An Acetylenic Lipid from the New Zealand Ascidian Pseudodistoma cereum: Exemplification of an Improved Workflow for Determination of Absolute Configuration of Long-Chain 2-Amino-3-alkanols.

An acetylenic 2-amino-3-alcohol, distaminolyne B (2), isolated from the New Zealand ascidian Pseudodistoma cereum, is reported. The isolation and structure elucidation of 2 and assignment of 2S,3S absolute configuration (AC) using the exciton coupled circular dichroism technique are described. Using a methodologically facile workflow, the same AC was also established by analysis of specific rotation, terminal methyl C-1 δC chemical shift, and NH δH and J values of the N,O-diacetate derivative.

Audit of patient experience of day-case inguinal hernia repair.

BACKGROUND: This study was prompted by a complaint from a patient citing he had suffered postoperative pain and scrotal bruising. We audit postoperative pain following inguinal herniorrhaphy and patient understanding of postoperative complications. METHODS: A telephone survey was carried out to assess patient experience of day-case inguinal herniorrhaphy (DIH). Having identified that there was some dissatisfaction with the outcome of DIH, a prospective audit was carried out to assess causative factors. Changes in practice were made; chiefly, the provision of patient-information leaflets and the standardisation of intraoperative and postoperative analgesia. Repeat audit then assessed the effects of these changes. RESULTS: Ten percent of patients had a poor understanding of postoperative complications following inguinal herniorrhaphy. Thirty-eight percent had early postoperative pain; wound infiltration of local anaesthetic at the end of inguinal herniorrhaphy reduced the incidence of early postoperative pain to 23%. CONCLUSIONS: Audit is an important tool in surgical quality assurance for DIH. Small changes in practice with adherence to good protocols can have a marked effect on patients' experience.

High frequency jet ventilation - its use in respiratory insufficiency. Two case reports.

High frequency jet ventilation was used in two patients with severe pulmonary disease, one of whom was deteriorating and the other not improving on a conventional regime of antibiotics, physiotherapy and intermittent positive pressure ventilation. In our first case high frequency jet ventilation was achieved using one side of a double lumen endotracheal tube, whilst intermittent positive pressure ventilation was applied to the other side. In the second case a specially designed endotracheal tube with a distal jetting orifice was employed. In both cases there was marked improvement in chest X-ray appearance, arterial blood gas analysis and clinical condition, permitting resumption of spontaneous ventilation, extubation and eventual discharge from the Intensive Therapy Unit.

Gastric volvulus in childhood.

Gastric volvulus is a rare surgical emergency in infancy and childhood. Only 51 cases have been reported. We describe four new cases. The classical features of the condition are discussed.

Surgeons' attitudes to the operative management of duodenal ulcer perforation and haemorrhage.

The currently preferred operative management of duodenal ulcer haemorrhage and perforation was assessed by means of a questionnaire sent to 274 consultant general surgeons in England. A 70% response rate was achieved. Simple closure, with or without H2 antagonist treatment, was the most popular management of a perforated acute duodenal ulcer. For perforation of a chronic duodenal ulcer occurring during H2 antagonist therapy, truncal vagotomy and drainage was the definitive procedure of choice. There was no consensus about the operative management of perforation complicating non-steroidal anti-inflammatory drug treatment in the elderly patient. Proximal gastric vagotomy appears to have few advocates in the definitive management of either duodenal ulcer perforation or haemorrhage. Of our sample 70% selected truncal vagotomy and drainage with underrunning of the ulcer as the operative treatment of choice for bleeding. Endoscopic coagulation appears to be used only rarely.

A standardised approach to the insertion of Hickman catheters.

A standardised technique for the insertion of Hickman catheters under local anaesthetic is described. The external jugular vein is to be preferred, but if this proves too small the catheter may be introduced via the internal jugular vein using a Seldinger technique. A total of 44 Hickman catheters were inserted into 44 patients using this approach without major complication.

'Fast track' carotid duplex scanning in a district general hospital.

UNLABELLED: 'Fast track' carotid scanning is designed to rapidly identify patients with significant symptomatic carotid stenosis and, thereby, allow prompt surgery. We review the outcome of patients referred to our open-access scanning service over 3 years and 6 months. A total of 807 cases (62% males and 38% females with a mean age of 64 years) were referred. The main presenting symptoms were TIA in 69%, amaurosis fugax in 11% and minor CVA in 8.3%. The mean time between referral and scan was 17 days. In 80% of the cases, the scan showed no significant disease and the patients were not seen in the clinic. Significant abnormality (stenosis > 70% or occlusion) was found in 20% of the patients. Of the total, 12% were reviewed in the out-patient clinic following which no action was taken, 2% had angiography but no surgery, while 5% had angiography and surgery. 1% were lost to follow-up. The mean delay from scan to operation was 36 days. CONCLUSION: Fast track scanning has led to early detection of surgically relevant carotid lesions and avoidance of delay in surgical intervention. It is an efficient and cost-effective practice.

Endoscopic thoracic sympathectomy in the treatment of upper limb hyperhidrosis.

