Could pre-mortem computerised tomography scans reduce the need for coroner's post-mortem examinations?

INTRODUCTION: Post-mortem examinations may result in considerable distress to the bereaved family. This audit was undertaken to examine whether computerised tomography (CT) scanning prior to death might reduce the need for post-mortems without compromising the accuracy of recording the cause of death. SUBJECTS AND METHODS: The case notes of 100 consecutive patients who had a coroner's post-mortem, because the cause of death was unknown, were reviewed by four senior clinicians. Along with the likely cause of death, the clinicians gave their opinion as to whether a CT scan would have enabled certification of death without the need for a post-mortem. Concordance between the post-mortem findings and the clinical events surrounding death was explored. RESULTS: It would have been possible to perform a pre-mortem CT scan on 90 of the 100 patients. A pre-mortem CT scan would have given the cause of death in 59 (66%) of these. In 30 patients, the cause of death established by the post-mortem was at variance with the clinical events surrounding death and clinically relevant information, such as recent surgery, was not recorded on the death certificates of 26 patients. CONCLUSIONS: The use of a pre-mortem CT scan and involvement of senior clinicians in the process of establishing cause of death will improve the accuracy and may obviate the need for a post-mortem in some patients. However, if a post-mortem is needed, the clinical notes should always be available for the pathologists and a senior member of the patient's team should attend the post-mortem to help accurate death certification.

Munchausen's syndrome presenting as rectal foreign body insertion: a case report.

BACKGROUND: This case report shows that Munchausen's syndrome can present as rectal foreign body insertion. Although the presentation of rectal foreign bodies has frequently been described in the medical literature, the insertion of foreign bodies into the rectum for reasons other than sexual gratification has rarely been considered. CASE PRESENTATION: A 30 year old, unmarried Caucasian male presented with a history of having been sexually assaulted five days earlier in a nearby city by a group of unknown males. He reported that during the assault a glass bottle was forcibly inserted into his rectum and the bottle neck broke. On examination, there was no evidence of external injury to the patient. Further assessment lead to a diagnosis of Munchausen's syndrome. The rationale for this is explained. A description and summary of current knowledge about the condition is also provided, including appropriate treatment approaches. CONCLUSION: This case report is important because assumptions regarding the motivation for insertion of foreign bodies into the rectum may lead to the diagnosis of Munchausen's syndrome being missed. This would result in the appropriate course of action, with regard to treatment, not being followed. It is suggested that clinicians consider the specific motivation for the behaviour in all cases of rectal foreign body insertion, including the possibility of factitious disorder such as Munchausen's syndrome, and avoid any assumption that it has been carried out for the purpose of sexual gratification. Early involvement of psychiatrists is recommended. Cases of Munchausen's syndrome presenting as rectal foreign body insertion may be identified and addressed more effectively using the approach described.

Analysis of bedside entertainment services' effect on post cardiac surgery physical activity: a prospective, randomised clinical trial.

BACKGROUND: A rising number of acute hospitals in the UK have been providing patients with bedside entertainment services (BES) since 1995. However, their effect on postoperative patient mobility has not been explored. OBJECTIVES: The aim of this prospective randomised clinical trial was to compare the level of postoperative physical activity and length of in-hospital stay of patients undergoing cardiac surgery depending on whether they had access to BES or not. METHODS: One hundred patients requiring elective cardiac surgery were randomised to receive access to BES (52 patients) or not (48 patients). Pedometers were used to quantify postoperative physical activity for 5 days. To assess the significance of the effect of intervention (TV off or on) on the pedometer counts over time a mixed effect Poisson regression model is used, with the time varying aspect as random component. The potential influence of gender difference and age on pedometer counts were assessed by incorporating these two factors as covariates in the Poisson model. RESULTS: On average, patients with no access to BES walked more than those with BES access. This difference ranged between 192 and 609 steps in favour of the first group for each individual postoperative day. Patients with no access to BES were 84% more likely (risk ratio: 1.84, 95% CI: 1.29-2.63) to walk higher number of steps than patients with access to BES. On average, participants with access to BES were likely to stay longer in hospital (median of 7 days with interquartile range 6-7 days), than participants with no access to BES (median of 6 days with interquartile range 5-7 days), however the difference did not reach statistical significance. CONCLUSION: We have demonstrated that the bedside entertainment systems may have an adverse effect on post cardiac surgery patient ambulation and may contribute to an increase in hospital stay.