Trans-anal evisceration of small bowel is a rare surgical presentation. The first case ever reported was in 1827. The exact mechanism of how this develops remains poorly understood. A 70-year-old lady presented with multiple small bowel loops eviscerated through the anus. Abdominal exploration was done. The bowel was carefully reduced. There was a longitudinal defect on the anterior wall of the rectum at the recto-sigmoid junction and a large mesenteric defect and thrombosed mesenteric vessels compromising blood supply to part of the bowel. Resection of 50 cm of ileum, jejunostomy and a mucous fistula were performed. Several preexisting pathologies such as rectal prolapse can result in thinning out of the wall of the rectum. That combined with increased intra-abdominal pressure can explain trans-anal evisceration of the bowel. This condition is managed by surgical intervention. The operation will depend on the extent of viability, contamination and patient’s general condition.
Encapsulating peritoneal sclerosis (EPS), also known as abdominal cocoon syndrome (AC) or sclerosing encapsulating peritonitis (SEP), is an uncommon condition typically presenting with features of bowel obstruction. We present the case of a 41-year-old male patient who presented to the accident and emergency department with a 7-day history of abdominal pain. Contrast CT of the abdomen and pelvis was ordered and was suggestive of small bowel obstruction involving most of the small bowel with no apparent transition point. Laparotomy showed a tough whitish fibrous membrane encasing the entire length of the small bowel. Advances in CT have made diagnosis possible before a decision on surgical intervention is made.
Aim Early recognition of high-risk malnourished patients is important for optimisation of nutritional status leading to better outcomes. The accurate recording of malnutrition universal screening tool (MUST) results is vital in this regard. This quality improvement project (QIP) aimed to review the quality of nutritional assessment of emergency laparotomy patients against the National Institute for Health and Care Excellence (NICE) guidelines and outline area of improvement.Method The QIP was conducted at Royal Oldham Hospital in 2019-2020 over a seven-month period. Fifty random patients were included in the first audit cycle over a 4-month period, followed by implementation of recommended changes and a re-audit of 30 patients over a 2-month period. The initial MUST scores which were calculated and documented by nursing staff were identified as the nursing staff MUST score (NSMS). To assess the accuracy of NSMS, we developed a MUST rescoring method which was performed by a senior member of the medical team and was identified as the medical team MUST rescore (MTMR). Results The initial audit showed a significant difference between NSMS and MTMR scores. According to MTMR, 23 patients (46%) had an inaccurate MUST score assessment by the nursing staff. A multidisciplinary approach using a standard online calculator were recommended. The second phase of the QIP showed an obvious improvement in the accuracy of MUST assessment. Our interventions improved the accuracy rate of MUST scores significantly (27, 54% vs 29, 96.6%, P = 0.00005).Conclusion A multidisciplinary team approach and online calculator are useful in improving the accuracy of MUST assessment in emergency laparotomy patients. This helped early involvement of the dietitian leading to improvement in morbidity and mortality.
Abstract. The authors introduce a method for extracting weather and climate data from a historical plantation document. They demonstrate the method on a document from Shirley Plantation in Virginia (USA) covering the period 1816–1842. They show how the resulting data are organized into a spreadsheet that includes direct weather observations and information on various cultivars. They then give two examples showing how the data can be used for climate studies. The first example is a comparison of spring onset between the plantation era and the modern era. Modern median final spring freeze event (for the years 1943–2017) is occurring a week earlier than the historical median (for the years 1822–1839). The second analysis involves developing an index for mid-summer temperatures from the timing of first malaria-like symptoms in the plantation population each year. The median day when these symptoms would begin occurring in the modern period is a month and a half earlier than the median day they occurred in the historical period. The authors suggest that this type of local weather information from historical archives, either direct from observations or indirect from phenophase timing, can be useful toward a more complete understanding of climates of the past.
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