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1.  All basic surgical trainees should rotate through an accident and emergency post. 
A 6-month post in accident and emergency is no longer compulsory for basic surgical training. Meanwhile, trauma teams have emerged in many UK hospitals to receive seriously injured patients, often with no involvement of basic surgical trainees (BSTs). This may lead to the appointment of surgical specialist registrars (SpRs) who have had little exposure to the initial management of seriously injured patients. This study documents the experience of a senior house officer undertaking a 6-month post in the accident and emergency department of a district general hospital. METHODS: Data concerning the nature of cases seen were collected retrospectively from all patient record cards signed by the author during the placement. RESULTS: During the period studied, the author was present in the resuscitation room on 41 occasions, of which 10 episodes involved the management of a multiply injured patient. A total of 159 fractures and significant soft tissue injuries in the upper limb and 122 such cases in the lower limb were seen. There were 25 head injuries, 17 spinal injuries, 5 significant cases of chest trauma, 4 of abdominal trauma and 5 significant urinary tract injuries. Some 86 practical procedures were carried out during the placement. DISCUSSION: The 6-month post in accident and emergency provided the BST with significant exposure to the care of seriously injured patients. Such a post should be compulsory to ensure that SpRs on appointment have already received exposure to managing the seriously injured. The post provided additional benefit in terms of performing practical procedures and exposure to other acute surgical conditions.
PMCID: PMC2503560  PMID: 11212444
2.  Primary care in London: an evaluation of general practitioners working in an inner city accident and emergency department. 
OBJECTIVE: To determine the characteristics of primary care attenders to St Mary's Hospital accident and emergency (A&E) department, evaluate the effects of the introduction of general practitioners (GPs) on patient care in A&E, and make recommendations for the provision of GPs in appropriate A&E departments. DESIGN: Prospective survey over a six week period. METHODS: Data collected from the attendances of 970 consecutive patients triaged with "minor" primary care problems, whether seen by A&E doctors or by GPs working in A&E, were analysed. RESULTS: During the study period 1078 patients (16.6%) were triaged as suitable for primary care. The A&E GPs saw 58.4% of these patients. The majority of primary care patients were young British residents, 71.1% of whom were registered with a GP. Sixty per cent of patients lived within St Mary's catchment area. Of those registered patients asked why they attended A&E, 27.1% thought their problem inappropriate for their GP. A&E doctors were more likely to investigate patients and arrange hospital follow up than GPs, who arranged community follow up in 80% of patients needing further care. CONCLUSIONS: The demand for primary care at St Mary's necessitates the provision of a primary care service, albeit for the first visit only. This can be provided by GPs in A&E. The features of the patients using the service suggests that discouraging first attendance is unrealistic, but using the visit to educate patients and return them to the care of the community is not.
PMCID: PMC1342597  PMID: 8821216
3.  Comparison of attendance and emergency admission patterns at accident and emergency departments in and out of London. 
BMJ : British Medical Journal  1993;306(6887):1241-1243.
OBJECTIVE--To compare the sociodemographic characteristics, diagnoses, and mode of referral of people and emergency admissions between an accident and emergency department in inner London and one in a town outside London. DESIGN--Standardised questionnaire completed prospectively over two weeks by field-workers in each accident and emergency department. SETTING--Accident and emergency departments in an inner London teaching hospital and an associated teaching hospital outside London. SUBJECTS--3039 adults newly attending the departments, 1476 in inner London and 1563 outside London. MAIN OUTCOME MEASURES--Sociodemographic characteristics, diagnosis, mode of referral, and whether the patient was admitted. RESULTS--General practitioner referrals accounted for similar proportions of the adult attendances (12% in inner London, 15% outside London). People attending at the inner London department were more likely to be tourists or long distance commuters (12% (179/1476) v 6% (95/1563)), single (43% (643) v 32% (505)), to live alone (24% (360) v 14% (225)), to have moved recently (13% (194) v 7% (107)), or to be homeless (3.3% (48) v 0.6% (10)). Broad clinical groupings of patients were similar in both departments. 291 people were admitted in inner London and 284 outside London. The proportions admitted from each sociodemographic group were similar in the two hospitals. CONCLUSION--Differences in sociodemographic characteristics were more important than general practice referral patterns in determining the differences in people attending at accident and emergency departments inside and outside London. Many of these characteristics are likely to be found in other inner city populations. A strategy to improve acute care in inner London should take account of the needs of these sociodemographically different groups.
PMCID: PMC1677609  PMID: 8123074
4.  Button Battery Foreign Bodies in Children: Hazards, Management, and Recommendations 
BioMed Research International  2013;2013:846091.
Objective. The demand and usage of button batteries have risen. They are frequently inadvertently placed by children in their ears or noses and occasionally are swallowed and lodged along the upper aerodigestive tract. The purpose of this work is to study the different presentations of button battery foreign bodies and present our experience in the diagnosis and management of this hazardous problem in children. Patients and Methods. This study included 13 patients. The diagnostic protocol was comprised of a thorough history, head and neck physical examination, and appropriate radiographic evaluation. The button batteries were emergently extracted under general anesthesia. Results. The average follow-up period was 4.3 months. Five patients had a nasal button battery. Four patients had an esophageal button battery. Three patients had a button battery in the stomach. One patient had a button battery impacted in the left external ear canal. Apart from a nasal septal perforation and a tympanic membrane perforation, no major complications were detected. Conclusion. Early detection is the key in the management of button battery foreign bodies. They have a distinctive appearance on radiography, and its prompt removal is mandatory, especially for batteries lodged in the esophagus. Physicians must recognize the hazardous potential and serious implications of such an accident. There is a need for more public education about this serious problem.
