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Biomedical subjects

M J Playforth

Publications and source records attributed to M J Playforth.

At least 19 recordsLinked to original sources
PubMed2001

The effect of the introduction of NHS Direct on requests for telephone advice from an accident and emergency department.

OBJECTIVES: To assess the effect of the introduction of NHS Direct on advice seeking calls to an accident and emergency (A&E) department. METHODS: Review of departmental telephone advice logbook before and after the introduction of NHS Direct together with recording of the number of calls redirected to NHS Direct by the hospital switchboard and the A&E department. RESULTS: The number of advice calls responded to within the department fell by 72.6% (84 in October 1998, 23 in October 1999). The number of calls redirected to NHS Direct was 242. The total number of calls to the hospital seeking advice thus increased by 315%. CONCLUSION: The introduction of NHS Direct has allowed for a mechanism to be put in place reducing the number of calls for advice being dealt with by the A&E department clinical staff with a concomitant time saving. At the same time the number of calls for advice made by the public to the hospital has dramatically increased.

Emergency Service, Hospital↗
PubMed2001

Collapse, hoarseness of the voice and swelling and bruising of the neck: an unusual presentation of thoracic aortic dissection.

A 66 year old woman presented to the accident and emergency department with history of collapse, hoarseness of the voice, and swelling and bruising of the neck. The diagnosis was not initially obvious because of the absence of chest pain. The findings on the radiograph of the soft tissue of the neck and chest radiograph suggested the need for computed tomography of the neck and chest. This confirmed the cervical haematoma and typical signs of aortic dissection. This unusual presentation of thoracic aortic dissection is discussed below.

Aged↗
PubMed1989

Early infective complications and late recurrent cancer in stapled colonic anastomoses.

Between 1978 and 1981, 73 patients with colonic or rectal cancer were randomized to have their anastomoses made by either a single interrupted layer of braided polyester sutures, or by a circular stapling instrument. Of these operations, 20 were considered to have been palliative, the remaining 53 being potentially curative. The incidence of local recurrence in the latter group was analyzed in relation to initial septic and anastomotic complications. The 53 patients were followed for a median of 36 months (range, 1 to 87); 24 were alive and well and 22 had died of disseminated cancer or unrelated causes. Seven patients died with local recurrent disease proved at laparotomy or autopsy after a median of 33 months (range, 3 to 72). Thirty anastomoses were stapled and 23 sutured; of the seven patients who died with local recurrent disease, six had stapled anastomoses (Fisher's exact probability F2 = 0.12; log rank chi-square = 3.53, 0.05 less than P less than 0.10). Two patients who died with locally recurrent disease had had clinically apparent anastomotic leaks and one other patient had had a radiologically demonstrated leak. This compares with a total of seven leaks (clinical or radiologic) in the remaining group of 46 patients with no recurrence (Fisher's exact probability F2 = 0.11). These results tend to support the hypothesis that anastomotic leaks may lead to locally recurrent disease, particularly after stapled anastomoses.

Colorectal Neoplasms↗
PubMed1988

Antimicrobial bowel preparation. Oral, parenteral, or both?

It has been suggested that wound infection rates after colorectal operations are influenced more by the presence of adequate tissue levels of antimicrobials at the time of contamination than by the extent of bacterial colonization of the intestinal lumen. There are, however, theoretical grounds for the belief that both levels are important. The authors therefore conducted a random control trial in 119 consecutive patients undergoing elective colorectal operations, comparing the results in a group receiving purely parenteral antimicrobial prophylaxis with those in one having a combined oral and parenteral regimen. The results in 83 contemporary nonrandomized patients, all of whom had the combined prophylactic regimen, are also reported. Oral bowel preparation resulted in a significantly smaller number of operation cultures showing growth of fecal gram-negative aerobes and anaerobes than did the purely parenteral regimen. There were more isolations of enterococci in the combined group but the excess did not achieve statistical significance. The rates of infective complications were higher in the parenteral than in the combined group, the difference in wound infection rates being statistically significant; the figures were 27.6 percent and 13.9 percent, respectively (P = .04). It is concluded that, in colorectal operations, it is advisable not only to ensure adequate tissue levels of antimicrobials but also to reduce the risk of endogenous bacterial infection by partially decontaminating the bowel.

