In 20 patients undergoing hybrid total hip arthroplasty, the reproducibility and accuracy of templating using digital radiographs were assessed. Digital images were manipulated using either a ten-pence coin as a marker to scale for magnification, or two digital-line methods using computer software. On-screen images were templated with standard acetate templates and compared with templating performed on hard-copy digital prints. The digital-line methods were the least reliable and accuracy of sizing compared with the inserted prostheses varied between -1.6% and +10.2%. The hard-copy radiographs showed better reproducibility than the ten-pence coin method, but were less accurate with 3.7% undersizing. The ten-pence coin method was the most accurate, with no significant differences for offset or acetabulum, and undersizing of only 0.9%. On-screen templating of digital radiographs with standard acetate templates is accurate and reproducible if a radiopaque marker such as a ten-pence coin is included when the original radiograph is taken.

SummaryThe crhility of midwives to assess accurately the level of epidural blockade after a short period of instruction was examined. Midwives are permitted by their National Board rules to administer a prescribed bolus of local anacsthetic (the topup) through an epidural catheter, after the first injection by an anaesthetisl, to maintain analgesia during labour. The decision to top-up is made when the mother complains of returning pain. The only check on accidental intrathecal injection is obvious respiratory difficulty or hypotension when the top-up is administered. This is unsatisfactory and has led to occasional serious complications. The assessment of thc lcvcl of blockade is an important precaution.against continuation of an accidental intrathecal injection, so it is essential that the level before, and after, top-up should be asscsscd accurately. Seventy-two midwives estimated theThe present trial assesses the ability of the midwife to determine the upper sensory level of the block after a short period of simple instruction by an anaesthctist. The ultimate aim would be to develop a safe technique for centres in which midwifery staff carry out thc top-up procedure. MethodThe duty obstetric anaesthetist administered the top-up when clinically indicated, and positioned the mother appropriately during routine rnanagemcnt of epidural analgesia in labour. Thirty minutes later the midwife who attended the mother was instructed by the anacsthetist how to assess the upper level of the block. It was explained that at the upper limit of the epidural block the mother would perceive a diffcrence in sensation caused by movement of an ice-cube over the skin. The midwife was told to move the ice-cube lightly up the left side of the mother's body from groin to neck and to ask her to indicate when she was aware of the cold from the ice-cube. This level was indicated with a skin marker. The procedure was then repeated on the right side. The anaesthetist then followed the same mcthod and finally recorded the dermatome levels of both assessmcnts. The grade of both the midwife and anaesthetist were recorded, as were any comments from the participants (mother, anaesthetist and midwife). ResultsOnc hundrcd patients were assessed by both a midwife and an anacsthetist during the study. Seventy-two midwives and twenty-four anaesthetists, of different grades, took part on a varying number of occasions ( Table I).The midwives and anaesthetists were in complete agreement on the level of the block (71.5%), or were within one spinal segment (a further 17%) on the majority of occasions (Fig. I). The greatest variation was three segments and the number of times the assessment differed by two or three segments was small (9.5% and 2% respectivcly). Midwives overestitnated the level in 9.5% of measurements, and underestimated it on 19% of occasions.

Percutaneous tracheostomy is a procedure frequently carried out in a critical care setting. It is performed in the majority of cases by anaesthetists in the United Kingdom. The ENT surgeon is only called in situations where it is deemed by the intensivist that percutanous tracheostomy would prove too great a risk. In this situation the patient was taken to the operating theatre for a surgical tracheostomy. In our paper, a retrospective analysis was performed of all percutaneous tracheostomies carried out by ENT surgeons in the Royal Glamorgan Hospital, during a two-year period from July 1999 to July 2001, to assess whether percutaneous tracheostomy is a feasible option as a first line procedure in all elective tracheostomies. Thirty-six patients were included in the study. The mean age was 60.2 years. Haemorrhage was noted to be a problem in only one patient and two patients developed postoperative wound infection that was treated with systemic antibiotics. No other complications were encountered. We propose that all ENT surgeons should be trained in performing percutaneous tracheostomy and that it should be used as the gold standard in elective tracheostomy insertion. In cases where difficulties are likely to be anticipated, percutaneous tracheostomy can still be considered as the first option. This can be performed in the operating theatre setting with the knowledge that if any complication should occur then conversion to surgical tracheostomy can be done without delay.

Intestinal malrotation is a common cause of upper gastro-intestinal obstruction and presents with duodenal obstruction caused by volvulus of the midgut loop [6]. Malrotation syndromes typically present during the first few months of life, but may sometimes present later, causing diagnostic difficulties [7]. We report an unusual presentation of malrotation.A 5-year-old boy initially presented, at the age of 18 months, with short history of anorexia, followed by nonbilious vomiting and fever, which was diagnosed as a non-specific viral infection with gastritis. Six months later, he presented with weight loss, occasional diarrhoea, vague recurrent abdominal pain but the most significant feature was his extremely poor appetite and suboptimal caloric intake. On both occasions, physical examination was unremarkable, but in view of his significant loss weight, he had a range of investigations including liver function tests, serum albumin level, coeliac disease screen, auto-antibody screen, immunoglobulin (Ig) profile, sweat test and urine and stool analyses. All investigations proved negative apart from an elevated C-reactive protein and the presence of fat globules in stool. Abdominal ultrasound and upper gastrointestinal endoscopy with biopsies were normal. Caloric supplements were prescribed.A few months later, he presented again with a similar picture. On physical examination, his abdomen was slightly distended without tenderness or rigidity and routine investigations showed a low lymphocyte count, hypoalbuminaemia (23 g/l), low serum IgG levels (total and subclasses), low but normal levels of the other immunoglobulins, raised faecal alpha-1-antitrypsin (9.75 mg/g stool, reference range 0.13-2.38 mg/g stool).He was recognised as having an unexplained proteinlosing enteropathy and, in view of poor caloric intake, was treated with nasogastric supplementary nutrition. However, he developed persistent diarrhoea and abdominal pain and was initially managed with total parenteral nutrition and subsequently with enteral elemental feed. Over the next 3 months, his nutritional state improved and his serum albumin returned to normal (41 g/l). Normal diet was introduced.At the age of 3 years he deteriorated again and was re-investigated. Colonoscopy revealed colonic inversus Fig. 1 A frontal view of the abdomen during barium meal followthrough examination shows a low-lying duodeno-jejunal junction and small bowel loops lying in the right flank consistent with malrotation Eur J Pediatr (2003) 162: 812-813

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