PMCID: PMC3725977  PMID: 23936851
5.  Neck pain 
BMJ Clinical Evidence  2008;2008:1103.
Non-specific neck pain has a postural or mechanical basis and affects about two thirds of people at some stage, especially in middle age. Acute neck pain resolves within days or weeks, but may become chronic in about 10% of people. Whiplash injuries follow sudden acceleration–deceleration of the neck, such as in road traffic or sporting accidents. Up to 40% of people continue to report symptoms 15 years after the accident, although this varies between countries.
Methods and outcomes
We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of treatments for people with non-specific neck pain without severe neurological deficit? What are the effects of treatments for acute whiplash injury? What are the effects of treatments for chronic whiplash injury? What are the effects of treatments for neck pain with radiculopathy? We searched: Medline, Embase, The Cochrane Library, and other important databases up to May 2007 (BMJ Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
We found 91 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of the evidence for interventions.
In this systematic review we present information relating to the effectiveness and safety of the following interventions: acupuncture, biofeedback, drug treatments (analgesics, antidepressants, epidural steroid injections, muscle relaxants, non-steroidal anti-inflammatory drugs [NSAIDs]), early mobilisation, early return to normal activity, exercise, heat or cold, manipulation (alone or plus exercise), mobilisation, multimodal treatment, patient education, percutaneous radiofrequency neurotomy, physical treatments, postural techniques (yoga, pilates, Alexander technique), pulsed electromagnetic field (PEMF) treatment, soft collars and special pillows, spray and stretch, surgery, traction, and transcutaneous electrical nerve stimulation (TENS).
Key Points
Non-specific neck pain has a postural or mechanical basis, and affects about two thirds of people at some stage, especially in middle age. Acute neck pain resolves within days or weeks, but becomes chronic in about 10% of people.Whiplash injuries follow sudden acceleration–deceleration of the neck, such as in road traffic or sporting accidents. Up to 40% of people continue to report symptoms 15 years after the accident.
The evidence about the effects of individual interventions for neck pain is often contradictory because of poor quality RCTs, the tendency for interventions to be given in combination, and for RCTs to be conducted in diverse groups. This lack of consistency in study design makes it difficult to isolate which intervention may be of use in which type of neck pain.
Stretching and strengthening exercise reduces chronic neck pain compared with usual care, either alone or in combination with manipulation, mobilisation, or infrared. Manipulation and mobilisation may reduce chronic pain more than usual care or less-active exercise. They seem likely to be as effective as each other or as exercise, and more effective than pulsed electromagnetic field (PEMF) treatment, or than heat treatment. Acupuncture may be more effective than some types of sham or inactive treatment at improving pain relief and quality of life at the end of treatment or in the short term.
Analgesics, NSAIDs, antidepressants, and muscle relaxants are widely used to treat chronic neck pain, but we don't know whether they are effective.
We don't know whether traction, PEMF treatment, TENS, heat or cold, biofeedback, spray and stretch, multimodal treatment, patient education, soft collars, or special pillows are better or worse than other treatments at reducing chronic neck pain.
Early mobilisation may reduce pain in people with acute whiplash injury compared with immobilisation or rest with a collar. We don't know whether exercise, early return tonormal activity, PEMF treatment, multimodal treatment, or drug treatment can reduce pain in people with acute whiplash injury.
We don't know whether percutaneous radiofrequency neurotomy, multimodal treatment, or physical treatment reduce pain in people with chronic whiplash injury.
We don't know whether surgery, analgesics, NSAIDs, muscle relaxants, or cervical epidural steroid injections reduce pain in people with neck pain plus radiculopathy.
PMCID: PMC2907992  PMID: 19445809
6.  Biphasic parapharyngeal synovial sarcoma: a cytologic and immunocytologic report of a case 
CytoJournal  2006;3:20.
Synovial sarcoma is a rare soft tissue sarcoma in the head and neck region and parapharyngeal space. There is no previous cytologic report of synovial sarcoma of parapharynx. The cytologic and immunocytochemical findings of a parapharyngeal biphasic synovial sarcoma together with diagnostic pitfalls are described.
Case report
A 21-year-old girl presented with a 6-month history of progressive right arm pain, neck mass and upper aerodigestive tract obstruction. On physical examination there was a large painless mass arising from the right-sided parapharyngeal space causing airway obstruction. Initial magnetic resonance imaging (MRI) revealed a large tumor in the right-sided parapharyngeal space. Fine needle aspiration through cervical region was performed and was reported as benign spindle cell tumor. Smears were cellular and composed mostly of tight and loose clusters of spindle cells. Epitheloid cells could also be identified intermingled with them. She underwent near total resection of the tumor. Pathologic report disclosed the diagnosis of synovial sarcoma. She then received postoperative adjuvant external radiotherapy.
Due to rarity of this tumor in this region and nonspecific cytologic features, we could not differentiate this tumor from the other more common spindle cell neoplasms. Considering synovial sarcoma in this region and immunocytochemistry can be helpful in rendering a correct initial diagnosis of this tumor.