Administration, Oral↗
PubMed1987

Pre-operative assessment of fitness score.

Death within 30 days or survival after a major operation depends on three things: the severity of the disease and the operation, the technical proficiency of the surgeon and the ability of the patient to withstand both disease and operation. The first of these can be estimated by reference to published figures, the second can only be guessed at and the third has in the past been a matter of subjective judgement. With the aim of producing an objective assessment of the likelihood of survival, we have constructed a score system comprising 26 items including age, chronic disease and acute presenting disease. These items are each given a weight of 1 to 4 and the total fitness score for any patient ranges from 0 (fit) to 10 (unlikely to survive). We have validated this score prospectively in 1517 consecutive patients undergoing emergency or elective major abdominal operations (excluding appendicectomies and hernia repairs). In 492 operations in which the patient scored 0 or 1, one patient died (0.2 per cent); in 290 with scores of 2 or 3, one died (0.3 per cent); in 313 with scores of 4 or 5, five died (1.6 per cent). It was when the score rose to 6 or over that the chances of survival progressively declined: 16 died of the 105 patients who scored 6 (15.2 per cent) as did 74 of the 191 who scored 7 or 8 (38.7 per cent) and 70 of the 126 who scored 9 or 10 (55.6 per cent). We now use the score as part of our audit and enquire particularly closely into the death of any patient with a pre-operative score of less than 6.

Abdomen↗
PubMed1987

Peroperative lavage of the obstructed left colon to allow safe primary anastomosis.

A series of 44 patients with complete or partial left-colon obstruction underwent laparotomy and intraoperative colonic lavage. Irrigation was unsuccessful in three, the operation being concluded by a Hartmann resection. In the remaining 41, the achievement of an empty colon allowed primary anastomosis after resection of the obstructing lesion. Seven patients (17.1 percent) died, none of dehiscence of the colorectal anastomosis, although minor anastomotic leaks occurred in four. The median postoperative hospital stay was 12 days. Two patients developed peritonitis (one fatal) from leakage of ileal contents when the irrigating catheter was introduced through an ileotomy and retained postoperatively, and this aspect of the technique is not recommended. The operation offers a single-stage alternative for patients with unprepared or ill-prepared bowels who require resection of left-colon lesions. The results compare favorably with the authors' previous experience of two- or three-stage resections (in-hospital mortality rate, 42 percent).

Aged↗
PubMed1986

Fluid sequestration: an early indicator of mortality in acute pancreatitis.

Complete daily intake and output charts were available for 218 patients with acute pancreatitis. The patients were divided into three groups according to the relation between fluid intake and output. In 105 patients in whom there was negligible fluid sequestration (daily output within 2 litres of intake) there were six deaths (5.8 per cent). In 69 patients the daily fluid intake exceeded the output by 2 litres or more but this imbalance lasted for 48 h or less; six patients died (8.7 per cent). The remaining 44 patients sequestered 2 litres or more of fluid per day for more than 48 h or until death. Thirty-eight patients in this group died (86.4 per cent). Fluid sequestration of 2 litres or more per day, and lasting longer than 48 h, is an accurate and simple predictor of mortality in acute pancreatitis. In this study it had a sensitivity of 76 per cent and a specificity of 96 per cent. The predictive value of a positive result was 86 per cent and of a negative result 93 per cent (efficiency 92 per cent).

Acute Disease↗
PubMed1986

Single-dose antibiotic prophylaxis of abdominal surgical wound infection: a trial of preoperative latamoxef against peroperative tetracycline lavage.

