RESUMEN
AIM: With the increasingly litigious nature of medical practice, accurate documentation is critical. This is particularly true for operative procedures, and medical councils have identified this and published guidelines to aid surgeons. However, these remain a frequently cited weakness in their defence in medico-legal cases. This study assessed the accuracy of operative notes in a general surgery unit in order to improve our practice. METHOD: An audit of 100 consecutive operative notes was performed, and notes were assessed using the Royal College of Surgeons guidelines. The quality of note-taking of trainees was compared with that of consultant surgeons. A series of operation note pro formas was designed in response to the findings. RESULTS: Of the notes, 66% were completed by trainees. The vast majority of notes had no diagram to demonstrate the surgical findings or illustrate the actions. Specialist surgeons were more likely to describe the actions accurately, but less likely to describe wound closure methods or dressings used. They were also less likely to complete adequate postoperative orders. CONCLUSIONS: This study identifies key areas of weakness in our operative note-keeping. Pro formas should be introduced and made available for commonly performed procedures, and diagrams should be used wherever possible.
Asunto(s)
Control de Formularios y Registros/normas , Cirugía General/normas , Registros Médicos/normas , Adhesión a Directriz , Humanos , Auditoría Médica , Control de Calidad , Calidad de la Atención de SaludRESUMEN
OBJECTIVE: We sought to evaluate the surgical service in the central part of the Eastern Cape Province by reviewing the practice of appendicectomy at Frere Hospital. Specifically, it was our aim to compare the service to those patients who reside in and outside the East London metropolitan area and the outcomes of patients according to their operative finding. PATIENTS AND METHODS: A retrospective study was performed on the medical records of all patients who underwent appendicectomy in a 26-month period. This entailed a thorough review of demographic factors, mode of presentation, operation factors and findings, and the postoperative course. RESULTS: . In the study period, 436 appendicectomies were performed, of which 81% were performed after hours, with a consultant surgeon present in only 6% of cases. Of the group, 51% had a perforated appendix at surgery, and 12% a normal appendix. There was a significantly increased risk of perforation at the extremes of age and in patients from outside East London (63% v. 35% in East London). Those with perforated appendices stayed an average of 7.3 days in hospital, compared with 5 days for those with earlier appendicitis. Of the perforated group, 21% developed a complication, with 86% of all complications occurring in this group. The hospital stays were longer in those perforated appendices that were drained (10.7 days v. 6.1 days), and the rate of complications higher in this subgroup. Four patients died (1%)--all in the perforated group. DISCUSSION: The perforation rate in our setting is significantly higher than other published results. Patients with perforated appendices have longer hospital stays and are more likely to develop significant complications, including re-operation. Patients from outside East London, males and those at the extremes of age are more likely to have perforated appendices. This study lends little support to the advocates of drains, and recommends the use of non-absorbable sutures for skin closure. The majority of procedures are performed after hours by medical officers and registrars, but there is no evidence to suggest that this practice be altered, particularly in light of the high perforation rate. The main factor identified as contributing to the huge discrepancy between perforation rates (and hence morbidity) is delay in presentation to the operating surgeon for the region. Patient factors may contribute, but service factors are regarded as significant, including poor access to clinics and hospitals, transport and ambulance services, and the expertise of the referring medical staff. The need to improve the quality of patient care in the under-serviced rural areas of the Eastern Cape is highlighted.
Asunto(s)
Apendicectomía/estadística & datos numéricos , Apendicitis/cirugía , Hospitales/estadística & datos numéricos , Auditoría Médica , Adolescente , Adulto , Apendicitis/epidemiología , Niño , Femenino , Humanos , Tiempo de Internación , Masculino , Área sin Atención Médica , Calidad de la Atención de Salud , Estudios Retrospectivos , Sudáfrica/epidemiología , Factores de TiempoRESUMEN
Retrorectal cystic hamartomas are rare congenital lesions derived from the vestigial portion of the embryonic hindgut. These lesions present in a vague manner and so mimic the presentation of more common mass lesions in the pelvic region. They most frequently afflict middle-aged women, causing vague pelvic pains, discomfort with defaecation or sitting, and altered bowel function. Malignant transformation within these lesions is extremely rare. We describe a case of adenocarcinoma within a retrorectal cystic hamartoma, initially manifesting in a 54-year-old woman and recurring over a'5-year period. A computed tomography (CT) scan and pathology reports are included in the study, and findings at operations are discussed. We also include a comprehensive review of the literature.
