F. T. de Dombal

Retrospective study of 1000 deaths from injury in England and Wales

One thousand consecutive deaths from injury in 11 coroners districts in England and Wales were reviewed by four independent assessors, who studied necropsy reports to identify deaths in hospital that might have been preventable. Of 514 patients admitted to hospital alive, 102 deaths (20%) were judged by all four assessors to have been potentially preventable. When those cases in which three out of four assessors considered that the death was preventable were added the total rose to 170 (33%). Nearly two thirds of all non-central nervous system deaths were judged to have been preventable. The median age of the 170 patients whose deaths were preventable was 41, and the mean Injury Severity Score was 29. Further analysis suggested that the preventable deaths were principally the result of failure to stop bleeding and prevent hypoxia and the absence of, or delay in, surgical treatment. The results closely parallel those from similar studies from the United States and suggest that there are serious deficiencies in the services for managing severe injury in England and Wales. Debate is needed now on how to correct these deficiencies. In particular, the place of trauma centres must be considered.

Computer aided diagnosis of acute abdominal pain: a multicentre study.

A multicentre study of computer aided diagnosis for patients with acute abdominal pain was performed in eight centres with over 250 participating doctors and 16,737 patients. Performance in diagnosis and decision making was compared over two periods: a test period (when a small computer system was provided to aid diagnosis) and a baseline period (before the system was installed). The two periods were well matched for type of case and rate of accrual. The system proved reliable and was used in 75.1% of possible cases. User reaction was broadly favourable. During the test period improvements were noted in diagnosis, decision making, and patient outcome. Initial diagnostic accuracy rose from 45.6% to 65.3%. The negative laparotomy rate fell by almost half, as did the perforation rate among patients with appendicitis (from 23.7% to 11.5%). The bad management error rate fell from 0.9% to 0.2%, and the observed mortality fell by 22.0%. The savings made were estimated as amounting to 278 laparotomies and 8,516 bed nights during the trial period--equivalent throughout the National Health Service to annual savings in resources worth over 20m pounds and direct cost savings of over 5m pounds. Computer aided diagnosis is a useful system for improving diagnosis and encouraging better clinical practice.

Local complications of ulcerative colitis: stricture, pseudopolyposis, and carcinoma of colon and rectum.

because of disordered function of the temporal lobe, which may be related to disorder of structure when morphological study is available. It follows that even though the lesion may be a small one the patient is brain-damaged, to use a topical phrase. As the part of the brain damaged is responsible for the integration of all sensation into total experience, and as that experience is primarily responsible for behaviour, it would not be surprising if the epilepsy was associated with psychological disorders reflected in disturbance of mood or attitude, or evidenL in disturbed social behaviour. That of course is the case, tor so many people with aggressive psychopathic behaviour also have disturbance of this part of the brain either reflected in the electroencephalogram or in morbid anatomical studies. If the clinician will keep clearly before him the distinction between what happens in the attack itself (the ictus) and what results from the post-ictal confusional state, and will then divorce these events from the total behaviour of the patient, he will be doing just what the neurologist does when he is faced with the much simpler situation in a patient who has a parietal lobe lesion. In this case there may be a hemiplegia with disturbance of feeling which will affect the patients behaviour at a lower level of functional integration, and this disturbance of movement or behaviour may well be associated with attacks of a parietal lobe kind-that is to say, a focal fit affecting arm or leg,. In this simple situation there is no difficulty in distinguishing between the intermittent epileptic event and the continued life handicap. Although the distinction is much less obvious with temporal lobe lesions, it exists, and in practice it can in most cases be made. To know that it exists will prevent serious mistakes. Lastly, a point which has been made before must be re-emphasized-that in any epileptic patient the impact of the attacks upon the subjects life is apt to lead to psychological difficulties the effects of which are to increase the frequency of attacks and severity of epilepsy ; when the epilepsy includes in its experiences psychic disturbances it is particularly prone to be aggravated by psychological distress.

Human and Computer-aided Diagnosis of Abdominal Pain: Further Report with Emphasis on Performance of Clinicians

This paper reports a controlled trial of human and computer-aided diagnosis in a series of 552 patients with acute abdominal pain. The overall diagnostic accuracy of the computer-aided system was 91·5% and that of the senior clinician to see each case was 81·2%. However, the clinicians diagnostic performance improved markedly during the period of the trial. The proportion of appendices which perforated before operation fell from 36% to 4% during the trial, and the negative laparotomy rate dropped sharply. After the trial closed in August 1972 these figures reverted towards their pretrial levels. It is suggested that while computer-aided diagnosis is a valuable direct adjunct to the clinician dealing with the “acute abdomen,” he may also benefit in the short-term from the constant feedback he receives and from the disciplines and constraints involved in communicating with the computer.

Surgical treatment of severe attacks of ulcerative colitis, with special reference to the advantages of early operation.