A randomized controlled clinical trial was undertaken in 542 consecutive emergency and elective abdominal operations, with one group of patients receiving tetracycline peritoneal and wound lavage and the other a single intravenous injection of 1 g latamoxef at induction of anaesthesia. Seventy-five patients were withdrawn because no potentially contaminated hollow viscus was opened, and a further 36 because they could not be assessed for wound infection. Of the remaining 431 patients, 212 received latamoxef resulting in 5 major and 8 minor wound infections in hospital; another 4 minor infections occurred at home (total incidence 8.0%). In the tetracycline group (n = 219) there were 7 major and 19 minor wound infections in hospital and 10 minor infections later (total incidence 16.4%). This is significantly higher than the rate with latamoxef (P = 0.012). Monitoring of operative and postoperative bleeding revealed no evidence (except in one doubtful case) of excessive bleeding associated with the use of a single dose of latamoxef. It is concluded that single-dose preoperative latamoxef is more effective than peroperative tetracycline lavage for the prevention of wound infections after potentially contaminated abdominal operations.

Abdominal Muscles↗
PubMed1986

The prediction of incisional hernias by radio-opaque markers.

On the hypothesis that incisional defects occur soon after operation but the resulting hernia may not be diagnosed until months or years later, we attached three to five pairs of stainless steel haemostatic clips to the cut edges of the anterior aponeurosis during the closure of 59 major laparotomy incisions and X-rayed the abdomen one month later. Three patients were withdrawn and the remaining 56 were examined with special reference to incisional herniation at their six-month follow-up visit. The senior author subsequently arranged a series of extra clinics for surviving patients up to three years later (median 30 months after operation). He had no knowledge of the results of the abdominal X-rays when assessing whether or not the patient had a hernia. Six patients were found to have incisional hernias, and correlation with the measurements on the one-month X-rays showed separation of pairs of clips ranging from 12-70 mm (median 40). Three of the six hernias were discovered within seven months, the remaining three at 13, 28 and 29 months. In contrast none of the 50 patients without incisional hernias had more than 9 mm of separation of any pair of clips on the one-month X-ray. We conclude that the origins of incisional hernias can be traced back to events during the first month after operation and that they are not the result of later weakening of a well-healed laparotomy wound.

Hernia, Ventral↗
PubMed1985

Suction drainage of the gallbladder bed does not prevent complications after cholecystectomy: a random control clinical trial.

Some surgeons drain the gallbladder bed routinely, some selectively and some not at all. We aimed to clarify this confusion by entering 155 consecutive patients undergoing emergency and elective cholecystectomy without exploration of the common bile duct into a random control clinical trial. In 78 patients a 3 mm suction drain was left in the gallbladder bed and in 77 the abdomen was closed without drainage. There were no withdrawals, one death (in the drainage group) from myocardial infarction and one intraperitoneal abscess complicating postoperative pancreatitis (in the no-drainage group). Other events studied were postoperative pyrexia, wound infection, respiratory tract infection and duration of hospital stay. In none of these did the two groups differ either clinically or statistically. We conclude that drainage or non-drainage of the gallbladder bed must remain a matter of individual preference.

Aged↗
PubMed1983

Functional recovery of the exocrine pancreas after acute pancreatitis.

A tubeless pancreatic function test (BTP test) using N-benzoyl-l-tyrosyl-p-aminobenzoic acid was used to assess exocrine function from urinary recovery of p-aminobenzoic acid produced by hydrolysis of the peptide by chymotrypsin. Patients with acute pancreatitis were studied at various time intervals after the acute attack and compared with controls with abdominal pain that was not pancreatic in origin. The initial BTP test carried out in the convalescent period was abnormal in all of 30 patients with acute pancreatitis but normal in 10 patients with non-pancreatic abdominal pain and also in 8 patients who had recovered from an attack of acute pancreatitis 2-6 years previously. Results were improved or normal in 12 of 15 patients re-tested 1 year after the attack of pancreatitis, but 4 out of 6 still had abnormal results 2-6 months after the attack. The data suggest that an attack of acute pancreatitis may impair exocrine pancreatic function for several months.