Asunto(s)
Adenocarcinoma/diagnóstico , Cistoadenoma/patología , Hamartoma/diagnóstico , Neoplasias del Recto/diagnóstico , Adenocarcinoma/patología , Adenocarcinoma/cirugía , Cistoadenoma/cirugía , Femenino , Hamartoma/patología , Hamartoma/cirugía , Humanos , Persona de Mediana Edad , Enfermedades del Recto/diagnóstico , Enfermedades del Recto/patología , Enfermedades del Recto/cirugía , Neoplasias del Recto/patología , Neoplasias del Recto/cirugíaRESUMEN
CONTEXT: Activation of the coagulation system and depletion of endogenous anticoagulants are frequently found in patients with severe sepsis and septic shock. Diffuse microthrombus formation may induce organ dysfunction and lead to excess mortality in septic shock. Antithrombin III may provide protection from multiorgan failure and improve survival in severely ill patients. OBJECTIVE: To determine if high-dose antithrombin III (administered within 6 hours of onset) would provide a survival advantage in patients with severe sepsis and septic shock. DESIGN AND SETTING: Double-blind, placebo-controlled, multicenter phase 3 clinical trial in patients with severe sepsis (the KyberSept Trial) was conducted from March 1997 through January 2000. PATIENTS: A total of 2314 adult patients were randomized into 2 equal groups of 1157 to receive either intravenous antithrombin III (30 000 IU in total over 4 days) or a placebo (1% human albumin). MAIN OUTCOME MEASURE: All-cause mortality 28 days after initiation of study medication. RESULTS: Overall mortality at 28 days in the antithrombin III treatment group was 38.9% vs 38.7% in the placebo group (P =.94). Secondary end points, including mortality at 56 and 90 days and survival time in the intensive care unit, did not differ between the antithrombin III and placebo groups. In the subgroup of patients who did not receive concomitant heparin during the 4-day treatment phase (n = 698), the 28-day mortality was nonsignificantly lower in the antithrombin III group (37.8%) than in the placebo group (43.6%) (P =.08). This trend became significant after 90 days (n = 686; 44.9% for antithrombin III group vs 52.5% for placebo group; P =.03). In patients receiving antithrombin III and concomitant heparin, a significantly increased bleeding incidence was observed (23.8% for antithrombin III group vs 13.5% for placebo group; P<.001). CONCLUSIONS: High-dose antithrombin III therapy had no effect on 28-day all-cause mortality in adult patients with severe sepsis and septic shock when administered within 6 hours after the onset. High-dose antithrombin III was associated with an increased risk of hemorrhage when administered with heparin. There was some evidence to suggest a treatment benefit of antithrombin III in the subgroup of patients not receiving concomitant heparin.
Asunto(s)
Anticoagulantes/uso terapéutico , Antitrombina III/uso terapéutico , Insuficiencia Multiorgánica/etiología , Insuficiencia Multiorgánica/prevención & control , Inhibidores de Serina Proteinasa/uso terapéutico , Choque Séptico/complicaciones , Choque Séptico/tratamiento farmacológico , Adulto , Anticoagulantes/administración & dosificación , Antitrombina III/administración & dosificación , Método Doble Ciego , Interacciones Farmacológicas , Femenino , Heparina/uso terapéutico , Humanos , Masculino , Inhibidores de Serina Proteinasa/administración & dosificación , Análisis de Supervivencia , Síndrome de Respuesta Inflamatoria Sistémica/complicaciones , Síndrome de Respuesta Inflamatoria Sistémica/tratamiento farmacológico , Trombosis/etiología , Trombosis/prevención & controlRESUMEN
BACKGROUND: Evidence that chronic gastric Helicobacter pylori (HP) infection is an aetiological factor in dyspepsia, peptic ulcer disease, gastric carcinoma and lymphoma has led to the suggestion that all serologically positive dyspeptic patients should be treated empirically with antibiotics to eradicate the infection, without endoscopic diagnosis. The following study was performed to determine whether such a policy would prove to be of benefit in rural Africa, where endoscopic facilities are lacking and infection rates high. METHODS: Four district clinics were visited and 97 consecutive patients with persistent upper gastro-intestinal symptoms studied. After history-taking and physical examination, a blood sample was taken for HP serology (IgG anti-HP EIA) and endoscopy was performed. RESULTS: In comparison with similar studies in westernised countries HP was considerably more common (80%), and similar to that reported for the background population (83-86%), but peptic ulceration (17%) and gastric cancer (1%) were not. HP status and antibody levels failed to predict the presence of serious disease; patients with 'alarm' signs (78%), cancer (78%) and peptic ulcers (81%) had similar seropositivity rates to patients with non-ulcer dyspepsia (81%). Interestingly, many patients with distal oesophagitis were seronegative (40%). Haemoglobin concentrations and nutritional status were similar in HP-positive and negative patients. On the basis of published decision analysis strategies, empiric treatment of HP-positive patients with uncomplicated dyspepsia could be expected to produce symptomatic relief in 50% of cases, but would have delayed the diagnosis of 3 cases of cancer if patients over the age of 45 were included. CONCLUSION: The lack of association between HP serology and upper gastro-intestinal disease indicates that serological investigation cannot substitute for endoscopy in the management of black Africans with dyspepsia, and that empiric anti-HP therapy cannot be justified.