PMCID: PMC1562442  PMID: 16907985
7.  Narrow-band imaging: a new tool for evaluation of head and neck squamous cell carcinomas. Review of the literature 
Head and neck squamous cell carcinoma of the upper aerodigestive tract is well known for its frequently late presentation and diagnosis at an advanced stage. In addition, it is well recognized that it may arise in multiple sites, either synchronously or metachronously. Thus it should be imperative to endoscopically screen the upper aerodigestive tract of patients at risk for head and neck squamous cell carcinoma with a new diagnostic tool, especially due to the fact that early lesions are very difficult to detect even by multiple passes with a standard endoscopy, if they are ≤ 1 cm in diameter. Lugol chromoendoscopy, which is mainly used in the oesophagus, is not suitable for the head and neck region due to severe mucosal irritation. Herein, narrow-band imaging is described, a diagnostic tool already proved as a useful screening method in other endoscopic fields, and its application in the early detection of head and neck squamous cell carcinoma is reviewed, as reported by previous studies in the otolaryngologic literature. Narrow-band imaging relies on the principle of depth of penetration of light, with the narrow-band blue light having a short wavelength (415 nm) penetrating into the mucosa and highlighting the superficial vasculature. Furthermore, the blue filter is designed to correspond to the peak absorption spectrum of haemoglobin to enhance the image of capillary vessels on surface mucosa. Thus, superficial mucosal lesions that would be missed by regular white light endoscopy, are identified, in view of their neoangiogenetic pattern of vasculature, using the blue light of the narrow-band imaging. Narrow-band imaging has been used extensively in the lower aerodigestive system, yet there are only 2 reports of applications in the region of the head and neck, specifically the oropharynx and the hypopharynx. However, these are not the only sites that can benefit from narrow-band imaging. Herewith, the uses and importance are highlighted of narrow-band imaging as a future diagnostic tool in otolaryngology, in the pre-, intra- and post-operative settings.
PMCID: PMC2644976  PMID: 18669067
Upper aero-digestive tract; Malignant tumours; Diagnosis; Endoscopy; Narrow-band imaging
8.  Hodgkin’s disease presenting as discharging neck sinuses and a mediastinal mass 
BMJ Case Reports  2011;2011:bcr1220103669.
A 23-year-old Asian lady presented with a hard indurated midline neck swelling of 2 months duration without any upper aerodigestive tract or systemic symptoms of note. Her inflammatory markers were elevated and she was commenced on antibiotics. Ultrasound scan and fine needle aspiration cytology (FNAC) were inconclusive. A CT scan showed an ill-defined soft tissue mass anterior to and not well demarcated from the thyroid, and contiguous with a superior and anterior mediastinal mass. Incisional biopsy revealed necrosis and pockets of purulent material.
Microbiology suggested a chronic pyogenic abscess negative for acid fast bacilli. She was treated with antituberculous therapy without resolution. She developed a discharging lateral neck mass with progressive increase of the mediastinal mass. She subsequently required a neck exploration and mediastinoscopy. Repeat mediastinal biopsies confirmed the diagnosis of Hodgkin’s disease and no organisms on culture. She was commenced on chemotherapeutic treatment with a satisfactory outcome.
PMCID: PMC3149508  PMID: 22689859
9.  Ulnar nerve injury after a comminuted fracture of the humeral shaft from a high-velocity accident: a case report 
Injury to the ulnar nerve following humerus shaft fracture is a very rare entity because the ulnar nerve is well protected from the bone by muscle and soft tissue, and thus remains unaffected in these fractures. We report what is, to the best of our knowledge, the first case of ulnar nerve injury due to a comminuted humeral shaft fracture. The injury manifested and was diagnosed the day after a high-velocity accident. The paucity of related literature and the necessity for early diagnosis and subsequent treatment of such injuries in high-velocity accidents urged us to document this case.
Case presentation
A 30-year-old Indian man presented to our Emergency Department after a road traffic accident. Our patient complained of right arm pain and the inability to move his extremity. The following morning he developed clawing. Nerve conduction studies on the peripheral nerves of his arm in addition to an X-ray confirmed the diagnosis of a possible injury to the ulnar nerve. Our patient was taken to our Operating Room for surgery, during which a fragment of bone was found abutting the ulnar nerve after penetrating his triceps. This fragment of bone was replaced and the fracture was reduced by open reduction and internal fixation using a dynamic compression plate and screws. Postoperatively, our patient received physical therapy and was discharged two weeks after surgery with no neurological deficit.
This case emphasizes the urgency and importance of careful neurological examination of all the peripheral nerves supplying the arm in patients with a fracture of the shaft of the humerus. In the setting of injury to the arm in high-velocity accidents, a differential diagnosis of ulnar nerve injury should always be considered.
PMCID: PMC3419694  PMID: 22781595
10.  Acute compartment syndrome in children: a case series in 24 patients and review of the literature 
International Orthopaedics  2010;35(4):569-575.
Trauma-associated acute compartment syndrome (ACS) of the extremities is a well-known complication in adults. There are only a handful of articles that describe the symptoms, the diagnostic procedure and treatment of ACS in children. The aim of this study was to analyse the diagnostic procedures in children compared to adolescents with ACS to obtain evidence for the diagnosis, treatment and outcome of children with ACS. Twenty-four children and adolescents with ACS have been treated at the Department of Trauma Surgery of the Medical University of Vienna, Austria. Two age-related groups were investigated to compare the diagnostic and therapeutic algorithm: group A comprising children aged 2–14 years (n = 12) and group B comprising adolescents aged 15–18 years (n = 12). Patient characteristics, diagnosis and therapy-associated data, complications and clinical outcome were analysed. In both groups we found fractures in most of our patients (n = 19) followed by contusion of the soft tissues (n = 3). In group A most of our patients were injured as pedestrians in car accidents (n = 5) followed by low-energy blunt trauma (n = 3). The most common region of injury and traumatic ACS was the lower leg (n = 7) followed by the feet (n = 3). For fracture stabilisation most of the patients (n = 6) received an external fixator. The mean time from admission to the fasciotomy was 27.9 hours. In four patients a compartment pressure measurement was performed with pressure levels from 30 to 75 mmHg. A histological examination of soft tissue was performed in five patients. From fasciotomy to definitive wound closure 2.4 operations were necessary. The mean hospital stay was 18.9 days. In group B most of our patients had a motorcycle accident (n = 5). The most common region for traumatic ACS in this group was also the lower leg (n = 9). In most of the patients (n = 6) intramedullary nails could be implanted. The mean time from admission to the fasciotomy was 27.1 hours. In six patients a compartment pressure measurement was performed with pressures from 25 to 90 mmHg. In five patients a histological examination was performed. From fasciotomy to definitive wound closure 2.3 operations were necessary. The mean hospital stay was 18.4 days. Secondary fasciotomy closure was performed in all cases. A split-skin graft was only necessary in three patients (13%). We avoided primary closure in the same setting when the fasciotomy was performed. Thus, we found no difference between the two groups in the diagnostic procedures, the indication for fasciotomy, the number of operations needed from fasciotomy to definitive wound closure, time of hospitalisation and clinical outcome. The rate of permanent complications was 4.2% (one patient from group A), which means that nearly all patients experienced full recovery after fasciotomy. ACS represents a surgical emergency and the indication should be determined early even in doubtful cases to avoid complications.
