Horton General Hospital

Abstract Small intestinal diverticula are rare and possibly acquired secondary to bowel dyskinesia, abnormal peristalsis, or high intraluminal pressures. Enterolith formation and obstruction are a less encountered complication of these diverticula. An elderly man, with no history of abdominal surgery, presented with 10 days of colicky right iliac fossa pain and recurrent episodes of bilious vomiting. He initially reported diarrhoea but complained of eventual absolute constipation for last 5 days. Physical examination revealed distended abdomen with right-sided tenderness and no mass or faeces on rectal examination. Abdominal CT revealed a 3.5 cm calculus in the distal ileum causing obstruction initially flagged as gallstone ileus. No gallstones or pneumobilia were identified although some intrahepatic duct dilatation was noted. An emergency laparotomy was conducted, where the radiological findings were reinforced, and the calculus was extracted via enterotomy. There were no abnormal communications between gallbladder and intestinal tract. The small bowel traced from duodenojejunal flexure to terminal ileum did not reveal any further calculi or diverticula. FTIR spectrum analysis of the extracted specimen indicated similarities to enterolith. Retrospective analysis of radiological images revealed a possible duodenal diverticulum. The case highlights the diagnostic conundrum and therapeutic challenges of small bowel diverticular enterolith.

Veterinary RecordVolume 185, Issue 17 p. 542-543 Letters and notices Farming and global warming Rosemary Perkins, Corresponding Author roseperkins14@gmail.com 3 School Hill, Banbury, Oxfordshire, OX17 1BLemail: roseperkins14@gmail.comSearch for more papers by this author Rosemary Perkins, Corresponding Author roseperkins14@gmail.com 3 School Hill, Banbury, Oxfordshire, OX17 1BLemail: roseperkins14@gmail.comSearch for more papers by this author First published: 02 November 2019 https://doi.org/10.1136/vr.l6240Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookTwitterLinked InRedditWechat No abstract is available for this article. Volume185, Issue17November 2019Pages 542-543 RelatedInformation

To understand the experience of directed living donor kidney transplant recipients to inform future nursing practice in the field. A qualitative literature review was undertaken. A search strategy was used to locate relevant articles in five electronic databases, and critical analysis was used to determine which articles should be included in the literature review. Seven articles were identified for inclusion in the literature review. Four themes were identified from these articles: pre-transplantation decision-making; psychological and emotional effects of transplantation; physical effects of transplantation and effect on home life; and the relationship with the donor and others. The psychosocial and physical effects of directed living donor kidney transplantation on the recipient can be profound, particularly with regard to the dynamics of the donor-recipient relationship. Although transplantation can transform lives, careful consideration, preparation and ongoing psychosocial support are vital to prevent recipients experiencing negative effects.

Currently, there is no consensus regarding services required to help families with consanguineous marriages manage their increased genetic reproductive risk. Genetic services for communities with a preference for consanguineous marriage in the UK remain patchy, often poor. Receiving two disparate explanations of the cause of recessive disorders (cousin marriage and recessive inheritance) leads to confusion among families. Further, the realisation that couples in non-consanguineous relationships have affected children leads to mistrust of professional advice. British Pakistani families at-risk for recessive disorders lack an understanding of recessive disorders and their inheritance. Such an understanding is empowering and can be shared within the extended family to enable informed choice. In a three-site qualitative study of British Pakistanis, we explored family and health professional perspectives on recessively inherited conditions. Our findings suggest, firstly, that family networks hold strong potential for cascading genetic information, making the adoption of a family-centred approach an efficient strategy for this community. However, this is dependent on provision of high-quality and timely information from health care providers. Secondly, families' experience was of ill-coordinated and time-starved services, with few having access to specialist provision from Regional Genetics Services; these perspectives were consistent with health professionals' views of services. Thirdly, we confirm previous findings that genetic information is difficult to communicate and comprehend, further complicated by the need to communicate the relationship between cousin marriage and recessive disorders. A communication tool we developed and piloted is described and offered as a useful resource for communicating complex genetic information.

