Objective To assess the incidence of prognostically important myocardial damage in patients with chest pain discharged from the emergency department. Design Prospective observational study. Setting District general hospital emergency department. Participants 110 patients presenting with chest pain of unknown cause who were subsequently discharged home after cardiac causes of chest pain were ruled out by clinical and electrocardiographic investigation. Interventions Patients were reviewed 12-48 hours after presentation by repeat electrocardiography and measurement of cardiac troponin T. Main outcome measures Incidence of missed myocardial damage. Results Eight (7%) patients had detectable cardiac troponin T on review and seven had concentrations >0.1 g/l. The repeat electrocardiogram showed no abnormality in any patient. Conclusion 6% of the patients discharged from the emergency department had missed prognostically important myocardial damage. Follow up measurement of cardiac troponin T allows convenient audit of clinical performance in the emergency department.

T he prevention of wound infection is central to the successful outcome of any operative procedure. This is especially so for 'day-case surgery' which now accounts for 30-50% of all in-hospital surgical procedures. As in any surgical procedure, complications following day-case surgery, including wound infection, can result in unexpected hospital admissions, prolonged follow-up and rehabilitation and delay in the patient's return to work. A review of the current literature reveals that little has been published about postoperative infection rates in day-case hand surgery and the possible factors promoting infection. Patients and Methods PatientsA prospective study of 1035 consecutive patients attending the Mayday University Hospital Hand Clinic for day-case surgery over the 2-year period from April 1999 to March 2001 was carried out. Seven patients were excluded as they were already taking antibiotics at the time of operation for an unrelated condition. The surgical procedures carried out are presented in Table 1. Operative technique and follow-upAll operations were performed in one of three dedicated operating theatres in the day-care surgical unit of the hospital by one of the two authors. Patients were allowed to wear a gown in theatre; the surgeons wore standard theatre greens and sterile gloves. The surgeons did not wear face masks during any of the procedures but sterile surgical gowns were worn in 9 cases of trapezioplasty. Wound infections in day-case hand surgery: a prospective studyKambiz Hashemi, Christopher J BlakeleyThe Hand Clinic, Mayday University Hospital, Croydon, UK Background: There is little published information about postoperative infection rates in day-case hand surgery and the possible factors promoting infection. Results: We report on infection rates observed in day-case hand surgery of 1035 cases over a 2-year period performed by two consultant surgeons. Infection rates of just over 1% were observed. Conclusion: We believe that this low infection rate reflects seniority of surgeon, operative technique and short duration of operation.

Rheumatoid arthritis is a chronic and common inflammatory autoimmune disease. This primarily involves the synovia of the joints, but can cause many extra-articular manifestations as well, including peripheral ulcerative keratitis (PUK) and necrotising scleritis. These are often a threat to vision; they significantly compromise not only the eye's structural integrity but are also important for prognosis and need urgent management. Three cases of peripheral ulcerative keratitis associated with rheumatoid arthritis were recorded in the electronic databank of the Jules Gonin Uveitis Clinic, two with necrotising scleritis and peripheral ulcerative keratitis and one with only peripheral ulcerative keratitis. They were all followed at Jules Gonin Eye Hospital (Lausanne, Switzerland), conjointly with the Department of Rheumatology at the Centre Hospitalier Universitaire Vaudois (Lausanne, Switzerland). Good initial therapeutic response was observed in the two patients who received rituximab therapy. The patient who received only high dose corticosteroid developed massive colon perforation as well as acute renal insufficiency a few days after her ocular event. From our limited number of patients, we found that the two patients who received the induction therapy with rituximab were stabilised from an ocular standpoint; however, rituximab had to be switched to other molecules, either due to other systemic symptoms from the disease itself or due to adverse effect of this treatment. This contributes to the increasing number of reports that rituximab can be an effective treatment for refractory ocular complications of rheumatoid arthritis (RA), at least as an induction therapy.

The objective of this study was to determine whether there is a greater incidence of psychotropic drugs in the blood of those 'responsible' for an accident compared with those not 'responsible' for an accident. Blood samples were taken from people involved in accidents presenting at the accident and emergency departments of two teaching hospitals over a five-month period and analysed for the presence of alcohol, tricyclic anti-depressants (TCAs) and benzodiazepines (BZs). Details of the accident were used to produce a test group (accidents where a drug may have contributed) and a control group (accidents where the presence of a drug could not have been a factor). In total, 229 samples were collected. The only criterion for inclusion in the study was that the accident was of sufficient severity to merit the routine taking of a blood sample, in which case an additional amount was taken for the purposes of this investigation. In all, 63 samples (27.5%) were positive for at least one of alcohol, TCA or BZ. Of the accidents represented by these samples, 48 could have been caused by the presence of the drug (responsible group) and 15 could not (not responsible group). There was a significantly greater representation of TCAs and BZs in the blood taken from the responsible group compared with the not responsible group (P < 0.0045).

The physical and environmental factors leading to domestic falls in the elderly have been assessed in many published studies; only one includes some assessment of environmental factors causing the elderly to fall outside their homes (Consumer Safety Unit, 1986). Many patients of all ages attend Accident and Emergency Departments with injuries sustained through such falls. This prospective study was undertaken to determine the frequency with which uneven surface or inadequate lighting was thought by the patients to have contributed to falls in public places, and to survey injuries sustained. Two hundred and thirty seven consecutive patients attending the Accident and Emergency Department were entered into the study, information being obtained by patient questionnaire and from A&E records. An average of 7 patients were entered into the study each day. The ratio of women to men was 1·7 :1. Patients of both sexes were most commonly aged between 15 and 34 years, with a second peak in women over 55 years. Two thirds of falls occurred on pavements. Uneven surface underfoot or inadequate street lighting was implicated in over half the falls. Injuries were mostly sprains and bruises, but facial lacerations and upper limb fractures were also common. Sixty eight per cent of fractures occurred in women over 55 years of age. Medical follow up was required in 40% of all cases. Uneven paving and inadequate lighting in public places are potentially avoidable factors in causing falls which lead to appreciable morbidity in large numbers of young and elderly patients attending A&E Departments.

SUMMARYThis prospective study was undertaken to assess demographic and social factors, assault characteristics and injuries sustained by assault victims attending a suburban A & E department. A total of 214 men and women who admitted to having been assaulted were entered into the study, information being obtained by patient questionnaire and from A&E records.The assault victims made up 3.3% of the total new patients seen in the study period. The majority of victims were employed, single young men (72%) who had been drinking alcohol prior to assault (66%). They were assailed late at night in the street, in pubs and clubs. Female domestic assault was two times more common in this population than in previous British studies, and women were more ext0nsively injured than men. Injuries were mostly to the face, caused by punches and kicks. Overall, 72% of fractures were facial. Most patients were referred to their G. P. for follow up (41%).The available evidence suggests that personal violence is on the increase, and is not confined to inner-City areas. As victims seeking help will usually attend an A&E department, staff should be alerted to recognize and advise these patients on possible psychological seqelae, as well as treating their physical injuries.

The use of non-contrast CT urography is recommended in the initial investigation of patients with ureteric colic.

Dislocation of the shoulder joint is a common presentation in the emergency department, the reduction of which is usually performed under sedation. At present post-reduction x rays are taken after the patient has recovered from this sedation. If reduction is unsuccessful, repeated attempts under further sedation may be required. In this small case series, bedside ultrasound was found to be accurate in determining whether reduction had been successful.