The technique of endoscopic sympathectomy is described and its value in the treatment of upper limb hyperhidrosis is reported in an initial series of 7 patients (13 sympathectomies). It is recommended as the treatment of choice for this condition.

A randomised comparison of polydioxanone (PDS) and polypropylene (Prolene) for abdominal wound closure.

Two hundred and eighty four patients undergoing laparotomy by vertical incision were randomly allocated to closure with interrupted mass sutures of No. 1 polydioxanone (PDS) or No. 1 polypropylene (Prolene). Dehiscence occurred in 0.7% of the PDS group but in 6.4% of the Prolene group (P = 0.018). Wound infection occurred in 8.6% of the PDS group and 15.4% of the Prolene group (P = 0.1). One hundred and ninety patients attended for review at a minimum of one year. Incisional herniation, usually asymptomatic, was present in 11% of each group. Knots were palpable in 2% of the PDS patients but in 12% of the Prolene: wound pain occurred in 12% of the PDS group but in 23% of the Prolene group (P = 0.06). These results suggest that PDS may be useful for abdominal closure.

The effect of cyclophosphamide on immunological control mechanisms.

Cyclophosphamide (CY) given three days before immunization with a range of antigens increases the intensity of cell-mediated immune responses. CY given around the time of immunization also reverses immunological tolerance, blocks antigenic competition and modifies desensitization. The effect on antibody production is not so predictable. However, it may increase the IgE response without affecting IgG1 or IgG2 response to the same antigen and may abolish immunological memory. The action of CY is on rapidly-turning-over cell populations. Lymphocytes are maximally at risk 48 hours before they transform into large pyroninophilic cells, that is just before the S phase of cell division. CY has a preferential effect on both T- and B- suppressor cells. The application of these findings to experimental cancer models is discussed. These findings are not restricted to CY, as a wide range of cytotoxic drugs with different actions at the cellular level may have similar profound effects on the regulation of the immune response.

A system for audit of obstetric anaesthesia.

A modification to a computer based system of audit, widely used in anaesthesia for general surgery, is described, which permits a more detailed analysis of obstetric anaesthetic workload. By adjusting entries, in the operation input field, further information can be collected automatically. This allows the total number of regional anaesthetic procedures, including those in patients with epidurals for labour who progressed to caesarean section, to be calculated. It identifies the total number of caesarean sections, including anaesthetic technique and whether an epidural catheter was, in any case, present. This modification may be applicable to other computerised audit systems.

Patient flow patterns in a recovery room and implications for staffing.

A detailed analysis of the occupancy of a new recovery room in a small district general hospital was undertaken during the initial three months of its use. The main problems were found to be irregular workload, consistently high patient occupancy over lunchtime, and difficulty in matching traditional nursing shifts to periods of heavy workload.

Gas exchange in abdominal cavity during laparoscopy.

Gas exchange occurring in the abdominal cavity during laparoscopy, using carbon dioxide as the insufflating gas, was investigated in 25 female patients being ventilated with 66.6% nitrous oxide and 33.3% oxygen. The gas remaining in the abdomen at the end of the procedure was collected and measurements were made using an infrared spectrometer, a paramagnetic analyser and a mass spectrometer. The mean duration of the laparoscopy was 9.5 minutes and the mean volume of carbon dioxide delivered was 6.8 litres. Nitrous oxide concentration in the abdomen was found to increase significantly with the duration of the procedure, varying from 1.4% to 12.8% with a mean of 4.3% (s.d. +/- 2.4). Oxygen concentration measured from 0.1 to 1.8% with a mean of 0.7% (s.d. +/- 0.4). Nitrogen concentration varied from zero to 1.8%, having a mean concentration of 0.8% (s.d. +/- 0.5). Carbon dioxide content was from 85.7 to 99.6% with a mean concentration of 94.2% (s.d. +/- 3.1).

Case series and literature review: popliteal artery injury following total knee replacement.

We present a case series and literature review of injury to the popliteal vessels during total knee replacement (TKR). This is rare but may be limb-threatening with devastating consequences for the patient. An individual surgeon will see few cases. Over a 28-month period 3913 elective TKRs were performed at three hospitals in East Anglia, United Kingdom. We present nine cases (0.23%) of popliteal artery injury following TKR. All required further investigation and intervention. The range of pathology included intra-operative haemorrhage (3 cases), thrombosis (2 cases), pseudo-aneurysm (3 cases) and arteriovenous fistula (1 case). Definitive treatment of the arterial injury was by primary repair (4 cases), interposition graft (2 cases), bypass graft (2 cases), endovascular stenting (1 case) and primary above-knee amputation (AKA; 1 case). There was morbidity in four patients: two AKAs, one case of foot-drop, and one unsightly fasciotomy scar. There was no mortality. Compared to other published studies (totalling 141 cases) complications resulting from direct arterial injury were significantly more common in our series. Incidence remains steady. More careful surgical technique may be the most effective preventative measure. Ongoing awareness is therefore essential for early diagnosis and management of this rare but serious complication.