Background. Magnetic resonance cholangiopancreatography (MRCP) is noninvasive and accurate for diagnosing intra common bile duct stones (ICSs). However, given limited access, routine utilisation for investigating all patients with gallstone disease is neither practical nor cost-effective. Conversely, many individuals proceed directly to endoscopic retrograde cholangiopancreatography (ERCP), an invasive test with appreciable complications. Aim. Identify factors associated with ICS in order to improve risk-stratification for MRCP/ERCP. Methods. All patients having undergone cholecystectomy between November 2007 and October 2008 were reviewed. High-risk features for ICS were predefined, and their true presence confirmed by ERCP or intraoperative cholangiogram. Multivariate logistic regression was performed on candidate risk features. Results. Of 231 patients, 10.4% had ICS. Defining a high-risk group with “both” biochemical and ultrasound risk factors predicted ICS with 92% specificity and also bore strong association (OR 8.88). However, isolated hyperbilirubinaemia, ultrasound impression of CBD stones, and clinical risk factors did not (OR 1.10, 0.97, and 1.26). Normal liver biochemistry and normal ultrasound had a NPV of 99.5% for ICS. Conclusions. Ultrasound impression of CBD calculi without ductal dilatation is not predictive of ICS. Patients with normal liver biochemistry and normal CBD diameter on ultrasound are unlikely to have ICS and should not proceed to ERCP.

Introduction : Malignant pleural effusions (MPEs) can be treated by indwelling pleural catheter (IPC) or chest drain and talc pleurodesis (usual care). This is the first direct, randomised comparison of these techniques as initial therapy assessing patient reported outcomes. Methods : Randomised trial of IPC versus usual care (1:1) in patients with symptomatic MPE. IPCs were inserted as day cases, followed by patient education and home drainage. Usual care was admission for chest drain and talc pleurodesis in patients with good lung re-expansion. The primary outcomes were daily visual analogue scale (VAS) scores of breathlessness and chest pain over 42 days (100mm line, 0mm = no breathlessness/chest pain, 100mm = maximum breathlessness/pain). Results : 106 patients were randomised. Dyspnoea improved in both arms, with no significant difference in intensity (mean VAS: IPC 24.7mm (SD 18.9), usual care 24.4mm (SD 17.0), difference 0.16mm, 95% CI -6.82 to 7.15, p=0.96). Dyspnoea decreased by mean 37mm (SD 27.1) IPC arm and 30.2mm (SD 27.7) usual care arm. Chest pain decreased from baseline in both arms (mean VAS: IPC 20.5mm (SD 18.2), usual care 17.6mm (SD 16.0), difference 5.4mm, 95% CI -3.0 to 13.8, p=0.21). Preliminary analysis demonstrated lower initial hospital stay in the IPC group (median days 0 (IQR 0-1) versus 4 (IQR 2-6)). Discussion : IPC and usual care are comparably effective treatments for the relief of breathlessness in patients with MPE. The pain profile of IPC and usual care is similar over 6 weeks.

A 56-year-old gentleman presented with a 6-week history of fatigue, drenching night sweats and 6 kg of weight loss. Clinical examination revealed a palpable right iliac fossa mass. He had a history of hypertension. Full blood count, differential white count and blood film were unremarkable. Inflammatory markers were elevated: …

To determine how emergency departments in England process laboratory investigation results, to identify risk, and to note examples of good practice. A telephone survey was conducted, and data were entered anonymously into Excel spreadsheets. Fisher's exact test was used to test the independence of pairs of variables. Data were collected from 167 out of 193 (87%) emergency departments in England. The majority had nurse-requested blood tests. There was a statistical association between nurse-requesting and failure by the clinician seeing the patient to check results. Fourteen (8%) departments did not allow patients to leave until all their results were available. A senior doctor did a second 'safety' check of results in 83 (50%) departments. Many respondents were able to give examples of patients who had been recalled to hospital after a second check. Only a minority of departments had information systems that could identify high-risk patients. A second 'safety' check by an experienced consultant, associate specialist or middle grade doctor identifies error. This is time-consuming, but could be supported and simplified by using intelligently designed information systems.