PMCID: PMC3066331  PMID: 20401657
11.  The Surgical Management of Traumatic C6-C7 Spondyloptosis 
A case of traumatic spondyloptosis of the cervical spine at the C6-C7 level is reported. The patient was treated succesfully with a anterior-posterior combined approach and decompression. The patient had good neurological outcome after surgery. A-51-year-old female patient was transported to our hospital's emergency department after a vehicle accident. The patient was quadriparetic (Asia D, MRC power 4/5) with severe neck pain. Plain radiographs, computerize tomography and spinal magnetic resonance imaging (MRI) showed C6-7 spondyloptosis and C5, C6 posterior element fractures. Gardner-Wells skeleton traction was applied. Spinal alignment was reachived by traction and dislocation was decreased to a grade 1 spondylolisthesis. Then the patient was firstly operated by anterior approach. Anterior stabilization and fusion was firstly achieved. Seven days after first operation the patient was operated by a posterior approach. The posterior stabilization and fusion was achieved. Postoperative lateral X-rays and three-dimensional computed tomography showed the physiological realignment and the correct screw placements. The patient's quadriparesis was improved significantly. Subaxial cervical spondyloptosis is a relatively rare clinical entity. In this report we present a summary of the clinical presentation, the surgical technique and outcome of this rarely seen spinal disorder.
PMCID: PMC3579083  PMID: 23441058
Cervical spondyloptosis; Spinal cord compression; Spinal stabilization
12.  'Bats below the bridge': is a potentially treatable neurovascular disorder being underdiagnosed in accident and emergency departments? 
Basilar artery thrombosis (BATS) is a progressive disorder which may present with fluctuating neurological signs of varying degrees of severity. Unless the diagnosis is considered, the confused young patient may be thought to be under the influence of drugs or to be psychologically ill, and indeed the Munchausen syndrome may be considered. The more elderly patient may be diagnosed simply as having had a cerebrovascular accident. This paper presents the cases of three patients admitted through the accident and emergency (A&E) department of St Mary's Hospital, London with basilar artery thrombosis during a 6-month period. All these patients demonstrated the classic triad for this syndrome of: (1) long tract neurological signs, (2) impaired conscious level, and (3) complex ocular signs. The concern is that, for patients with more subtle signs, a diagnosis of BATS may not be considered, and a neurological opinion may be thus delayed and no treatment with anticoagulants or thrombolytic agents would be given. Two of the three patients were treated with anticoagulants and improved, while in the third patients anticoagulation was judged inappropriate and the patients died from progression of the disease with respiratory complications.
PMCID: PMC1342397  PMID: 7921562
13.  Posttraumatic persistent shoulder pain: Superior labrum anterior-posterior (SLAP) lesions 
Patient: Male, 57
Final Diagnosis: Typ 2 Superior labrum anterior-posterior lesion
Symptoms: Shoulder pain after trauma
Medication: —
Clinical Procedure: —
Specialty: Orthopedics and Traumatology • Emergency Medicine
Rare disease
Due to the anatomical and biomechanical characteristics of the shoulder, traumatic soft-tissue lesions are more common than osseous lesions. Superior labrum anterior-posterior (SLAP) lesions are an uncommon a cause of shoulder pain. SLAP is injury or separation of the glenoid labrum superior where the long head of biceps adheres. SLAP lesions are usually not seen on plain direct radiographs. Shoulder MRI and magnetic resonance arthrography are useful for diagnosis.
Case Report:
A 57-year-old man was admitted to the emergency department due to a low fall on his shoulder. In physical examination, active and passive shoulder motion was normal except for painful extension. Anterior-posterior shoulder x-ray imaging was normal. The patient required orthopedics consultation in the emergency observation unit due to persistent shoulder pain. In shoulder MRI, performed for diagnosis, type II lesion SLAP was detected. The patient was referred to a tertiary hospital due to lack of arthroscopy in our hospital.
Shoulder traumas are usually soft-tissue injuries with no findings in x-rays. SLAP lesion is an uncommon cause of traumatic shoulder pain. For this reason, we recommend orthopedic consultation in post-traumatic persistent shoulder pain.
PMCID: PMC3745270  PMID: 23961305
trauma; shoulder pain; superior labrum anterior posterior lesions
14.  Comparison of standard and nonstandard helmets and variants influencing the choice of helmets: A preliminary report of cross-sectional prospective analysis of 100 cases 
The literature does not offer the rate of protection provided by different types of helmets used, especially as it applies to developing countries. We hypothesize that standard versus nonstandard types of helmets might differ in the rate of complications of head and neck trauma occurring in victims of motorcycle accidents. Here we report the rate of occurrence, the type of injuries and differences thereof in standard and nonstandard helmet bearers, and its relevance to protection from serious injury.
