SummaryThis paper reports a controlled prospective unselected real-time comparison of human and computer-aided diagnosis in a series of 304 patients suffering from abdominal pain of acute onset.The computing system's overall diagnostic accuracy (91-8%) was significantly higher than that of the most (79 6%). It is suggested as a result of these studies that the provision of such a system to aid the clinician is both feasible in a real-time clinical setting, and likely to be of practical value, albeit in a small percentage of cases.

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One thousand consecutive deaths from injury in 11 coroner's districts in England and Wales were reviewed by four independent assessors, who studied necropsy reports to identify deaths in hospital that might have been preventable. Of 514 patients admitted to hospital alive, 102 deaths (20%) were judged by all four assessors to have been potentially preventable. When those cases in which three out of four assessors considered that the death was preventable were added the total rose to 170 (33%).Nearly two thirds of all non-central nervous system deaths were judged to have been preventable. The median age of the 170 patients whose deaths were preventable was 41, and the mean Injury Severity Score was 29. Further analysis suggested that the preventable deaths were principally the result of failure to stop bleeding and prevent hypoxia and the absence of, or delay in, surgical treatment.The results closely parallel those from similar studies from the United States and suggest that there are serious deficiencies in the services for managing severe injury in England and Wales. Debate is needed now on how to correct these deficiencies. In particular, the place of trauma centres must be considered.

A multicentre study of computer aided diagnosis for patients with acute abdominal pain was performed in eight centres with over 250 participating doctors and 16737 patients. Performance in diagnosis and decision making was compared over two periods: a test period (when a small computer system was provided to aid diagnosis) and a baseline period (before the system was installed). The two periods were well matched for type of case and rate of accrual.The system proved reliable and was used in 75-1% of possible cases. User reaction was broadly favourable. During the test period improvements were noted in diagnosis, decision making, and patient outcome. Initial diagnostic accuracy rose from 45-6% to 65 3%. The negative laparotomy rate fell by almost half, as did the perforation rate among patients with appendicitis (from 23.7% to 11-5%). The bad management error rate fell from 0-9% to 0-2%, and the observed mortality fell by 22-0%. The savings made were estimated as amounting to 278 laparotomies and 8516 bed nights during the trial period-equivalent throughout the National Health Service to annual savings in resources worth over £20m and direct cost savings of over £5m.Computer aided diagnosis is a useful system for improving diagnosis and encouraging better clinical practice.

SUMMARYI. The incidence of dehiscence of the anastomosis after anterior resection of the sigmoid colon and rectum was studied by digital examination of the rectum, sigmoidoscopy, and radiological examination after a small barium enema in 73 patients who had undergone the operation for carcinoma, villous papilloma, or diverticular disease.2. Dehiscence was detected in 37 (or 51 per cent) of the entire series, in 19 (or 40 per cent) of the 47 cases treated by high anterior resection, and in 18 (or 69 per cent) of the 26 cases submitted to low anterior resection. The dehiscences were usually much more extensive after low resection. The possible reasons for these differences are discussed.3. The effect of other factors on the occurrence of dehiscence was examined :-a. A simultaneous transverse colostomy was performed in 28 of the 68 patients undergoing primary resection. It was used in most cases after low resection, whilst after high resection it was reserved largely for cases with faecal loading. The unfavourable nature of the patients submitted to simultaneous covering colostomy makes it impossible to evaluate the influence of this step on the incidence of dehiscence.b. A preliminary transverse colostomy was established 14-21 days before resection in 5 patients. Three of these cases developed anastomotic dehiscence after the resection, so that clearly an empty distal colon at the time of resection provides no certain guarantee against breakdown of the suture line.c. Preoperative administration of bowel antiseptics in the form of phthalylsulfathiazole and neomycin was associated with a significantly lower rate of dehiscence after high anterior resection, but had no obvious beneficial effect on the incidence of this complication after low resection.4. Though minimal dehiscences, especially after high anterior resection, often pursued an innocuous, subclinical course, major dehiscences endangered the patient's life and prolonged convalescence. There were 2 deaths in this series attributable to dehiscence, a mortality of 2.7 per cent. The mean period in hospital after high anterior resection was 17 days in patients who did not develop dehiscence and 35 days in those who did; and after low anterior resection it was 44 days when dehiscence did not occur and 48 days when it did.WHEN anterior resection with sutured anastomosis was originally advocated by Dixon (1939, 1944), Wangensteen (1945), Waugh and Custer (1945), Mayo and Smith (1948), and Mayo, Lee, and Davis 9* (195 I) for the treatment of certain carcinomas of the rectum and rectosigmoid, one of the fears entertained by many surgeons about this operation was that anastomoses at this level in the intestinal tract might be very liable to leak with resulting serious sepsis. It was, indeed, soon discovered that leakage and infection did sometimes occur after anterior resection, but the incidence of complications from this source was insufficient to prohibit the general adoption of this operation in the cases for which it might be deemed suitable. The precise incidence...