267
arthroplasty 6 years previously may have caused a local peritonitis with the subsequent development of an omental band which was firmly adherent to the pelvic side wall. This band crossed the sigmoid colon and, by undergoing fibrosis and shortening, eventually obstructed the bowel. Some 30 000 hips are replaced each yearand may require the use of bone cement within the acetabulum. Large-bowel obstruction in a patient who has had a hip replaced some years previously, particularly if it is left-sided replacement, may be due to a readily treatable adhesion, as in this patient, rather
left
Indices of bowel habit in C.D.C.A. or placebo.
seven
patients after
2 weeks
on
days. After the 2 weeks of treatment no significant differences in bowel frequency or total or colonic segmental transit-times were found for either C.D.C.A. or placebo (see figure). Thus C.D.C.A. can often cause diarrhoea, but at 15 mg/kg/ day this side-effect seems to be well tolerated and of short duration. Loose stools and/or increased bowel frequency in the first few days of C.D.C.A. therapy at a daily dose of 15 mg/kg need not prompt a reduction of dosage or discontinuation of therapy.
Department of Gastroenterologia, Medical Clinic II,
University of Rome, 00100 Rome,
Italy.
E. CORAZZIARI C. POZZESSERE S. DANI M. PICCINNI-LEOPARDI F. ANZINI A. ALESSANDRINI
ACETABULAR CEMENT CAUSING INTESTINAL OBSTRUCTION some total hip prostheses the acetabular comhas to be cemented in place. The bony floor of the aceponent tabulum is thin, and only the obturator internus separates its internal aspect from the pelvic peritoneum. The cement is an inactive powder which rapidly polymerises and hardens when benzoylperoxide is added. This reaction is exothermic, and the temperature can rise to 80-900C.’ Some of this heat may be conducted to the internal aspect of the pelvis and a local peritonitis may result, leading, in a patient we have seen, to adhesions and intestinal obstruction. A 63-year-old man presented in February, 1978, with a 3-day history of colicky lower abdominal pain, vomiting, constipation, and flatus. His abdomen was distended and tender in the left lower quadrant. X-rays showed dilated small and large bowel loops with air/fluid levels suggesting obstruction in the distal colon. In 1972, a left low-friction arthroplasty for osteoarthritis had been done, followed by a similar operation on the right side 4 years later. Both operations were uneventful, and there
SIR,-With
postoperative complications. On his recent admission to hospital he was treated with intravenous fluid and nasogastric suction. However, he did not respond to this treatment and laparotomy was undertaken. At operation, the colon was distended to the level of the sigmoid to a point where it was crossed by an omental band which was adherent to the pelvic side wall in the region of the left acetabulum. No other abnormality was found within the abdomen.
were no
The band was divided and the abdomen closed. Postoperatively, he slowly improved and was discharged on the 10th postoperative day. When seen at outpatients, 6 weeks after operation, he was well and symptom-free. Inspection of his preoperative radiographs showed some bone cement to have extruded through the acetabular floor onto the right pelvic side wall. The base of the left acetabulum was fractured but no cement had entered the abdomen on this side. In this patient, the’ heat from the cement used during the 1.
Charnley, J. Acrylic
Cement in
Orthopædic Surgery, London,
1970.
than the more usual carcinoma. Abdominal surgeons should be aware of this unusual complication of the use of bone cement in the acetabular floor. Department of Surgery, City and General Hospitals,
Nottingham NG1 6HA
G. E. FOSTER J. B. BOURKE
PLUGGING OF NEEDLES WITH NEWER INSULINS
SIR,-The report by Dr O’Mullane and Dr Robinson (July 15, p. 165) on the plugging of needles by ’Monotard’ insulin is interesting. I have noticed that needles and syringes may also become coated by a white precipitate when ’Actrapid’ insulin is used. In two patients the syringe had become difficult to use, and in one case it jammed. There was a white precipitate in the barrel and in the partly used vial of 80 unit strength actrapid insulin. This patient had been readmitted three times close together in ketoacidosis for no clear reason. Yet he was insulin sensitive and recovered rapidly in hospital. The insulin vial was returned to Novo Industries Ltd., and subsequently Miss C. J. Borthwick reported: "macroscopic, microscopic, and chemical examinations have shown that the vial (pierced 19 times, residual volume 2 ml) had been polluted with another insulin preparation (’Rapitard’ or an insulin of the lente type)." The patient had indeed been using rapitard insulin before being switched to twice daily actrapid. The use of disposable syringes and a fresh supply of insulin proved effective. It is important that needles, syringes, and the insulin vials currently in use be inspected should there be otherwise unexplained injection difficulties or loss of control in a patient on monotard or actrapid insulin. It is surprising that contamination with rapitard insulin should have produced a precipitate in actrapid vials. I had suspected either spirit contamination or changes in the physical properties of actrapid by heat or by dropping on the floor. In the two earlier patients, we were not alerted to this potential problem, and the half-used insulin vials were not returned to the manufacturers. Perhaps this precipitation problem is not uncommon. Derbyshire Royal Infirmary, Derby DE1 2QY
K.
J. GURLING
SIR,-The letter on plugging of needles with ’Monotard’ insulin by Dr O’Mullane and Dr Robinson is interesting but inconclusive. Their suggestion that the problem might have been caused by inadequate cleaning of the reusable needle before use is not borne out by experiences of a diabetic who uses 1 ml disposable syringes with attached needles (size 18). After a series of complaints from this patient about all aspects of the disposable syringes, investigation showed that the problem lay in a vicious circle which arose because of blocked needles. These caused overdue force to be used on sensitive syringes with the result that rubber pistons were pulled off the plungers, the needles were bent and appeared blunt, and distress was experienced 2.