The data were gathered from a data set of motorcycle accident victims admitted to the emergency department of Sina Hospital (Teheran/Iran). A cross-sectional study was designed for a 6-month period of time, June to December 2007. Variants analyzed included: demographics, types of helmets used, level of education of the victims (as in: being trained for using helmets and status of holding a valid driving license). The latter variants were evaluated for possibly influencing the outcome of the injured motorcyclists using either kind of helmets.
Among a total of 576 injured motorcyclists who had head, face, or neck injuries, 432 (75%) were using some kind of helmet. A total of 144 (25%) of the injured patients were admitted to the neurosurgical emergency service. There were 100 patients whose data sheets contained all variables which could be included in the pilot analysis of this cohort.
All 100 subjects were male patients with the age range of 32 ± 11 years. Twenty-five percent were using standard helmets at the time of accident, 43% had no cranio-facio-cervical injury except very mild skin abrasions, and 23% had facial injury, including skin lacerations needing sutures, two nasal bone fractures, and no maxillofacial damage. Among the patients using standard helmets, 44% had head injuries which needed to be taken care of (mostly nonoperatively), while 61% using nonstandard helmets had head trauma (P > 0.05). The other variables did not reach a significant value affecting the use of either standard or nonstandard helmets in prevention of craniofacial damages.
This pilot analysis (comprising the data from 100 cases of motorcycle accidents) could not demonstrate statistically significant differences in injury patterns of different types of helmets and variants influencing their respective use. However, it can lead the way for further analysis of larger and more comprehensive head trauma databases regarding factors contributing to the issue of head injury.
PMCID: PMC3108430  PMID: 21660267
Cranio-cervico-facial trauma; cross-sectional analysis; head trauma; helmet; motorcycle accident
15.  Hearing half the message? A re-audit of the care of patients with acute asthma by emergency ambulance crews in London 
Quality & safety in health care  2005;14(6):455-458.

Problem: An initial audit of the care provided to emergency asthma patients by the ambulance service was carried out in 1996. Some under-recognition and under-treatment of severe asthma was found as well as a lack of documentation of patient condition on scene. A re-audit was undertaken in 1999.
Design: A multidisciplinary advisory group was reconvened. The same method was adopted as for the first audit. Patients included were those administered nebulised salbutamol by crews in the catchment areas of four hospitals and those diagnosed with asthma at the Accident & Emergency (A&E) departments of those hospitals between January and March 1999.
Setting: London Ambulance Service.
Key measures for improvement: (1) Accuracy of diagnosis and appropriateness of treatment, and (2) adherence to protocol.
Strategies for change: Following the first audit, treatment protocols were widened and brought into line with the British Thoracic Society guidelines for care of acute asthma patients. The results were widely disseminated within the service and training was initiated for all operational staff.
Effects of change: The number of patients included in the re-audit more than doubled (audit 1: n = 252, audit 2: n = 532). The increase occurred exclusively in those administered nebulised salbutamol by ambulance crews but diagnosed with conditions other than asthma in A&E (audit 1: n = 15, audit 2: n = 161). The proportion of patients diagnosed with asthma in A&E who were administered nebulised salbutamol by their attending crew rose from 58% to 75%. However, 43 asthma patients were not treated; several of these were not recognised as suffering from asthma and others fell within the changed protocols for treatment. Adherence to protocol for administration of salbutamol remained high. Pre-hospital documentation of key observations did not improve.
Lessons learnt: Messages from the first audit seem to have been acted upon selectively. Implementing change is complex, and re-audit is necessary to understand the effects of the changes made.
PMCID: PMC1744100  PMID: 16326794
16.  Time delays in provision of thrombolytic treatment in six district hospitals. Joint Audit Committee of the British Cardiac Society and a Cardiology Committee of Royal College of Physicians of London. 
BMJ : British Medical Journal  1992;305(6851):445-448.
OBJECTIVE--To measure the delays between onset of symptoms and admission to hospital and provision of thrombolysis in patients with possible acute myocardial infarction. DESIGN--Observational study of patients admitted with suspected myocardial infarction during six months. SETTING--Six district general hospitals in Britain. SUBJECTS--1934 patients admitted with suspected myocardial infarction. MAIN OUTCOME MEASURES--Route of admission to hospital and time to admission and thrombolysis. RESULTS--Patients who made emergency calls did so sooner after onset of symptoms than those who called their doctor (median time 40 (95% confidence interval 30 to 52) minutes v 70 (60 to 90) minutes). General practitioners took a median of 20 (20 to 25) minutes to visit patients, rising to 30 (20 to 30) minutes during 0800-1200. The median time from call to arrival in hospital was 41 (38 to 47) minutes for patients who called an ambulance from home and 90 (90 to 94) minutes for those who contacted their doctor. The median time from arrival at hospital to thrombolysis was 80 (75 to 85) minutes for patients who were treated in the cardiac care unit and 31 (25 to 35) minutes for those treated in the accident and emergency department. CONCLUSION--The time from onset of symptoms to thrombolysis could be reduced substantially by more effective use of emergency services and faster provision of thrombolysis in accident and emergency departments.
PMCID: PMC1882547  PMID: 1392956
17.  Pituitary apoplexy can mimic acute meningoencephalitis or subarachnoid haemorrhage 
Pituitary apoplexy is an uncommon but life-threatening condition that is often overlooked and underdiagnosed. We report a 45-year-old man who presented to our emergency department with a sudden onset headache, acute confusion, signs of meningeal irritation and ophthalmoplegia. An initial diagnosis of acute meningoencephalitis was made, which was amended to pituitary apoplexy following thorough investigation within the emergency department.
