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ObjectivesTo assess the role of serum amylase and lipase in the diagnosis of acute pancreatitis. Secondary aims were to perform a cost analysis of these enzyme assays in patients admitted to the surgical admissions unit.DesignCohort study.SettingSecondary care.ParticipantsPatients admitted with pancreatitis to the acute surgical admissions unit from January to December 2010 were included in the study.MethodsData collated included demographics, laboratory results and aetiology. The cost of measuring a single enzyme assay was £0.69 and both assays were £0.99.ResultsOf the 151 patients included, 117 patients had acute pancreatitis with gallstones (n=51) as the most common cause. The majority of patients with acute pancreatitis had raised levels of both amylase and lipase. Raised lipase levels only were observed in additional 12% and 23% of patients with gallstone-induced and alcohol-induced pancreatitis, respectively. Overall, raised lipase levels were seen in between 95% and 100% of patients depending on aetiology. Sensitivity and specificity of lipase in the diagnosis of acute pancreatitis was 96.6% and 99.4%, respectively. In contrast, the sensitivity and specificity of amylase in diagnosing acute pancreatitis were 78.6% and 99.1%, respectively. Single lipase assay in all patients presenting with abdominal pain to the surgical admission unit would result in a potential saving of £893.70/year.ConclusionsDetermining serum lipase level alone is sufficient to diagnose acute pancreatitis and substantial savings can be made if measured alone.

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The use of cetuximab to conventional chemotherapy regimens may improve the efficacy of down-staging programmes, leading to more patients being offered potentially curative resection.

An 80-year-old woman without any previous otological symptoms underwent laparoscopic abdominoperineal resection for T3N0M0 low rectal carcinoma 4-5 cm from the anal verge. The total operative time was 6 h, of which she spent long hours in the Trendelenburg (35°) position due to difficult pelvic dissection. Midway through the procedure, she developed spontaneous non-traumatic bilateral otorrhagia. This case highlights the potential risk of increased intracranial pressure during prolonged periods of being in a steep Trendelenburg position caused either by the position itself or in combination with carbon dioxide pneumoperitoneum. We also consider the effect of a sudden change from this position to supine as a potential risk.

A 62-year old woman presented with a 1-month history of left otalgia, facial palsy and hearing loss. She had a background of non-insulin-dependent diabetes mellitus and stage 2 endometrial adenocarcinoma, treated 18 months ago. Computed tomography scan showed erosion of the skull base and temporal bone. She was referred to the otolaryngology team with a diagnosis of necrotising otitis externa. On clinical examination, there was an exophytic, necrotic lesion in the ear canal arising from the posterior canal wall. A subsequent magnetic resonance imaging scan showed a lesion located in the left jugular foramen extending into the middle ear, with characteristics consistent with a glomus jugulo-tympanicum. Interestingly, histology of the lesion showed malignant cells with immunohistochemical staining suggestive of an adenocarcinoma. This is the first reported case of metastatic endometrial carcinoma involving the jugular foramen and temporal bone. Although a diagnosis is rare, it is important to consider it when other differential diagnoses are not fitting. Imaging should always be interpreted with caution, correlating to the clinical findings.

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Although the headline subheadings and prose letter had the highest word count, it scored the highest in almost all the rating categories analysed. This study is the first published work to study primary care physician's preference for the structure of letters from secondary care. Prominent headline subheadings of diagnosis and management improve interpretation of content and comprehension and are helpful to GPs for co-ordinating patient management. Lack of subheadings or conversely an excess of subheadings may be a hindrance to effective communication between healthcare professionals.