Lancet, 1976, i, 234.
arthroplasty 6 years previously may have caused a local peritonitis with the subsequent development of an omental band which was firmly adherent to the pelvic side wall. This band crossed the sigmoid colon and, by undergoing fibrosis and shortening, eventually obstructed the bowel. Some 30 000 hips are replaced each yearand may require the use of bone cement within the acetabulum. Large-bowel obstruction in a patient who has had a hip replaced some years previously, particularly if it is left-sided replacement, may be due to a readily treatable adhesion, as in this patient, rather
left
Indices of bowel habit in C.D.C.A. or placebo.
seven
patients after
2 weeks
on
days. After the 2 weeks of treatment no significant differences in bowel frequency or total or colonic segmental transit-times were found for either C.D.C.A. or placebo (see figure). Thus C.D.C.A. can often cause diarrhoea, but at 15 mg/kg/ day this side-effect seems to be well tolerated and of short duration. Loose stools and/or increased bowel frequency in the first few days of C.D.C.A. therapy at a daily dose of 15 mg/kg need not prompt a reduction of dosage or discontinuation of therapy.
Department of Gastroenterologia, Medical Clinic II,
University of Rome, 00100 Rome,
Italy.
E. CORAZZIARI C. POZZESSERE S. DANI M. PICCINNI-LEOPARDI F. ANZINI A. ALESSANDRINI
ACETABULAR CEMENT CAUSING INTESTINAL OBSTRUCTION some total hip prostheses the acetabular comhas to be cemented in place. The bony floor of the aceponent tabulum is thin, and only the obturator internus separates its internal aspect from the pelvic peritoneum. The cement is an inactive powder which rapidly polymerises and hardens when benzoylperoxide is added. This reaction is exothermic, and the temperature can rise to 80-900C.’ Some of this heat may be conducted to the internal aspect of the pelvis and a local peritonitis may result, leading, in a patient we have seen, to adhesions and intestinal obstruction. A 63-year-old man presented in February, 1978, with a 3-day history of colicky lower abdominal pain, vomiting, constipation, and flatus. His abdomen was distended and tender in the left lower quadrant. X-rays showed dilated small and large bowel loops with air/fluid levels suggesting obstruction in the distal colon. In 1972, a left low-friction arthroplasty for osteoarthritis had been done, followed by a similar operation on the right side 4 years later. Both operations were uneventful, and there
SIR,-With
postoperative complications. On his recent admission to hospital he was treated with intravenous fluid and nasogastric suction. However, he did not respond to this treatment and laparotomy was undertaken. At operation, the colon was distended to the level of the sigmoid to a point where it was crossed by an omental band which was adherent to the pelvic side wall in the region of the left acetabulum. No other abnormality was found within the abdomen.
were no
The band was divided and the abdomen closed. Postoperatively, he slowly improved and was discharged on the 10th postoperative day. When seen at outpatients, 6 weeks after operation, he was well and symptom-free. Inspection of his preoperative radiographs showed some bone cement to have extruded through the acetabular floor onto the right pelvic side wall. The base of the left acetabulum was fractured but no cement had entered the abdomen on this side. In this patient, the’ heat from the cement used during the 1.
Charnley, J. Acrylic
Cement in
Orthopædic Surgery, London,
1970.
than the more usual carcinoma. Abdominal surgeons should be aware of this unusual complication of the use of bone cement in the acetabular floor. Department of Surgery, City and General Hospitals,
Nottingham NG1 6HA
G. E. FOSTER J. B. BOURKE
PLUGGING OF NEEDLES WITH NEWER INSULINS
SIR,-The report by Dr O’Mullane and Dr Robinson (July 15, p. 165) on the plugging of needles by ’Monotard’ insulin is interesting. I have noticed that needles and syringes may also become coated by a white precipitate when ’Actrapid’ insulin is used. In two patients the syringe had become difficult to use, and in one case it jammed. There was a white precipitate in the barrel and in the partly used vial of 80 unit strength actrapid insulin. This patient had been readmitted three times close together in ketoacidosis for no clear reason. Yet he was insulin sensitive and recovered rapidly in hospital. The insulin vial was returned to Novo Industries Ltd., and subsequently Miss C. J. Borthwick reported: "macroscopic, microscopic, and chemical examinations have shown that the vial (pierced 19 times, residual volume 2 ml) had been polluted with another insulin preparation (’Rapitard’ or an insulin of the lente type)." The patient had indeed been using rapitard insulin before being switched to twice daily actrapid. The use of disposable syringes and a fresh supply of insulin proved effective. It is important that needles, syringes, and the insulin vials currently in use be inspected should there be otherwise unexplained injection difficulties or loss of control in a patient on monotard or actrapid insulin. It is surprising that contamination with rapitard insulin should have produced a precipitate in actrapid vials. I had suspected either spirit contamination or changes in the physical properties of actrapid by heat or by dropping on the floor. In the two earlier patients, we were not alerted to this potential problem, and the half-used insulin vials were not returned to the manufacturers. Perhaps this precipitation problem is not uncommon. Derbyshire Royal Infirmary, Derby DE1 2QY
K.
J. GURLING
SIR,-The letter on plugging of needles with ’Monotard’ insulin by Dr O’Mullane and Dr Robinson is interesting but inconclusive. Their suggestion that the problem might have been caused by inadequate cleaning of the reusable needle before use is not borne out by experiences of a diabetic who uses 1 ml disposable syringes with attached needles (size 18). After a series of complaints from this patient about all aspects of the disposable syringes, investigation showed that the problem lay in a vicious circle which arose because of blocked needles. These caused overdue force to be used on sensitive syringes with the result that rubber pistons were pulled off the plungers, the needles were bent and appeared blunt, and distress was experienced 2.
Lancet, 1976, i, 234.
