Atypical presentation of an oesophageal carcinoma with metastases to the left buttock: a case report

© 2009 Smyth et al; licensee Cases Network Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution Licens

Are Alcohol-Related Acute Surgical Admission Rates Falling?

BACKGROUND: Alcohol-related admissions (ARA) represent a significant burden on hospital resources. The study objectives were to assess alcohol-related acute surgical admissions to a District General Hospital over a 5-year period, to determine the cost of these admissions and to consider strategies to affect future admission rates. METHODS: A prospective observational study was completed from October 2007 to March 2008. A daily review of acute surgical admissions determined whether alcohol was a factor for patients admitted. Data recorded included patient demographics, clinical presentation, investigations and final outcomes. This data was then compared with a previously completed prospective study between November 2002 and March 2003. RESULTS: Overall emergency surgical admissions during the study period were 1,125 (10.4%) compared to 838 (11.02%) in 2002. There was a 1.1% reduction in ARA from 9.5% (80/838) in 2002 to 8.4% (94/1,125) in 2007. The majority of ARA were male (82.8%) and 59.8% of ARA were under 40 years of age. ARA secondary to road traffic collisions (RTC) were reduced in 2007 compared to 2002 (12.5% to 8.5%). However, head injuries (30.0% to 48.9%) and pancreatitis (3.8% to 19.1%) secondary to alcohol had increased (p=0.27). 79.3% of admissions occurred out of hours. Although use of plain x-rays had decreased (70% to 54.3%, p=0.018), CT imaging (11.3% to 20.2%, p=0.67) and upper GI endoscopy had increased (2.5% to 7.4%, p=0.82). Blood alcohol levels increased with 83.0% of patients in 2007 compared to 60.9% in 2002 admitted with a level greater than 151mg/100mls (p=0.10). The overall cost of ARA over one year was calculated at £341,796. CONCLUSION: Alcohol-related admissions have reduced at this District General Hospital. However, despite recent government initiatives it still remains unclear how these factors affected ARA, as blood alcohol levels, alcohol-related head injuries and pancreatitis admissions all increased. Our findings highlight the relevance of the implementation of an inpatient alcohol policy combined with the availability of an alcohol liaison nurse in all acute surgical units

The skiers knee without swelling or instability, a difficult diagnosis: a case report

Skiing as a recreational activity has increased exponentially in the last twenty-years. Similar to any sporting activity, participants can sustain various types of injury, which provides the emergency departments with a continuous supply of patients. The injury pattern from the slopes has also changed over this time period, due to alterations and improvements in ski equipment. An increased diversity in alpine skiing techniques, as well as snowboarding and cross-terrain disciplines has also influenced this change. We present a multi-media experience of a high-speed ski fall that caused a valgus-external rotation injury to the right knee that precluded the patient from further ski activity. There was no bruising, swelling or instability demonstrated and the patient returned to ski activities 24-hours post-injury. Although this injury appeared clinically benign initially, the patient complained of persistent pain around the right knee which was causing occupational difficulties. Following normal clinical assessment, the patient returned to work but continued to complain of persistent pain at the lateral aspect of the right knee. Magnetic Resonance Imaging (MRI) demonstrated extensive bone marrow oedema (BMO), a mild depression of the articular cortex compression with a small focus of articular cartilage disruption and microfractures of the lateral tibial plateau. The patient was treated conservatively and remains well with avoidance of impact exercises 14-months post-injury. In the presence of any high speed injury, we would stress that regardless of initial normal investigations, clinical suspicion should remain paramount and not deter the physician from further investigation in the presence of continuing symptomatology

The effects of abdominal compartment hypertension after open and endovascular repair of a ruptured abdominal aortic aneurysm

ObjectiveThis study assessed if emergency endovascular repair (eEVR) reduces the increase in intra-abdominal compartment pressure and host inflammatory response in patients with ruptured abdominal aortic aneurysm (AAA).MethodsThirty patients with ruptured AAA were prospectively recruited. Patients were offered eEVR or emergency conventional open repair (eOR) depending on anatomic suitability. Intra-abdominal pressure was measured postoperatively, at 2 and 6 hours, and then daily for 5 days. Organ dysfunction was assessed preoperatively by calculating the Hardman score. Multiple organ dysfunction syndrome, systemic inflammatory response syndrome, and lung injury scores were calculated regularly postoperatively. Hematologic analyses included serum urea and electrolytes, liver function indices, and C-reactive protein. Urine was analyzed for the albumin-creatinine ratio.ResultsFourteen patients (12 men; mean age, 72.2 ± 6.2 years) underwent eEVR, and 16 (14 men; mean age, 71.4 ± 7.0 years) had eOR. Intra-abdominal pressure was significantly higher in the eOR cohort compared with the eEVR group. The eEVR patients had significantly less blood loss (P < .001) and transfused (P < .001) and total intraoperative intravenous fluid infusion (P = .001). The eOR group demonstrated a greater risk of organ dysfunction, with a higher systemic inflammatory response syndrome score at day 5 (P = .005) and higher lung injury scores at days 1 and 3 (P = .02 and P = .02) compared with eEVR. A significant correlation was observed between intra-abdominal pressure and the volume of blood lost and transfused, amount of fluid given, systemic inflammatory response syndrome score, multiple organ dysfunction score, lung injury score, and the length of stay in the intensive care unit and hospital.ConclusionThese results suggest that eEVR of ruptured AAA is less stressful and is associated with less intra-abdominal hypertension and host inflammatory response compared with eOR