Biomedical subjects
Publications and source records attributed to D N Quinton.
After amputation digital prostheses are infrequently used. With modern methods of fabrication both cosmetic and functional use are now possible. We have assessed the use of single digit prostheses in a district general hospital setting.
OBJECTIVE: To describe the duration of symptoms and long term outcome in patients who were discharged home from the A and E department having sustained an isolated fracture of the sternum. DESIGN: Postal questionnaire. OUTCOME MEASURES: Patients were asked specific questions regarding advice and analgesia given on discharge, length of time off work, if appropriate, and length of time of symptoms related to the injury. RESULTS: A response rate of 55% was achieved. The majority of patients had been involved in a motor vehicle accident. Chest pain was the predominant persisting symptom lasting for a mean period of 10.9 weeks. Duration of symptoms was significantly prolonged in patients over the age of 50 (p < 0.03). Although injury was more common in females this was not statistically significant (p < 0.09). Advice given regarding rehabilitation was poor and variable. CONCLUSION: Patients suffering a sternal fracture have prolonged symptoms. Those being discharged home from the A and E department are at present being given variable and poor advice. A more formal approach to rehabilitation, analgesia and a letter to the general practitioner outlining prognosis will improve their standard of care.
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OBJECTIVE: To investigate the bacterial cleanliness of tap water in a large accident and emergency (A&E) department for its possible use in the cleansing and irrigation of open traumatic wounds. METHODS: Tap water samples were collected from different areas within the department and analysed on two separate occasions for coliforms, S aureus, clostridia, pseudomonas, and beta haemolytic streptococci. RESULTS: Pathogenic bacteria were not isolated from the tap water samples within the A&E department. CONCLUSIONS: Tap water of drinking quality can be used to irrigate open traumatic wounds.
OBJECTIVE: To describe the development of a non-heart-beating donor (NHBD) programme in an accident and emergency (A&E) department over a three year period. BACKGROUND AND METHODS: The A&E department at the Leicester Royal Infirmary at present deals with approximately 200 prehospital cardiopulmonary arrests per year. A programme of kidney retrieval from non-heart-beating donors was started in April 1992. Strict criteria for admission to the programme, appropriate consent procedures, facilities, lines of communication, and feedback were developed to enhance its success. RESULTS: Of 66 patients referred to the NHBD programme over a three year period from 1 April 1992, 51 sets of relatives were available to be asked for possible organ donation, and 34 sets (66%) gave their consent. Twenty five patients had successful in situ perfusion of the kidneys. Forty seven organs were retrieved and 34 went on to be transplanted. To date, 27 kidneys are still working. As a result, 23.8% of kidneys transplanted in Leicester over this time period have been from the NHBD programme. CONCLUSIONS: The NHBD programme in Leicester has proved very successful, requiring organisation of resources and personnel both from the transplant service and the A&E department. The programme has provided such a significant boost to the renal transplant rate in Leicester that other hospitals with large A&E departments should consider setting up similar programmes.
To identify changes in treatment methods and types of drugs taken in overdoses over a 10-year period we conducted a retrospective study in the accident and emergency department of a large teaching hospital. The influence of a protocol to direct medical management was also studied. Results were compared with those of a 1984 survey at the same institution. 409 cases of accidental and deliberate poisoning were reviewed. In deliberate poisoning 52% of drugs taken were prescription drugs, 41.6% over-the-counter medications and the remaining 6.4% illicit drugs. Only 13% of patients had a stomach emptying procedure compared with 75.2% of patients in the previous survey. Charcoal was administered or offered in over 95% of cases. Medical management of overdoses in this centre changed drastically over 10 years. A department protocol had been adhered to in the great majority of cases, and we recommend that all accident and emergency departments as well as medical and paediatric teams establish similar protocols. Over-the-counter drugs are increasingly troublesome, especially paracetamol, which accounts for 28.8% of drugs taken in deliberate overdose.
A review of 179 autopsies was undertaken over a 1-year period to determine if clinically useful information was obtainable from coroners post mortems performed on patients referred from the A&E department. Fifty-six patients had undergone unsuccessful resuscitation. The leading causes of death were heart disease and trauma. Discrepancies between the diagnosis made during resuscitation and the cause of death found at autopsy were revealed especially in those dying from noncardiac causes. Iatrogenic trauma from resuscitation attempts occurred in a significant number of cases. It is suggested that review of selected Coroners post mortems should be part of departmental audit, with a view to improving clinical skills.
