G. G. Youngson

Acute appendicitis: the continuing role for active observation.

Abstract We present the results of a 6-year review of appendicitis. In the event of diagnostic doubt, a policy of active observation was instituted. This review endorses the validity of such a policy, indicating that it does not expose patients to increased morbidity. Data were collected prospectively over a 6-year period on 1,479 children admitted with suspected acute appendicitis (AA); 1,028 (69.5%) were discharged with a diagnosis of non-specific abdominal pain after a mean observation period of 2.5 days, whilst in the remaining 451 a clinical diagnosis of AA was confirmed. The male-to-female ratio was equal, with no difference in the mean age of males (11 years) or females (12 years); 95% of patients were over the age of 5 years. In 324 (72%) cases surgery was performed on the day of admission, whilst in the remaining 126 (28%) it was deferred for 1 to 6 days because the clinical diagnosis of AA remained doubtful. The mean hospital stay was 4 days (range 1 – 32). Analysis of the histological reports of all 451 cases confirmed a positive predictive value for clinical assessment alone of 97.9% and a normal appendicectomy rate of 2.6%. No mortality was observed; surgical morbidity was recorded at 6% with no correlation between post-operative morbidity and timing of surgery evident (Spearmans correlation coefficient = −0.079, p=0.9). Active observation for suspected AA thus remains a valid technique for achieving an accurate diagnosis and successful outcome.

Undergraduate medical students' perceptions and expectations of theatre-based learning: How can we improve the student learning experience?

OBJECTIVE Much of the student experience in theatre depends on the interaction between student and surgeon, and having the opportunity to take part in procedures. Theatre-based teaching can be seen as having little inherent benefit otherwise. We wished to identify other factors contributing to the experience of theatre-based teaching. DESIGN A questionnaire survey, using forced-choice and open questions, of undergraduate medical students with experience of surgical attachments. SETTING AND PARTICIPANTS 54 final (5th) year medical students, University of Aberdeen. ANALYSIS Responses on the closed questions are presented as percentages. The themes arising from the open questions were identified and the relationships among these themes explored. RESULTS Student expectations of learning focused on knowledge acquisition. Students learning experiences varied widely, depending on how welcome they felt in theatre. Visibility and active participation influenced the experience. Students did not feel adequately prepared for getting the most out of this learning experience. CONCLUSIONS The student experience may be skewed by unrealistic expectations of theatre-based learning. Clear and realistic learning objectives, preparation in terms of familiarity with the environment and staff roles, embedding the experience in the patients journey/care pathways, faculty expectations being clearly communicated to clinical teaching staff and, perhaps above all, approachability of theatre staff are likely to improve the learning experience.

Patient safety in surgery: non-technical aspects of safe surgical performance

The performance of operative surgery has an understandable focus placed on dexterity, technical precision, as well as the choice of procedure. There is less appreciation of the cognitive and social skills of the individual surgeon and the effect that these have on the surgical team and on patient outcome. This article highlights that impact and explores the contribution of non-technical skills to safe practice within the operating room.

Abdominoscrotal hydrocoeles: little place for conservatism

Abstract Abdominoscrotal hydrocoeles (ASH) are infrequently reported in children. The presence of bilateral ASH is even rarer, with fewer than five cases reported to date. ASH are present at birth and tend to be progressive in nature. Spontaneous resolution has not been documented. The pathogenesis is uncertain and their presence in the neonatal period suggests a preformed abnormality of the processus vaginalis. Diagnosis is suspected on clinical examination and confirmed by ultrasonography, which is a reliable diagnostic tool. Undescended testes frequently coexist. Early surgery is the preferred management, and complications are frequent if left unattended. Surgery is simply an extension of a hernia operation, without the need for a laparotomy.

Management of the impalpable testis: Long-term results of the preperitoneal approach

During a 12-year period 396 operations for undescended testes were carried out by one surgeon. In 90 boys the testis was impalpable, and exploration was performed using a muscle-splitting preperitoneal approach. Testicular volume and location were prospectively recorded at 3 months and 1 year, 94% were intrascrotal at 1 year and 84% were judged to have grown. At late follow-up 6 to 16 years (mean, 11 years) after ochidopexy, 81% of testes were in the scrotum and 57% were of normal volume. The value and advantages of this operative approach and its place in the management strategy of the impalpable testis are discussed.

Amyand’s hernia presenting as neonatal testicular ischaemia

Testicular ischaemia presenting in the neonatal period is most often attributable to neonatal torsion. We present an unusual case of a male neonate who presented with acute appendicitis within a patent processus vaginalis, causing cord compression and consequent testicular ischaemia.