4-Aminobenzoic Acid↗
PubMed1982

The amylase-to-creatinine clearance ratio--a non-specific response to acute illness?

It was felt that the apparent specificity of the amylase-to-creatine clearance ratio (ACCR) in several previous studies of pancreatitis might reflect a failure to utilize adequately ill control subjects. The ACCR and the renal clearances of beta 2-microglobulin (B2-m), similarly related to creatinine (BCCR) as well as the urinary concentration of albumin, were compared in 27 patients with acute pancreatitis, 8 with a perforated peptic ulcer and 7 with mild biliary colic, during the first 5 days in hospital. Acute pancreatitis was graded as mild (6), moderate (14) or severe (7), using a combination of clinical data, diagnostic peritoneal lavage and multiple criteria. Further assessment of the severity of the acute illness was obtained from measurement of C-reactive protein (C-RP). Lowest C-RP levels were found in the patients with mild pancreatitis and biliary colic, and highest levels in the patients with severe pancreatitis and perforated ulcer (P less than 0.002). Similarly, ACCR and BCCR levels were significantly lower in the two mild groups than in the two severe ones (P less than 0.01 and less than 0.002 respectively), although plasma amylase was raised only in patients with pancreatitis and plasma B2-m was similar in all groups. Electrophoresis of urine showed dense bands of tubuloprotein in patients from both severe groups. Urine albumin was higher in severe pancreatitis than in perforated ulcer (P less than 0.1), perhaps indicating a more specific glomerular lesion in pancreatitis. Thus a rise in amylase clearance appeared to be related to the severity of the acute illness, and may be a component of a non-specific tubuloproteinuria. In this study patients with a perforated peptic ulcer had increases in ACCR similar to those seen in patients with severe pancreatitis, and we are therefore doubtful whether ACCR has any role in the clinical diagnosis of pancreatic disease.

Acute Disease↗
PubMed1982

Parathyroid function during acute pancreatitis.

The renal handling of calcium and phosphate, which normally reflects parathyroid hormone (PTH) activity, was studied during the first 5 days after admission to hospital in 18 patients with acute pancreatitis. The ionized calcium level in plasma was calculated from the total calcium, albumin, total protein and pH. Hypocalcaemia (Ca less than 1.08) was found in 6 patients and was associated with low urine calcium concentrations, hypophosphataemia and lower renal tubular reabsorption of phosphate. Although these changes were all consistent with an appropriate renal response to increased PTH production in the hypocalcaemic patients, measured levels of PTH were very variable. In one patient who developed tetany, calcium infusion resulted in a rise in plasma calcium and a reversal of renal changes, but had little influence upon PTH levels. We found no evidence that hypomagnesaemia or proteolytic degradation of PTH were factors in the aetiology of hypocalcaemia. The discrepancy between evidence of PTH activity from renal function and immunoassayable levels of PTH in plasma might indicate that the parathyroid response, although present, was inadequate to mobilize enough skeletal calcium to prevent hypocalcaemia; it underlines the need for caution in the interpretation of data fom radioimmunoassay techniques when taken in isolation in situations where they have not been fully evaluated.

Acute Disease↗
PubMed1981

Identification of risk factors for acute pancreatitis from routine radiological investigation of the biliary tract.

The size and shape of gallstones, the diameter of the common bile duct and the presence of reflux into the pancreatic duct were studied by examining routine contrast investigations of the biliary tract in 174 patients with gallstones. Patients were divided into two groups: 69 who had been admitted to hospital with an attack of acute pancreatitis (group 1) and 105 patients with gallstones who had not had a known attack of pancreatitis (group 2). Four or more gallstones were present in 38 (78 per cent) of 49 visualized gallbladders in group 1 compared with 45 (52 per cent) of 87 in group 2 (P less than 0.005). The smallest gallbladder stone was less than 4 mm in diameter in 69 per cent of group 1 and 44 per cent of group 2 gallbladders (P less than 0.005). Twenty-nine per cent of gallbladder stones in group 1 were clearly faceted compared with 20 per cent in group 2. There were no significant differences in the diameter of the common bile duct or the presence of stones in the common bile duct, although the latter were more common in group 1. Reflux of contrast into the pancreatic duct (on operative or T tube cholangiogram) was more common in group 1 (50 per cent) than group 2 (25 per cent) (P less than 0.025). This study supports the role of numerous small stones and a 'common channel' at the ampulla as aetiological factors in patients who develop acute pancreatitis as a complication of gallstones.