25 patients were assessed following repair of an acutely ruptured ulnar collateral ligament of the thumb metacarpo-phalangeal joint. The patients were divided into two groups, repaired by either a horizontal mattress suture using 4/0 polybutylate (nine patients), or a pre-fashioned steel wire (16 patients). Assessment included a physical examination and functional testing at a mean of 12.9 months (range 4-36 months) after the operation. Both techniques were equally effective, and the use of the more expensive steel wire, while technically satisfying and easy to perform, offers no clinical advantage over simple suture. This pre-fashioned steel wire is, however, recommended in those cases with an avulsion fracture or where distal avulsion of the ligament is associated, since the technique allows easy secure reduction.
In a prospective study, 27 consecutive patients with dorsal fracture subluxation of the PIP joint were treated conservatively using an extension block splint, with good results in 70%. The percentage surface involved with the fracture varied considerably (19-77%) the average being 55%. Three patients initially managed with splintage proceeded to surgery because the splint failed to hold the joint in reduction. These patients had a less favourable outcome. We feel that all such fractures can be treated by splintage, provided that early reduction is maintained in the splint and checked by serial radiology.
In a prospective study six patients with dorsal fracture subluxation of the IP joint of the thumb or the DIP joint of the finger were treated conservatively using an extension block splint. The fracture size varied from 22% to 47% of the articular surface of the volar base of the terminal phalanx. Good or excellent results were reported in all cases except for one, which was fair. Only one case in the study complained of any pain, and this was minimal. Conservative treatment using extension block splintage for this injury is as good as a surgical approach.
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Flexible endoscopy was used to assess the intragastric residue after either ipecacuanha-induced emesis or gastric lavage in 30 self-poisoned patients. Of the 13 patients treated by induced-emesis, five (38.5%) had residual solid in the stomach; 17 patients were treated by gastric washout, and 15 (88.2%) of these had residual intragastric solid. The study provides direct evidence that the gastric decontaminating procedures employed, and especially gastric lavage, do not remove stomach contents completely.
A prospective, randomized, single-blind study was carried out to determine whether gastric content is forced into the small bowel when gastric-emptying procedures are employed in self-poisoned patients. They were asked to swallow barium-impregnated polythene pellets, immediately prior to either gastric lavage or ipecacuanha-induced emesis. A second group of patients, who did not require treatment, were used as controls. Sixty patients were recruited to the study. The data show a significant difference in the number of residual pellets in the small bowel of the treated group (n = 40), when compared with the control group (P less than 0.0001). There was no statistical difference in the number of pellets in the small bowel when the treated groups were compared with each other. In addition, the inefficiency of gastric-emptying procedures is highlighted; 58.5% of the total number of pellets ingested were retained in the gastrointestinal tract of the ipecacuanha-treated group, while 51.8% of total pellets ingested were retained in the gastric lavage-treated group.
After operative repair, the conventional management of open injuries to the middle slip of the extensor tendon involves prolonged immobilisation of the P.I.P. joint. We report our results using controlled mobilisation with a Capener splint after two weeks rigid splintage. In a series of 99 patients seen soon after injury, 88% had excellent or good results after six months. Poor results were more common in patients with complex joint injuries and in patients who did not comply with the treatment. We advocate early mobilisation following repair of the middle slip.
A prospective study has been made of 29 human bite injuries caused by the clenched fist, 27 over M.P. joints and two over P.I.P. joints. All were treated by surgical exploration, within 24 hours in 84% of cases. In 62% the wound had entered the underlying joint and in 58% the bone was injured. Significantly less morbidity was noted in those cases where there was no joint injury (P less than 0.001). Early surgical exploration to identify and to treat the joint injury is recommended.
A retrospective study was made of 74 volar avulsion fractures of the P.I.P. joint in which there was no radiological evidence of subluxation. Overall, 96% of those reviewed achieved good results but morbidity was increased by immobilisation. Providing the joint is stable, simple neighbour strapping is recommended for these injuries.
Nine patients undergoing manipulation of Colles' fractures with varying doses of local anaesthetic injected into the fracture haematoma, were investigated by monitoring the arterial levels of lignocaine. Although the procedure was considered satisfactory by all patients, potentially toxic concentrations of lignocaine were found in the arterial circulation, reaching a maximum after manipulation of the fracture. A mean peak level of 2625 micrograms/l was found when 10 ml of 2 per cent lignocaine was used and a mean peak level of 846 micrograms/l in patients receiving 10 ml of 1 per cent lignocaine.