Serum cytokine profile in reflux nephropathy

Abstract Cytokines are small regulatory peptides with diverse functions. They regulate the immune system and modulate the inflammatory response, both of which are implicated in vesico-ureteric reflux (VUR) and associated reflux nephropathy (RN). The cytokine profile in VUR and RN has yet to be fully investigated. Blood was obtained from three subject groups immediately after induction of anaesthesia: group A [subjects with VUR and established RN, (N=9)]; group B [VUR alone but no associated RN, (N=6)]; and group C [age- and sex-matched controls with no history of urinary sepsis, (N=14)]. Serum cytokine levels of tumour-necrosis factor-alpha (TNF-α), interleukin-6 (IL-6), soluble TNF receptor-1 (sTNF-R1), and interleukin-8 (IL-8) were measured using standard ELISA technique. Serum levels of IL-6 were higher in group A subjects (1.798–4.638 pg/ml, median 3.253 pg/ml) than controls (1.531–2.078 pg/ml, median 1.798 pg/ml). There was no significant difference in levels in group B subjects (1.498–3.048 pg/ml, median 1.948 pg/ml) and controls. These same relationships were observed for levels of TNF-α (group A: 8.501–14.471 pg/ml, median 13.483 pg/ml; group B: 7.088–10.650 pg/ml, median 8.886 pg/ml; group C: 6.746–13.344 pg/ml, median 7.671 pg/ml) and sTNF-R1 (group A: 690.34–5780.74 pg/ml, median 1197.38 pg/ml; group B: 366.65–1401.62 pg/ml, median 592.82 pg/ml; C: 313.49–636.33 pg/ml, median 504.17 pg/ml). IL-8 was not significantly elevated in any of the study groups (A or B) compared with control group C (group A: 27.08–56.38 pg/ml, median 31.35 pg/ml; group B: 29.90–35.87 pg/ml, median 31.35 pg/ml; group C: 25.05–30.22 pg/ml, median 29.90 pg/ml). These results suggest there may be an immunological basis to RN.

Teaching and assessing non-technical skills

The terms human factors and non-technical skills have recently been introduced to the language of surgical education. Both tend to be used interchangeably and yet each has a specific definition. More importantly, however, is the fact that the attributes and qualities contained within these headings relate to behaviours, attitudes and cognitive skills. They are recognised as crucially important in the practice of surgery, but are often poorly articulated during surgical performance, during training, during any assessment process and, indeed, seldom measured with reference to any metric in any of these activities. Most research in this area addresses non-technical skills in the operating theatre and it remains to be seen whether the same attributes and skills are used outwith theatre, particularly in the ward setting. However, the contribution that these aspects of performance make to a safe and successful outcome following surgery is being increasingly appreciated and there is increasing recognition of the need to train and assess.

The accuracy of clinical data: A comparison between central and local data collection

BACKGROUND The recent liberalisation of public access to information, including surgical performance, emphasises the necessity for accurate data collection. The Information and Statistics Division of the Scottish Executive (ISD) collect such data for each patient episode, but there is concern about the reliability of this information compared with that collected in local surgical departmental audit. AIM To determine if diagnostic and operative details were consistent between local audited and national non-audited data sets. METHODS Three surgical units comprising eight consultants were studied. Epidemiological, diagnostic and operative data for each consultant were accessed from the eScrips Internet resource (ISD Data) and from the departmental database. A unique patient number and date of birth matched individual patient episodes and the correlation between datasets graded for accuracy and consistency. RESULTS 8375 individual data entries were recorded (ISD 4642, local databases 3733). 3402 pairs, 6408 (76.5%) of the total, matched accurately. 742 (16%) of the ISD entries were duplicates, and in 21% of unpaired entries the wrong consultant was recorded. Overall a clinically acceptable match occurred in 86.9% of paired entries for diagnosis and 84.0% for operation. The highest match with ISD data for diagnosis (88.8%) and operation (91.8%) occurred in the unit which holds a weekly audit meeting to validate information. DISCUSSION There are significant discrepancies in surgical data between the local audit databases and central data. There is significant duplication of entries and inaccurate consultant allocation in ISD data. The promulgation of inaccurate information could threaten reputation or career and clinicians should play a more active role in ensuring clinical data are correct.

Hospital re-admission in children with non-specific abdominal pain

Abstract.In children with non-specific abdominal pain (NSAP) who were subsequently re-admitted to hospital with a further episode of pain within 30 days, the contribution of active observation to the initial and subsequent admission was evaluated and the diagnostic process reviewed. The cohort comprised all children with a discharge diagnosis of NSAP admitted to Royal Aberdeen Childrens Hospital between January 1990 and December 1999. Data were extracted from a computerised database. A measure was made of the investigations employed in the children who were re-admitted and an arbitrary score produced in an attempt to measure the intensity and degree of the diagnostic process. This investigation score was then related to both clinical outcome and the need for revision of the original diagnosis of NSAP. A total of 1,238 children (675 males, 563 females) were admitted with NSAP; 46 (22 males and 24 females, age range 4–14 years) were re-admitted with further abdominal pain within a 30-day period. The total number of re-admission events was 53. In 19 children the subsequent diagnosis was revised. Ten of the 46 children underwent an operation; in 31 cases re-admission investigations were more detailed and invasive, but contributed to a change in diagnosis in only 13. There was no recorded mortality over the study period. In children re-admitted with abdominal pain, the subsequent diagnosis thus changed from the original in over one-third of cases. Most children undergo more invasive and more detailed investigations on re-admission in comparison to the initial episode of hospitalisation. The majority, however, continue to be managed conservatively. This study endorses the continued use of active observation in the management of NSAP in children, and recognises that even intense investigation may fail to contribute to a more specific diagnosis.