Acute Disease↗
PubMed1980

A compaative study of methods for the prediction of severity of attacks of acute pancreatitis.

Diagnostic peritoneal lavage was carried out in 79 patients with acute pancreatitis, at a mean time of 7 h after admission to hospital. The presence of more than 10 ml of free peritoneal fluid, brown-coloured free fluid or mid-straw-coloured lavage fluid was the criterion used for the prediction of a severe attack by lavage. Prior to lavage the attack was assessed as mild or severe by the clinician and reassessed by him at 24 and 48 h. All attacks were finally classified as mild or severe by means of a simple clinical grading scheme. There were 61 mild and 18 severe attacks (including 4 deaths). Initial clinical assessment correctly predicted only 39 per cent of the severe attacks compared with a 72 per cent succwss rate for diagnostic lavage. All the mild attacks were correctly predicted by clinical assessment but lavage was wrong in 3 out of 61 cases (95 per cent success rate). By 48 h after admission clinical assessment was comparable to systems using multiple criteria in its predictive value, success rates being 83 per cent and 82 per cent respectively for prediction of severe attacks. We did not find either the presence of methaemalbumin in the serum or the presence of hypocalcaemia to be of additional value. Diagnostic peritoneal lavage was the most accurate early guide to severity, and correctly predicted all patients who developed shock or died.

Acute Disease↗
PubMed1980

The management of haemorrhagic complications of pseudocysts and abscesses of the pancreas.

We have reviewed the literature relating to experience of haemorrhage associated with pancreatic pseudocysts and abscesses in an attempt to evaluate different types of management. A further case, where extensive pancreatic resection successfully halted bleeding which followed drainage of a pancreatic abscess, is described to illustrate some of the principles of management.

Abscess↗
PubMed1980

Early prediction of severity of acute pancreatitis using peritoneal lavage.

Diagnostic peritoneal lavage was attempted in 96 out of a consecutive series of 168 attacks of acute pancreatitis, in order to evaluate its ability to predict severe disease. Lavage was successful in 89 instances, and resulted in relief of pain in many patients, and in one complication. Lavage indicated (by the presence of numerous organisms) that the diagnosis was incorrect in 1 patient with suspected acute pancreatitis; the correct diagnosis, biliary peritonitis, was revealed at post mortem examination. The severity of the attack was predicted by the clinician prior to lavage, and each attack was classified as mild or severe when the patient left hospital according to a simple clinical scheme. Although there was a strong correlations between severe attacks and the concentrations of G. O. T., albumin, protein, magnesium, potassium and phosphate in the lavage fluid, a simple and immediate classification based upon the physical features of the free peritoneal fluid and the lavage return fluid was adopted. The presence of brown free fluid, or more than 10 ml of free fluid, or mild-straw coloured lavage was taken as the lavage criterion of a severe attack. Of the 89 attacks with a successful lavage, 68 were classified as mild and 21 as severe according to the clinical outcome. Clinical assessment of the attack on the day of admission to hospital successfully predicted only 8 (38%) of the severe attacks, but 17 (76%) were correctly predicted by lavage, carried out at an average time of 7 hours after admission. False positive results of lavage were seen in only 4 (6%) of the 68 mild attacks. All attacks in which a shock-like illness developed, or which resulted in death (4) were predicted as severe by lavage. We feel that diagnostic lavage especially suited to select patients who may be expected to benefit from therapeutic peritoneal lavage.

Acute Disease↗