Delayed presentation following accidental inhalation of a pushpin.

A previously fit and well 18-year-old woman presented to the accident and emergency department following referral by her general practitioner with a provisional diagnosis of appendicitis. The history obtained from the patient revealed the presence of a bitemporal headache with associated neck stiffness, photophobia and vomiting for approximately 1.5 weeks. The patient complained of abdominal pain localised to her right iliac fossa and anorexia for approximately 1 week. She also noted the presence of a cough productive of green sputum for 3 weeks. A chest radiograph was obtained which showed a large area of consolidation in the right lower lobe consistent with infection and a linear density in keeping with a metallic foreign body. Following review of the chest radiograph, the patient was interviewed further and recalled having inhaled a pushpin approximately 1 year before her presentation. Aspiration of foreign bodies is relatively common in children and is often associated with delayed diagnosis and high morbidity. To prevent delayed diagnosis, characteristic symptoms and clinical and radiological signs of foreign body aspiration should be checked in all suspected cases and a low index of suspicion for ordering additional imaging or using bronchoscopy for diagnostic purposes should be employed.

The needle catcher--a safer way to suture.

The needle catcher is a novel surgical instrument which has been developed in Belfast in conjunction with Queen's University Belfast that aims to reduce suture needle exposure and increase operator safety during suturing. The instrument was used to close wounds in 20 patients presenting to A&E in the Royal Group of Hospitals and to the plastic surgery service in the Ulster Hospital. This letter includes a technical description of the instrument, evaluation of needle exposure, comments from users, evaluation of the needle catcher and a discussion on the need for additional protection for medical staff in surgical based specialties where there is frequent exposure to blood, open wounds and sharps.

Urological complications of renal transplantation: the impact of double J ureteric stents.

In a 10 year series of 350 consecutive renal transplant operations, the overall urological complication rate was 7.7%. During this period double J stents were introduced and were used either in the treatment of actual urological complications or as a prophylactic measure to protect ureters which had been damaged at retrieval. A total of 34 double J stents were used in 33 patients. The indications were: ureteric obstruction (n = 13), urinary leak (n = 5), short transplant ureter anastomosed using an extravesical ureteroneocystostomy (n = 10) and ureteric injury at the time of organ retrieval (n = 6). Thirty-two double J stents were inserted at open operation and two were inserted by an antegrade method after percutaneous nephrostomy. Improvement in renal function occurred in 16 out of the 18 cases of urological complications. No kidneys were lost and there were no deaths as a direct result of these complications. In a number of cases the insertion of a double J stent was the only treatment, thus eliminating the need for more complex surgery. All 16 patients who had a ureteric stent inserted as a prophylactic measure at the time of transplantation made uncomplicated postoperative recoveries. Urinary tract infection was relatively common (27%) after double J stent insertion, but other complications were rare. In conclusion, double J stents have proved to be a useful adjunct in the management of renal transplant related urological complications.

The surgical management of acute limb ischaemia due to native vessel occlusion.

OBJECTIVES: Data from the STILE study have indicated that for patients with subacute limb ischaemia due to native vessel occlusion, surgery is both more effective, and durable than thrombolysis. The purpose of this study was to evaluate the outcome of an aggressive surgical approach in patients presenting with acute limb-threatening ischaemia. DESIGN: Details of patients presenting with salvageable acute limb ischaemia due to native artery occlusion over a 6-year period in a University hospital vascular unit setting were obtained from the vascular audit and the outcome of the surgical management of these patients was analysed. RESULTS: One hundred and seventy-four consecutive patients underwent surgery for acute native vessel limb ischaemia (76% lower, 24% upper limb). Fogarty thrombectomy or embolectomy was initially performed in 153 (89%) patients. Of these, 37 (24%) immediately underwent a further procedure: 28 (18%) had on-table thrombolysis and 14 (9%) underwent vascular reconstruction. Twenty-six patients (15%) underwent further limb salvage surgery within 30 days. Life table analysis demonstrated a limb salvage rate of 88% and 76% at 30 days and 2 years, respectively. Patient survival was 75% and 48% at the same time intervals. CONCLUSIONS: These results demonstrate that a role for aggressive surgical intervention still exists, resulting in high limb salvage rates.

A systematic review of outcome following synchronous carotid endarterectomy and coronary artery bypass: influence of surgical and patient variables.

OBJECTIVES: Outcomes after synchronous carotid endarterectomy (CEA) plus coronary artery bypass (CABG) relative to surgical and patient based variables. DESIGN: Systematic review of 94 published series (7863 synchronous procedures). RESULTS: 11.5% of patients died or suffered a stroke/myocardial infarction in the peri-operative period (95% CI 10.1-12.9). The risk of death/stroke appeared to significantly diminish in studies published between 1993-2002, compared with 1972-1992 (7.2% (95% CI 6.5-9.1) versus 10.7% (95% CI 8.9-12.5), p = 0.03). However, increasing operative experience was not associated with significantly lower risks of death/stroke; (1-49 cases (9.6% (95% CI 7.5-11.8); 50-99 cases (9.1% (95% CI 6.4-11.8); 100+ cases (8.4% (95% CI 6.9-10.1) (p = 0.64)). Patients with severe bilateral carotid disease were significantly more likely to suffer death and/or stroke compared to patients with unilateral disease (odds ratio 2.5, 95% CI 1.4-5.0, p = 0.001). Similarly, patients with a prior history of stroke/transient ischaemic attack (TIA) were significantly more likely to suffer a further stroke than asymptomatic patients (odds ratio 1.8, 95% CI 1.1-2.8, p = 0.008). There was no difference in the risk of death/stroke relative to the timing of CEA (pre- versus on-cardiopulmonary bypass), but recent small studies indicate that improved outcomes might be achieved by performing CABG 'off-bypass'. CONCLUSIONS: Synchronous CEA + CABG is associated with a not insignificant cardiovascular risk. No comparable information is available for similar patients undergoing CABG without prophylactic CEA.

Work-load generated by the establishment of a non-heart beating kidney transplant programme.

The work-load generated by a non-heart-beating donor (NHBD) kidney transplant programme over a 3-year period is reported. A total of 73 referrals were made, 64 from the Accident department and 9 from the wards. Organ procurement was performed in 24 cases (33%) and resulted in the retrieval of 44 kidneys. Reasons for failure to achieve organ procurement were; refused consent (n = 13; 18%), relatives unavailable to ask for consent (n = 9; 12%), technical problems with catheter insertion or perfusion (n = 10; 14%), transplant staff unavailable (n = 1; 1%), long asystolic period (n = 8; 11%) and donor unsuitable for other reasons (n = 8; 11%). Of the 44 kidneys retrieved, 30 were transplanted locally, 8 were transplanted at other United Kingdom centres and 6 were discarded. Locally transplanted NHBD kidneys represented 21% of the total transplant programme during the time period under study. We conclude that NHBD kidneys are a good source of additional organs for transplantation, but only one-third of referrals result in a successful procurement procedure. Moreover, the setting up of a successful programme is labour-intensive and requires a highly committed staff.