A 45-year-old man was brought to our emergency department by ambulance with a history of sudden onset of frontal headache and acute confusion. His wife provided the history. There was no significant past medical history of diabetes, hypertension, recent travel abroad, exposure to sick contacts, involvement in outdoor pursuits such as hiking/cave diving, or trauma. He worked in a bank and had been well until 24 h prior to the onset of sudden headache, which was gradually worsening in nature and associated with increasing confusion. The patient's wife reported that he had neither experienced any fevers, night sweats, or coryzal symptoms nor received any recent vaccinations. He was not on any regular medications. He was a non-smoker and occasionally consumed alcohol. There was no significant family history. On examination in the ED, his temperature was 37.6°C, his pulse was 110/min, and he was normotensive and normoglycaemic. A macular blanching rash was noted over the patient's trunk. The patient was disoriented to time and place. Neurological examination revealed reduced GCS (11/15-E3, M6, V2), marked neck stiffness, a positive Kernig's sign and a right sixth nerve palsy.
A provisional diagnosis of acute meningoencephalitis was made and the patient was started on a course of intravenous antibiotics with benzyl penicillin 1.2 g, cefotaxime 2 g and acyclovir 750 mg. Baseline blood investigations revealed hyponatraemia (122 mmol/l), a white-cell count of 11 × 109/l and a C-reactive protein > 250. Due to the sudden onset of the symptoms and lack of prodrome, an urgent CT head scan was performed to rule out a cerebrovascular event. The scan demonstrated an enlarged pituitary gland (3 cm in diameter) with impingement of the optic chiasm. The centre of the enlarged pituitary gland was noted to be hypodense in comparison to its periphery, which was consistent with a diagnosis of pituitary apoplexy. A subsequent MRI confirmed the diagnosis (Figure 1) of an enlarged sella containing abnormal soft tissue with increased signal intensity suggestive of haemorrhage (Figure 1A).
Post-MRI a lumbar puncture was performed revealing glucose 3.4 mmol/l, protein 1.0 g/l, red cells of 53/mm3 and white cells of 174/mm3 with predominant neutrophilia. No organisms were seen, and CSF cultures and HSV DNA tests were found to be negative. Endocrinological investigations demonstrated low concentrations of thyroid hormones [TSH: 0.14 mIu/l (0.35-5.5 mlU/l), FT3: 1.1 nmol/l (1.2-3.0 nmol/l), FT4: 9.6 pmol/l (8-22 pmol/l)], gonadal hormones (LH: < 1 u/l) and prolactin: 16 u/l (<450 u/l). Serum FSH was 2.9 u/l (0.8-11.5 u/L) and cortisol 575 nmol/l (450-700 nmol/l). The patient was treated for hypopituitarism based on clinical and radiological findings with intravenous fluids, hydrocortisone (100 mg) and thyroxine (50 μg) as loading doses in the ED.
Within 24 h of commencement of therapy the patient's GCS rose to 15, and within 48 h there was marked improvement in the right sixth cranial nerve palsy. Formal visual field assessment demonstrated temporal visual field loss in the left eye. The patient was discharged to his usual residence a week later and follow-up was organised with both the endocrinologists and ophthalmologists. Follow-up MRI demonstrated that there was no significant change in either size or signal characteristics of the pituitary fossa mass (Figure 1B).
PMCID: PMC3205010  PMID: 21975129
18.  Patients with suspected Lassa fever in London during 1984: problems in their management at St Thomas's Hospital. 
During 1984, 23 patients in whom a diagnosis of viral haemorrhagic fever was considered presented to the accident and emergency department at St Thomas's Hospital. There were no confirmed cases of viral haemorrhagic fever. Nine patients were transferred to Coppett's Wood Hospital, the nearest specially designated high security isolation unit. Malaria was the final diagnosis in 14, and in six this diagnosis was confirmed only after examining repeated smears at Coppett's Wood Hospital. Transferral of patients to such units is time consuming, expensive, and often unnecessary. Specially designated isolation units in district general hospitals and all teaching hospitals would simplify and improve the care not only of patients with a possible viral haemorrhagic fever but also patients with tuberculosis, multiply resistant staphylococcal infections, and viral infections that may be hazardous if transmitted to immunocompromised patients.
PMCID: PMC1418167  PMID: 3933748
19.  A Complication of Tracheobronchopathia Osteochondroplastica Presenting as Acute Hypercapnic Respiratory Failure 
Patient: Male, 27
Final Diagnosis: Tracheobronchopathia osteochondroplastica
Symptoms: Shortness of breath • stridor
Medication: —
Clinical Procedure: Neck computer tomography • pulmonary function test • neck surgical exploration • tracheostomy placement
Specialty: Critical Care Medicine
Unusual clinical course
Tracheobronchopathia osteochondroplastica is a rare benign and often indolent disease. We report the first case of tracheobronchopathia osteochondroplastica (TBO) presenting as acute hypercarbic respiratory failure due to superimposed subglottic submucosal abscess.
Case Report:
A 27-year-old man presented to the emergency department in respiratory distress that required mechanical ventilation for acute hypercarbic respiratory failure. Upon extubation the next day, stridor was elicited with ambulation. Spirometry revealed fixed upper airway obstruction. Neck imaging showed a 2.8×2.0×4.0 cm partially calcified subglottic mass with cystic and solid component obstructing 75% of the airway. Surgical exploration revealed purulent drainage upon elevation of the thyroid isthmus and an anterolateral cricoid wall defect in communication with a subglottic submucosal cavity. Microbiology was negative for bacteria or fungi. Pathology showed chondro-osseous metaplasia compatible with tracheobronchopathia osteochondroplastica (TBO). The patient received a course of antibiotics and prophylactic tracheostomy. Since tracheostomy removal 3 days later, the patient remains asymptomatic.
