Assessing outcome following calcaneal fracture: a rational scoring system.

Six existing clinical scoring systems for assessing outcome after calcaneal fracture are reviewed. All were applied to a diverse group of 75 patients who had sustained this injury. Stepwise multiple regression analysis was used to identify the most relevant variables within these systems. Based on this, a simplified and rational outcome scoring system was devised. This system was then tested on a further group of 41 patients and shown to comply well with the characteristics required of an objective outcome score.

Laboratory investigation in the diagnosis of pulmonary thromboembolism.

Laboratory findings were compared with lung scans in a prospective study of 260 patients undergoing ventilation-perfusion (V/Q) lung scanning for suspected pulmonary thromboembolism. The best discrimination between different lung scan results was obtained from the level of plasma cross-linked fibrin degradation products, every patient with a scan indicating a high probability of thromboembolism having detectable levels. An acute phase response was demonstrated in patients with pulmonary thromboembolism by a raised neutrophil count and elevated levels of plasma fibrinogen and serum C-reactive protein. A normal level of serum C-reactive protein and/or plasma cross-linked fibrin degradation productions in blood taken within 4 days of onset of symptoms virtually excluded the diagnosis of pulmonary thromboembolism. Detection of free plasma DNA was not helpful in discriminating between groups with different lung scan results. Discriminant analysis was used to assess the variables examined and to derive diagnostic models. An accuracy of 78 per cent was obtained with one model for classifying test patients according to the three lung scan classes of low, intermediate and high probability. A second model, for distinguishing patients with a low and a high probability of pulmonary thromboembolism on the basis of lung scans, and a third for predicting those with a low probability on lung scan, were accurate in 94.6 per cent and 83.5 per cent of patients respectively. Discriminant models could be used in the diagnosis of pulmonary thromboembolism, especially when diagnostic imaging is not available.

A bacteriological study of the effect on the environment of using a one- or two-trolley system in theatre.

In a survey of 53 hospitals, 62% still had a transfer zone in theatre, involving the use of two trolleys. Reluctance to use one trolley without patient transfer was probably because of concerns about excessive bacterial contamination of the theatre. In an attempt to see if these concerns were justified, air in the operating theatre was sampled for bacterial content, as were the surfaces and wheels of trolleys and the floor in the theatre, anaesthetic room and at the 'red line' in the transfer zone. Samples were taken during the first and second cases on the list of each session in one plenum-ventilated theatre over a four-week period, alternating each week between a one- and two-trolley system. Using one trolley did not significantly influence the bacterial counts in the theatre and anaesthetic room. There were significant differences between counts from the trolley wheels and from the floor of the transfer zone, with counts being higher for one trolley than two. These differences were greatly diminished after the trolleys were washed half way through the study. We conclude that there is no deleterious effect on the environment of the operating theatre, the most sensitive area, if only one trolley is used. If it is considered desirable to decrease the contamination of less important areas when using a one-trolley system, trolleys should be washed regularly, particularly the wheels.

Appendicectomy and carcinoma of the caecum.

A total of 519 patients presenting with carcinoma of the caecum in the Plymouth Health District between 1975 and 1987 were reviewed. The clinical course was determined in relation to patients with and without a history of previous appendicectomy. There was no difference in the incidence of previous appendicectomy between patients with carcinoma of the caecum and an age and sex matched control group. The presence of synchronous carcinomas and/or adenomas was unrelated to previous appendicectomy. Ten patients presented with appendicitis and 11 with a mucocele of the appendix as the first sign of carcinoma of the caecum. Previous appendicectomy was associated with a higher incidence of local fixity, invasion of the abdominal wall, metastatic spread and poor differentiation. These differences were reflected in a significantly lower resection rate for carcinomas in patients who had previously undergone appendicectomy. The survival of patients who had previously had appendicectomy was significantly reduced. Four independent prognostic factors for survival were identified using multivariate discriminant analysis. These were Dukes' classification, local invasion, tumour differentiation and previous appendicectomy. Local recurrence was more common in patients who had previously had appendicectomy and was often in the old appendicectomy wound itself. Appendicectomy does not increase the risk of carcinogenesis in the caecum. In this study a history of appendicectomy was an independent risk factor for survival and significantly worsened the prognosis for patients who subsequently developed carcinoma of the caecum.

A study of cytoplasmic oestrogen receptors in patients with breast cancer in a district general hospital.

The tumors of 61 patients suffering from primary adenocarcinoma of the breast were assayed for oestrogen receptors (ER), using the dextran-coated charcoal method. A statistically significant relationship (P less than 0.05) was found to exist between ER status and the histological grade of the tumour. No relationship was found between ER status and either tumour size or the pathological state of the axillary lymph nodes. It is concluded that it is a practical proposition to establish an ER assay service in a district general hospital, with subsequent benefits for the individual patient.

Spleen scanning with 99Tcm-labelled red blood cells after splenectomy.

In order to correlate the haematological changes which occur after splenectomy, with the presence or absence of residual splenic tissue, spleen scans using 99Tcm-labelled red blood cells were performed in 36 patients who had had a splenectomy. Positive spleen scans were found in 44 per cent (8 out of 18) of patients who had undergone splenectomy for trauma and in 17 per cent (3 out of 18) of patients who had undergone elective splenectomy. No relationship was found between the presence of Howell-Jolly bodies, platelet counts, the levels of IgG, IgM and IgA and the scan result. It is concluded that these findings are due to the presence of splenunculi, whose incidence is more common than the 12 per cent usually quoted.