The management and outcome of 258 severe attacks of ulcerative colitis from 1952 to 1969 has been reviewed. If remission did not occur during an initial course of intensive medical treatment, including administration of corticosteroids, operation (generally ileostomy with proctocolectomy or subtotal colectomy) was performed. This took place some 12 to 17 days after admission as a rule during the years 1952-63, but usually within five to seven days from 1964 to 1969. Roughly half the attacks underwent spontaneous remission during the two periods, but the medical mortality was 4·8% in the former and 0·7% in the latter, the operative mortality 20·0 and 7·0%, and the overall mortality 11·3 and 4.5% respectively. The lowering of the mortality was particularly striking in severe first attacks and in severe attacks in patients over 60 years of age. Perforation of the colon was found in 21 cases, or nearly 20% of 112 patients coming to operation during attacks, being commoner in the first period (32·5%) than in the second (11·1%). The immediate mortality of all such operations was 11·6%; in cases with perforation it was 28·6%. Acute colonic dilatation was observed in 28 cases. All but one were treated by emergency colectomy, at which the colon was noted to be perforated in 11. The mortality of these operations was 18·5%. Follow-up of the 140 patients who survived without coming to operation during their attacks shows that 52 (37·1%) subsequently underwent surgical treatment either during further attacks or electively. Though all 258 attacks were thought at the time to be due to ordinary ulcerative colitis, subsequent pathological examination of operative specimens derived from 98 patients who came to urgent or subsequent operation during the 1964-9 period revealed that the lesion in the large bowel was Crohns disease in 17 instances.

Clinical findings, early endoscopy, and multivariate analysis in patients bleeding from the upper gastrointestinal tract.

A simple system has been developed to identify patients with upper gastrointestinal tract haemorrhage who run a high risk of continued bleeding or rebleeding. The system is based on six items of patient data available at or soon after arrival in hospital. It was evaluated in a prospective study of 66 patients with upper gastrointestinal tract haemorrhage. Over half of the patients classified by the system into a high-risk category either continued bleeding or rebled after apparent cessation (as against one out of 33 patients in the low-risk category). The high-rish group also had a higher mortality (21%) than those in the low-risk group (nil). The addition or subtraction of early endoscopic findings made little difference to the accuracy of prognosis.

Clinical Presentation of Acute Abdomen: Study of 600 Patients

This paper presents the clinical features of 600 patients suffering from abdominal pain of acute onset and admitted to either the General Infirmary or St. Jamess Hospital, Leeds. The survey was initially retrospective, but later put on a prospective basis. Roughly two-thirds of these 600 patients presented a “typical” picture of the disease with which they presented, while the remaining third presented one or more atypical features. Since other prospective studies have indicated that the diagnostic accuracy of a group of clinicians in respect of the acute abdomen is roughly 65% it is tentatively suggested (a) that clinical diagnosis contains a large element of “pattern-matching,” and (b) that such a policy can be expected to be ineffective in roughly one-third of all cases of acute abdominal pain.

Long-term Prognosis of Ulcerative Colitis

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Computer-aided Diagnosis: Description of an Adaptable System, and Operational Experience with 2,034 Cases

This paper describes a system of computer-aided diagnosis using an English Electric KDF9 computer linked to a terminal in a busy clinical department. Data from a series of patients were recorded, coded, and entered into the computer, which then performed a Bayesian analysis and displayed diagnostic probabilities in an adaptable format. Experience in this setting suggests that computer diagnosis may be a valuable aid to the clinician.

Can computer aided teaching packages improve clinical care in patients with acute abdominal pain

OBJECTIVE--To compare three methods of support for inexperienced staff in their diagnosis and management of patients with acute abdominal pain--namely, with (a) structured data collection forms, (b) real time computer aided decision support, and (c) computer based teaching packages. DESIGN--Prospective assessment of effects of methods of support on groups of doctors in one urban hospital and one rural hospital. SETTING--Accident and emergency department at Whipps Cross Hospital, London, and surgical wards of Airedale General Hospital, West Yorkshire. PATIENTS--Consecutive prospective series of all patients presenting to each hospital in specified time periods with acute abdominal pain; total patients in the various periods were 12,506. MAIN OUTCOME MEASURES--Diagnostic accuracy of participating doctors, admission rates of patients with non-specific abdominal pain, perforation rates in patients with appendicitis, negative laparotomy rates. RESULTS--Use of any one modality resulted in improved diagnostic accuracy and decision making performance. Use of structured forms plus computer feedback resulted in better performance than use of forms alone. Use of structured forms plus a computer teaching package gave results at least as good as those with direct feedback by computer. CONCLUSIONS--The results confirm earlier studies in suggesting that the use of computer aided decision support improves diagnostic and decision making performance when dealing with patients suffering from acute abdominal pain. That use of the computer for teaching gave results at least as good as with its use for direct feedback may be highly relevant for those who are apprehensive about the real time use of diagnostic computers in a clinical setting.