Tracheobronchopathia osteochondroplastica is a rare disease with usually benign clinical course and incidental diagnosis. It may present as acute hypercarbic respiratory failure when subglottic infection is superimposed.
PMCID: PMC4311905  PMID: 25629203
Abscess; Airway Obstruction; Asthma
20.  Missed upper cervical spine fracture: clinical and radiological considerations 
This report presents a case of missed upper cervical spine fracture following a motor vehicle accident and illustrates various clinical and radiographic considerations necessary in the evaluation of post traumatic cervical spine injuries. Specific clinical signs and symptoms, as well as radiographic clues should prompt the astute clinician to suspect a fracture even when plain film radiographs have been reported as normal.
Clinical features:
A 44-year-old male was referred for an orthopaedic consultation for assessment of headaches following a high speed head-on motor vehicle accident eleven weeks prior to his presentation. Cervical spine radiographs taken at an emergency ward the day of the collision were reported as essentially normal.
Subsequent radiographs taken eleven weeks later revealed a fracture through the body of axis with anterior displacement of atlas. A review of the initial radiographs clearly demonstrated signs suggesting an upper cervical fracture.
Intervention and outcome:
Initially the patient was prescribed a soft collar which he wore daily until an orthopaedic consultation eleven weeks later. Fifteen weeks following trauma, the patient was considered for surgical intervention, due to persistent headaches associated with the development of neurological signs suggestive of early onset of cervical myelopathy.
Cervical spine fractures can have disastrous consequences if not detected early. A thorough clinical and radiological evaluation is essential in any patient presenting with a history of neck or head trauma. Repeated plain film radiographs are imperative in the event of inadequate visualization of the cervical vertebrae. When in doubt, further imaging studies such as computed tomography or magnetic resonance imaging are required to rule out a fracture.
PMCID: PMC2485171
upper cervical fracture; odontoid fracture; cervical spine trauma; chiropractic
21.  Psychiatric consequences of road traffic accidents. 
BMJ : British Medical Journal  1993;307(6905):647-651.
OBJECTIVE--To determine the psychiatric consequences of being a road traffic accident victim. DESIGN--Follow up study of road accident victims for up to one year. SETTING--Emergency department of the John Radcliffe Hospital, Oxford. SUBJECTS--188 consecutive road accident victims aged 18-70 with multiple injuries (motorcycle or car) or whiplash neck injury, who had not been unconscious for more than 15 minutes, and who lived in the catchment area. MAIN OUTCOME MEASURES--Present state examination "caseness"; post-traumatic stress disorder and travel anxiety; effects on driving and on being a passenger. RESULTS--Acute, moderately severe emotional distress was common. Almost one fifth of subjects, however, suffered from an acute stress syndrome characterised by mood disturbance and horrific memories of the accident. Anxiety and depression usually improved over the 12 months, though one tenth of patients had mood disorders at one year. In addition, specific post-traumatic symptoms were common. Post-traumatic stress disorder occurred during follow up in one tenth of patients, and phobic travel anxiety as a driver or passenger was more common and frequently disabling. Emotional disorder was associated with having pre-accident psychological or social problems and, in patients with multiple injuries, continuing medical complications. Post-traumatic syndromes were not associated with a neurotic predisposition but were strongly associated with horrific memories of the accident. They did not occur in subjects who had been briefly unconscious and were amnesic for the accident. Mental state at three months was highly predictive of mental state at one year. CONCLUSIONS--Psychiatric symptoms and disorder are frequent after major and less severe road accident injury. Post-traumatic symptoms are common and disabling. Early information and advice might reduce psychological distress and travel anxiety and contribute to road safety and assessing "nervous shock."
PMCID: PMC1678958  PMID: 8401049
22.  Occult renal cell carcinoma with acrometastasis and ipsilateral juxta-articular knee lesions mimicking acute inflammation 
Generally, skeletal peripheral metastases below the elbow and the knee are rare. Skeletal metastases to the hand or foot are very rare; but when they do it may be a revealing clinical finding. Purely lytic lesions are commonly seen in metastases from lung, renal, and thyroid tumors, but they are also known to occur in primary myeloma, brown tumor and lymphomas. A 70-year-old man was brought to the emergency department with acute painful swelling involving his right hand and the right knee. Due to significant accompanying soft tissue swellings cellulitis, acute osteomyelitis and gouty arthropathy were included in the initial differential diagnosis. Radiographs showed pure lytic bony lesion with complete disappearance of lower two third of the second metacarpal, trapezium and trapezoid bones of the right hand along with a lytic subarticular lesion of medial condyle of ipsilateral femur. Chest X-ray (CXR) was normal but sonography of the abdomen readily demonstrated a large renal mass, later confirmed at biopsy as renal cell carcinoma (RCC). Clinicians should be cognizant of the strong association between digital acrometastases and renal cell carcinoma in male patients with normal CXR findings. In suspected hand acrometastasis associated with a soft tissue component outside the contours of normal bone, screening the abdomen by sonography should be done prior to bone biopsy and before costly or time-consuming investigations are offered. Metastatic RCC should be included in the differential diagnosis of all unilateral expansile bony lesions of the digit. It is particularly important if such lesion/lesions are accompanied by local inflammation. Screening the abdomen by sonography may be of particular value in such elderly male patient when Chest X-ray shows no abnormality.
