrence of septic complications prior to clinical diagnosis. Diagnostic criteria for septic complications and positive CRP response were defined in advance of the study. The CRP assays were carried out using an automated laser nephelometer system after the patient's discharge from the hospital. Forty-six septic complications were diagnosed in 40 patients. These complications consisted of wound infection (23), urinary tract infection (11), pneumonia (six), upper respiratory tract infection (three), intra-abdominal abscess (one), and other (two). The CRP testing was found to have a positive predictive value of 69% and a negative predictive value of 78%. We conclude that serial CRP measurements may be a valuable adjunct to surgical care in patients at high risk of postoperative septic complications.     

On the Edge: a drama‐based mental health education programme on early psychosis for schools

Aims: On the Edge is a mental health education programme designed to support early intervention by increasing knowledge and understanding of early psychosis, reducing the stigma associated with mental health issues and improving awareness of avenues of help. The target audience was young people aged 14–22 years in schools and colleges. Methods: An interactive drama programme was developed through collaborative working across psychiatry, applied drama and those with direct experience of psychosis. A national tour engaged 2500 students in 71 performances that took place in 51 schools and colleges. The programme was evaluated against its aims with data collected both during and after the tour. Results: Quantitative and qualitative evaluation found significant gains with respect to all three aims. Thirty‐one schools developed supportive links with local mental health services. Conclusions: This programme shows the value and effectiveness of delivering health education on early psychosis through the medium of applied drama, and offers a model for a programme that can be incorporated into early intervention services. Lessons learned through delivering this programme are a valuable contribution towards future developments of mental health education programmes for schools.     

Children's categorisation of play and learning based on social context

While much time has been spent deliberating about the definition of play, little emphasis has been placed on what children themselves perceive as play. The aim of the present study was to examine social context as a cue for children's perceptions of play and learning. Ninety-two children aged between four and six years (mean four years nine months) participated in the study and completed the Activity Apperception Story Procedure. Children were asked to sort photographic stimuli into those they believed depicted play/not play and learning/not learning. Each of the stimuli were identified by independent raters as containing one of the following social cues; teacher absence (solitary activity, parallel activity or cooperative activity) or teacher presence (teacher involved activity or teacher directed activity). Findings revealed that children associated teacher absence with play. More specifically, children made links between play and the presence of peers (parallel and cooperative activity). Findings are discussed in relation to play in the early years curriculum, differences in children's early educational experiences and the importance of understanding children's perceptions of play.     

Common pancreaticobiliary channels and their relationship to gallstone size in gallstone pancreatitis.

Bile reflux into the pancreatic duct after impaction of a stone in a common pancreaticobiliary channel has been suggested to be the initiating factor in gallstone pancreatitis. Such reflux would require that the impacted stone be smaller than the length of the common channel. The incidence of common channels was studied and gallstone size was compared with common channel length in patients with gallstone pancreatitis and those with cholelithiasis or choledocholithiasis without pancreatitis. Sixty-seven per cent of patients with gallstone pancreatitis had a common channel present on intraoperative cholangiography versus 32% of patients with cholelithiasis or choledocholithiasis without pancreatitis (p less than 0.005). Common channel length was greater than the diameter of the smallest stone in nine of 27 patients with gallstone pancreatitis and in 13 of 109 patients with cholelithiasis or choledocholithiasis without pancreatitis (p less than 0.025). In conclusion, common channels are more frequent in patients with gallstone pancreatitis than in patients with other biliary tract disease. Furthermore, gallstone pancreatitis is associated with stones that are smaller than the common channel, which favors obstruction of both pancreatic and bile ducts while allowing reflux of contents between them.     

Tolerance for light and sound of patients with persistent post-concussional symptoms 6 months after mild head injury

Summary Patients with post-concussional symptoms (PCS) about 6 months after a mild head injury (MHI) were examined for tolerance of light and sound in comparison with concussed patients without PCS and nonconcussed healthy controls. MHI patients with PCS were individually matched with subjects from the two control groups for the time elapsed from the injury, and for age and sex. Using a computerized rating technique, we assessed both the maximal and submaximal levels of lowered tolerance for light and sound over a wide range of stimuli. We found that the MHI patients with PCS 6 months after the trauma (n=11) tolerated significantly less well stimuli of intensities of 71 dB and 500 lx than MHI patients without PCS (n=11) and non-concussed controls (n=11). There were no significant differences in tolerance for light and sound between MHI patients without PCS and the non-injured controls. Decreased tolerance for light and sound may contribute to the persistence of symptoms up to 6 months after a mild head injury. The psychophysical method provides an objective measure for the evaluation of the late persistent postconcussional syndrome.     

Post-traumatic and emotional symptoms in different subgroups of patients with mild head injury

Post-concussional symptoms, such as headache, dizziness and irritability, are thought to result from the emotional stress associated with decreased cognitive performance after a head injury. A questionnaire-based investigation was carried out in 71 patients with mild head injury (MHI), using a heterogeneous item pool in order to study the interrelationships between traditional post-concussive complaints, cognitive problems, and more emotional and functional complaints. Factor analysis indicated that post-concussive symptoms loaded together with items on problems associated with decreased work performance and fatigability on a first factor, whereas psychovegetative and emotional complaints loaded together on a second factor. Two rating scales were constructed from the relevant items and were used to compare between subgroups of MHI patients and non-concussed controls. Patients with uncomplicated MHI had significantly higher scores than non-concussed subjects on the post-concussive-cognitive scale, but not on the emotional-vegetative scale. Patients with multiple head injuries or pre-existing emotional problems had higher scores on both the post-concussive-cognitive scale and the emotional-vegetative scale than MHI patients without a history of emotional problems. Reliable rating scales may be useful m multidiagnostic studies of MHI patients.     

Prognosis of trochanteric pain in primary care

BACKGROUND: Trochanteric pain is the second most important diagnosis of hip problems presenting in primary care, but its incidence and prognosis in this context is largely unknown. AIM: To determine the 1- and 5-year prognoses of trochanteric pain and the predictive variables for consistent complaints. DESIGN OF THE STUDY: Retrospective cohort study. SETTING: One hundred and sixty-four patients (mean age = 55 years, 80% female) with incidental trochanteric pain in the years 1996 or 2000 were asked in 2001 for past and present symptoms of trochanteric pain. Therapeutic interventions, demographic factors and comorbidity were also investigated. METHOD: The databases of 39 GPs were screened in order to identify all incident cases with a suspicion of trochanteric pain in the years 1996 or 2000. These cases were sent a questionnaire. RESULTS: The incidence of trochanteric pain in primary care is 1.8 patients per 1000 per year. After 1 year at least 36% still suffered from trochanteric pain, and after 5 years this was 29%. Patients with osteoarthritis (OA) in the lower limbs had a 4.8-fold risk of persistent symptoms after 1 year, as compared to patients without OA. Patients who had received a corticosteroid injection had a 2.7-fold chance of recovery after 5 years, as compared with patients who had not received an injection. CONCLUSION: Trochanteric pain is shown to be a chronic disease in a substantial number of patients. The disorder is associated with much impairment when conducting daily activities.