A retrospective study of 645 cholecystectomies performed in a surgical unit over a 10-year period is presented, of which 236 were carried out during an acute admission. Of these 236 cholecystectomies, 195 were performed for acute cholecystitis and 41 for acute gallstone pancreatitis. In the acute cholecystitis group the proportion of patients over 70 years of age was significantly higher (35 per cent) than the corresponding elective group (10.3 per cent). Of those patients presenting with complications (empyema, gangrene, perforation, and biliary peritonitis) 51 per cent were over the age of 70 years. The most valuable investigation in the diagnosis of acute cholecystitis was ultrasound carried out within the first 48 h, with positive results in 83 per cent of those examined. The mortality for elective cholecystectomy was 0.5 per cent rising to 4.7 per cent in the urgent/early cholecystectomy group. The mean age of the 11 patients who died was 76 years, 8 of these patients being over the age of 70 years. The mortality in the subgroup of patients over 70 years was 10 per cent rising to 20 per cent in the over-80 age group. There were no deaths in the acute gallstone pancreatitis group. We conclude that emergency or early cholecystectomy is a safe procedure in patients under 70 years of age. However, patients over 70 years present with more serious complications of acute gallbladder disease which necessitate urgent surgery. We therefore recommend early cholecystectomy in patients over 70 years despite the high attendant mortality.

Thirty patients with acute pseudo-obstruction of the large bowel are presented, and the aetiology and diagnosis of this recognized clinical entity are described. Emergency barium enema examination is recommended in patients with symptoms and signs of large bowel obstruction. When no mechanical blockage is found a diagnosis of pseudo-obstruction can be made. The management of pseudo-obstruction is conservative, with nasogastic suction, intravenous fluids and the treatment of any associated condition such as cardiac failure and inflammatory conditions. The indications for surgery in pseudo-obstruction are discussed.

Background Mediastinitis costs hospitals thousands of dollars a year and increases the incidence of patient morbidity and mortality. No studies have been done to evaluate adenosine triphosphate (ATP) counts on disposable and nondisposable electrocardiography (ECG) lead wires in pediatric patients. Objective To compare the cleanliness of disposable and nondisposable ECG lead wires in postoperative pediatric cardiac surgery patients by measuring the quantity of ATP (in relative luminescence units [RLUs]). ATP levels correlate with microbial cell counts and are used by institutions to assess hospital equipment and cleanliness. Methods A prospective, randomized trial was initiated with approval from the institutional review board. Verbal consent was obtained from the parents/guardians for each patient. Trained nurses performed ATP swabs on the right and left upper ECG cables on postoperative days 1, 2, and 3. Results This study enrolled 51 patients. The disposable ECG lead wire ATP count on postoperative day 1 (median, 157 RLUs) was significantly lower (P < .001) than the count for nondisposable ATP lead wires (median, 610 RLUs). On postoperative day 2, the ATP count for the disposable ECG lead wires (median, 200 RLUs) was also lower (P = .06) than the count for the nondisposable ECG lead wires (median, 453 RLUs). Conclusion Results of this study support the use of disposable ECG lead wires in postoperative pediatric cardiac surgery patients for at least the first 48 hours as a direct strategy to reduce the ATP counts on ECG lead wires.

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Paroxysmal sympathetic hyperactivity environmental strategies need to be explored further in subsequent studies. Environmental interventions could complement pharmacological strategies for the management of this elusive phenomenon with the goal of improving outcomes in children who experience severe brain injury and show PSH.