PMCID: PMC3544093  PMID: 23326779
Acrometastasis; abdominal sonography; peripheral skeletal metastases; renal cell carcinoma
23.  A retrospective analysis of maxillofacial injuries in patients reporting to a tertiary care hospital in East Delhi 
Background and Aim:
Maxillofacial trauma is frequently encountered in the Accident and Emergency department of hospitals either as an isolated injury or as a part of multiple injuries to the head, neck, chest, and abdomen. This study aimed to assess retrospectively the profile of maxillofacial injuries in patients reporting to a tertiary care hospital in East Delhi.
Materials and Methods:
The study was conducted in the Department of Dentistry, UCMS and GTB Hospital, Delhi. Dental case record sheets of 1000 medicolegal cases reporting to the hospital emergency were scrutinized and various demographic and epidemiologic factors, including the patient's age and gender, time and day of reporting, and the etiology and nature of injury were recorded.
The peak incidence of maxillofacial injury was observed in the age group of 21–30 years, with males outnumbering females in all age groups. Maximum number of trauma cases reported in late evening hours, especially on weekends. Interpersonal assault was the primary etiological factor followed by road traffic accidents. Soft tissue injuries were very common and maxillofacial fractures, when present, were most frequently observed in the mandible followed by the midface.
The changing trend of the etiology of maxillofacial injuries in East Delhi necessitates strict legislation against violence and education in alcohol abuse. Periodic review of driving skills and stricter implementation of traffic rules in this area is a must to minimize the physical, psychological, and emotional distress associated with maxillofacial trauma.
PMCID: PMC3354380  PMID: 22624095
Interpersonal assault; maxillofacial trauma; retrospective analysis
24.  An unusual presentation of an infected vallecular cyst presenting as supraglottitis 
BMJ Case Reports  2013;2013:bcr2013009180.
A 50-year-old gentleman presented to the emergency department with a 24 h history of stridor, dysphonia, dysphagia and vomiting. On examination, the patient had fever and tachycardic. There was no palpable cervical lymphadenopathy. Flexible nasendoscopy and lateral neck x-ray revealed soft tissue swelling around the epiglottis. The swelling subsided with conservative management of intravenous antibiotics and steroids, only to later reveal a vallecular cyst, which was confirmed on microlaryngoscopy. The cyst was subsequently deroofed and sent for biopsy. Histological examination revealed an infected, benign vallecular cyst consisting of a squamous epithelium with underlying lymphoid tissue. In adults, vallecular cysts are usually asymptomatic, but can become infected and initiate acute supraglottitis, potentially leading to life-threatening airway obstruction. The case described here, although rare, highlights how early definitive diagnosis and management of vallecular cysts can lead to significantly improved patient outcomes.
PMCID: PMC3645288  PMID: 23608863
25.  Suitability of imaging methods (X-ray, CT, MRI) in the diagnostics of Ewing’s sarcoma in children – analysis of own material 
Polish Journal of Radiology  2010;75(1):18-28.
Ewing sarcoma is a malignant, small round cell bone tumor, presenting predominantly in children and adolescents. Ewing sarcoma may develop in every bone; diaphyses of long bones, ribs and flat bones are the main locations. Local and systemic clinical symptoms are nonspecific - pain, swelling, fever or ill-being.
The aim of the study was to assess the role of radiography, computed tomography and magnetic resonance imaging in the analysis of bone lesions in children and young adults with Ewing sarcoma.
Twenty-seven patients, aged between 1 year and 10 months, and 17 years and 2 months, with histologically verified Ewing sarcoma of the bone, referred to the Radiological Department of University Hospital No 6., John Paul II Upper Silesian Centre for Child Health Katowice, in the period from 1996 to 2007, were included in the study.Plain radiography was performed in every child, CT in 20 and MRI in 12 individuals. Tumour location, extension of the tumour, soft tissue mass, and periosteal reaction were taken into consideration in the evaluation of the lesion. In some cases, pathological features of the MRI and CT were compared. The prevalence of some radiological features was compared to the literature data.
The most common site of tumor was: ribs (6 children), femoral bone (6 children), pelvis (4 children) and tibia (3 children). In 2 children, a primary tumor was diagnosed in the spine (multifocal in 1 child).
X-rays revealed: periosteal reaction in 17 children (63%), soft tissue involvement in 19 children (70%), permeative component in 16 children (59%), and sclerotic component in 5 children (19%). In 10 children (37%), periosteal reaction was not detected. The examination revealed: soft tissue calcifications in 7 cases (26%), a well-delineated focus of destruction within bones in 3 children (11%), cortical thickening in 4 children (15%), cortical destruction in 4 children (15%), saucerisation in 3 children (11%), bone expansion in 3 children (11%), pathological fracture in 2 children (7%), cystic component in 1 child (4%), and vertebra plana in 1 child (4%).Reaction of tumors after i.v. contrast administration, shown on CT, was visible in 16 children – it was useful for a better description of the tumor and extension of the mass within the soft tissue. All MRI examinations (12 children) showed a heterogenous mass with ill-defined borders and a violated cortex. Low signal intensity of the tumor in a T1-weighted image and high signal intensity in a T2-weighted image was shown as well.
Heterogenous enhancement of signal intensity on T1-weighted images could be observed after i.v. contrast administration.
MRI examinations showed: tumor in an adjacent soft tissue in 11 children, and involvement of the epiphyseal plate or of the joint cavity in 6 children.
X-ray and MRI are essential in diagnostics. CT examination is more useful to estimate periosteal reactions and destruction of bone and marrow cavity, especially in flat bones. However, to recognise a malignancy, it is necessary to perform a histopathological examination. In doubtful cases, the examination has to be verified as well.
PMCID: PMC3389856  PMID: 22802757
Ewing sarcoma; bone tumour; children; X-rays; CT; MRI

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